Based on record review, interview, and facility policy review, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency within the required timeframe of two hours for 1 (Resident #15) of 2 residents reviewed for physical abuse allegations. The findings are: A review of a Progress Note, dated 06/05/2025 at 2:20 PM, indicated Certified Nursing Assistant (CNA) #2 reported to Licensed Practical Nurse (LPN) #1 at 10:30 AM that Resident #15 was emotional about an incident that happened on 06/04/2025. Resident #15 alleged being punched in the genital area by a night shift staff member identified as CNA #3. The progress note indicated LPN #1 asked Resident #15 later [in the shift] what happened last night [06/04/2025] with CNA #3, and the resident reported the same information. The progress note indicated LPN #1 checked the resident and Resident #15 reported soreness with palpation. The progress note indicated LPN #1 reported the incident to the Interim Administrator for further investigation. There was no documentation to indicate the State Survey Agency, medical provider, family, or law enforcement were notified of the allegation by Resident #15 of being hit in the genital area by CNA #3. A review of Resident #15 ' s admission Record revealed the facility admitted the resident on 01/03/2025. The resident was admitted with diagnoses which included schizophrenia, major depressive disorder, anxiety, and intellectual disabilities. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/07/2025, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. The MDS also revealed the resident exhibited no behaviors, no rejection of care, or wandering. The MDS indicated Resident #15 required substantial/maximal assistance with toileting, personal hygiene, and shower/bathe self and was dependent for chair/bed-to-chair, toilet, and tub/shower transfer. A review of Resident #15 ' s Care Plan report, with a review date of 03/15/2025, revealed impaired cognitive function related to schizophrenia. Interventions included to incorporate cues, reorientation, and supervision as needed. During an interview on 06/11/2025 at 12:47 PM, the [NAME] President (VP) of Operations, who was Interim Administrator during the time of the alleged incident, stated she was notified by LPN #1 of an allegation of Resident #15 being punched in the genital area by CNA #3. The VP of Operations stated she spoke with CNA #1 and LPN #1, and that she and the Social Worker went to speak with Resident #15. The VP of Operations stated Resident #15 ' s storyline kept changing and the resident could not provide a name for the CNA in question. The VP of Operations stated she spoke with CNA #3 when she came to work that night, 06/05/2025, and CNA #3 stated the resident was confused. The VP of Operations stated after speaking with CNA #3, she, LPN #1, and CNA #3 went to Resident #15's room and the VP of Operations asked the resident if it was okay for CNA #3 to care for the resident and the resident stated, Well of course. The VP of Operations stated she did not report this allegation, because the facility was unable to prove anything. The VP of Operations stated she spoke with Resident #15 and the staff [CNAs and nurses] about Resident #15 ' s allegation, which was her investigation and had a folder that she was trying to locate with staff witness statements. The VP of Operations stated she did not involve Resident #15 ' s family member, because she did not know if the resident had family. On 06/11/2025, the VP of Operations provided a folder with an Office of Long-Term Incident and Accident Report (I&A) form, not dated, which only had the facility ' s name, area code, and address on it. All the other areas were blank. Page 2 of the I&A report indicated Resident [#15] reported multiple different stories to a variety of staff about getting hit in the [genital area]. The resident was a poor historian with a history of making false accusations at their previous place of residency. Resident #15 had a BIMS of 6 and a diagnosis of schizophrenia, with hallucinations and a history of behavior and accusatory behavior with staff and other residents. After conducting an investigation, it was found that the residents' allegations were unfounded. Staff were educated to have two people present during personal care. The MDS Coordinator was informed to care plan Resident #15 for history of false allegations. The VP of Operations stated she was familiar with the facility's abuse policy and the policy indicated all allegations of abuse were to be reported to the state agency, but she did not state the time frames when reporting allegations. A review of the Abuse Prevention Program policy, revised 12/2016, revealed the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included physical abuse. The policy revealed the administration would do the following: protect the residents from abuse by anyone, develop and implement policies and procedures to aid the facility in preventing abuse, neglect or mistreatment of the residents, identify and assess all possible incidents of abuse, and investigate and report any allegations of abuse in the timeframes as required by federal requirements and protect residents during abuse investigations. The facility did not provide any further documentation on reporting abuse.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure hand hygiene was performed to prevent cross contamination and the risk for infection during incontinence care for one (Resident #15) of one resident reviewed. The findings include: During an observation on 06/12/2025 at 2:07 PM, this surveyor observed Certified Nursing Assistant (CNA) #2 perform hand hygiene, put on gloves, and then assist Resident #15 in rolling side to side, to remove the resident ' s wet brief. Licensed Practical Nurse (LPN) #7 entered Resident #15 's room and instructed CNA #2 to put cream on the resident ' s perineal area. With their soiled gloves, CNA #2 first looked in Resident #15 's bedside drawer, then went to a dresser across from the foot of the bed and removed a white tube of cream. CNA #2 placed a clean brief on Resident #15 and was observed applying cream to the perineal area while still wearing the same contaminated gloves. CNA #2 then repositioned the resident onto their right side, and pulled up the linens, without changing gloves or performing hand hygiene. A review of Resident #15 ' s quarterly Minimum Data Set (MDS), with an Assessment Reference Date, of 04/09/2025 revealed a Brief Interview for Mental Status score of 06, which indicated severe cognitive impairment. The MDS revealed Resident #15 was dependent on staff for toileting, dressing, bathing, and personal care. The MDS confirmed Resident #15 was always incontinent of bowel and bladder. During an interview with CNA #2 and LPN #7 on 06/12/2025 at 2:17 PM, CNA #2 stated, we wash hands before and after perineal care, and wear gloves during perineal care. CNA #2 confirmed her dirty gloves should have been changed before going from dirty body sites to clean body sites and touching Resident #15 ' s environment, to prevent the transferring of germs around the room. LPN #7 confirmed hand hygiene should have been performed during Resident #15 ' s perineal care, to prevent cross contamination. During an interview on 06/12/2025 at 2:40 PM, with the [NAME] President (VP) of Operations and the Administrator, the VP of Operations stated, the Infection Preventionist (IP) did competencies and perineal care check offs with all the CNAs. The VP of Operations stated, I know the IP provided education for peri-care to protect the resident from infections. The Administrator revealed it was not appropriate to go from dirty to clean without changing gloves, due to cross contamination, and staff were expected to perform hand hygiene. A review of an undated Perineal Care Protocol revealed staff should not touch anything with soiled gloves after providing perineal care including clean linens, rails, or call light. A review of a policy titled Employee Training on Infection Control, revised 01/2012, revealed all staff were oriented and received training on preventing the transmission of healthcare acquired infections. Infection control training involved hand hygiene and included preventative and monitoring measures. A review of a policy titled Handwashing/Hand Hygiene, revised 08/2015, revealed hand hygiene was the primary means to prevent the spread of infection. Staff were in-serviced regularly on hand hygiene and were to follow procedures to prevent the spread of infection. Staff were expected to perform hand hygiene when moving from a contaminated body site to a clean body site during personal care. In-service on hand hygiene was requested.

Based on record review and interview, the facility failed to ensure the facility had a full-time Director of Nursing (DON) to promote effective leadership and nursing care oversite, with the potential to affect all 60 residents. The findings include: A review of the Facility Assessment, dated 06/2025, revealed the DON position was documented as vacant. During an interview on 06/10/2025 at 1:20 PM, the Administrator said, we do not have a DON. The Administrator also stated they were not sure when the DON left the facility, and that nobody was working in the role as the DON at this time. The Administrator revealed there were no nursing waivers. During an interview on 06/10/2025 at 2:00 PM, the Administrator provided documentation which revealed a posting for the DON position began on 05/06/2025. During an interview on 06/11/2025 at 6:25 AM, the [NAME] President (VP) of Operations provided documentation which revealed the former DON was employed from 03/27/2025 to 05/06/2025. They also stated the facility had not had a DON in about a month. The VP of Operations confirmed employing a DON was a regulation requirement, and needed to provide clinical leadership to staff. During an interview on 06/11/2025 at 10:30 AM, the Medical Records (MR) Nurse indicated not having a DON had broken the chain of command for the nursing staff working the floor. The MR Nurse revealed the Administrator started at the facility on Friday, 06/06/2025. During an interview on 06/11/2025 at 11:13 AM, Licensed Practical Nurse #1 said, not having a DON has been terrible and makes it stressful when I do not know something. A review of the DON Job Description indicated the primary purpose of the DON position was to direct Nursing Services in planning and organizing according to state, federal, and local laws. In the absence of the Medical Director, the DON was to carry out the resident care policies, as well as administrative functions including care planning, safety, sanitation, equipment and supplies, education, budgeting, and resident rights.

Based on observation, record review, and interview, the facility failed to report to the State Survey Agency an elopement for 1 (Resident #3) of 3 sample residents reviewed for elopement risk and failed to report altercations between residents that resulted in injury or had the potential to result in injury for 4 (Resident #1, #6, #12, #13) of 7 sample residents reviewed for abuse. The findings are: 1. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2025, indicated Resident #1 had a diagnosis of non-Alzheimer's dementia, anxiety disorder, and psychotic disorder, score of 3 (indicating severe impairment) on the Staff Interview for Mental Status (SAMS), and had physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, or grabbing.) a. A review of the Care Plan with a revision date of 12/17/2024, indicated Resident #1 had the potential to be physically aggressive related to dementia and history of combativeness. The goal of the resident's care was the resident would not harm self or others. b. A review of an Incident Audit Report dated 12/17/2024 at 6:50 PM, indicated Resident #1 was standing in the hallway against the wall when another resident punched Resident #1 in the face. The report indicated Resident #1 was placed in a room and assessed. A body audit revealed the resident had a busted lip that resulted from the incident. c. On 04/07/2025 at 11:50AM, Resident #1 was sitting on the bed in their room. The resident was able to respond to name but did not answer any other questions. d. During an interview on 04/08/2025 at 1:30 PM, the Administrator indicated that she would have to look at the incident involving Resident #1 on 12/17/24, to determine who the other resident was that was involved. e. During an interview on 04/08/25 at 3:50 PM, the Administrator stated that she had identified the other resident involved in the incident on 12/17/2025, with Resident #1. The Administrator stated there was an incident report for that date on another resident that occurred about the same time. The Administrator stated the incident between the two residents was not reported to the state agency. f. A review of a policy titled Abuse Investigating and Reporting revised July 2017, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injury of unknown source (abuse) shall be reported immediately but no later than 2 hours if the allegation is abuse to local, state, federal agencies (as indicated by current regulations). g. A review of the policy Resident-to-Resident Altercations revision December 2016, indicated resident-to- resident altercations shall be reported to the Administrator and reported incidents, findings and corrective measures reported to appropriate agencies as outlined in the facilities abuse reporting policy. 2. A review of the quarterly MDS with an ARD of 03/14/2025, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #3 had delusional behaviors, a potential indicator for psychosis. a. A review of the Care Plan Report revision date 02/03/2025, revealed Resident #3 was identified to be at risk for wandering/elopement. Resident #3 ' s Care Plan Report revision date 12/24/2024, revealed Resident #3 was at risk for behavior problems related to unspecified dementia and moderate agitation. b. A review of the Elopement Risk Evaluation dated 04/07/2025, revealed that Resident #3 had a history of attempting to leave the facility without informing staff and a history of wandering. c. According to a Behavior Note dated 04/04/2025 at 9:22 PM, Resident #3 got upset and exited the facility. Due to Resident #3 ' s wander guard, the automatic door locked, but the resident was able to pull the door apart. Resident #3 was accompanied by a staff member upon exiting the facility, and there was a second staff member outside of the facility. The two staff members walked with Resident #3 in the parking lot trying to encourage Resident #3 to come back into the facility, but Resident #3 did not comply. Resident #3 was able to get away from the two staff members and enter the woods. d. According to a Behavior Note dated 04/05/2025 at 6:48 AM, Resident #3 exited the facility and was off the facility's premises. Law enforcement was called to help with search for Resident #3 requiring the assistance of search dogs. Resident #3 was located by the dogs sitting on the patio chair between the facility, and the assisted living facility next door. e. On 04/08/25 at 1:45 PM, during an interview, Registered Nurse (RN) #7 stated Resident #3 had gotten upset, pulled the doors open, and exited the facility. The van driver and RN #7 were walking with Resident #3 until the resident broke away and proceeded into the woods. The facility was informed by the Police Department not to enter the woods behind the resident, because it would throw off the scent trail for the dogs. f. On 04/18/25 at 11:00 AM, during an interview, the Administrator voiced that the incident that occurred on 04/04/25 involving Resident #3 was not reported to the state. 3. Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/16/2025, indicated the resident had a Staff Assessment for Mental Status (SAMS) with a score of 3, indicating Resident #6 was severely mentally impaired. Other diagnoses on the MDS included seizure disorder or epilepsy, traumatic brain injury, psychotic disorder, and schizophrenia. The MDS indicated the resident had a score of 3 on the Behavioral Symptoms assessment, indicating Resident #3 daily exhibited behaviors of physical behavioral symptoms (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and a Wandering score of 3, indicating that wandering behavior occurred daily. 4. Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/2025, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #12 was severely cognitively impaired. Other diagnoses and conditions listed included delusions, non-Alzheimer's dementia, and muscle weakness. 5. Resident #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/2025, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #13 was cognitively intact. 6. A review of the following records revealed the following incidents. a. The Incident Note on 10/27/2024 at 6:43 PM, indicated Resident #6 initiated an altercation by hitting an unknown resident and knocking them down in the hallway on the secure unit. No injuries recorded. b. The Incident and Accident report (I&A) for 12/29/2024 at 9:45 AM, indicated Resident #6 initiated an altercation on an unknown resident by hitting them on the back of the right shoulder, in the hall. No injuries recorded. c. The I&A report for 02/26/2025 at 4:33 AM, indicated Resident #6 initiated an altercation by wandering into Resident #13's room and hitting Resident #13. The location on the resident's body, where Resident #13 was hit was not disclosed in the record. No injuries recorded. d. The I&A report for 03/04/2025 at 12:00 PM, indicated Resident #6 initiated an altercation by wandering into Resident #12's room and jumping on Resident #12 while in bed. No injuries recorded. e. The resident-to-resident altercations listed above were not reported to the State Survey Agency. f. A review of a policy titled Resident-to-Resident Altercations, revised December 2016, stated report incidents, findings, and corrective measure to appropriate agencies as outlined in our facility's abuse reporting policy. g. During an interview on 04/17/2025 at 2:37 PM, the Administrator indicated that a Facility-Reportable Incident (FRI) would include any incidence of resident-to-resident verbal or physical altercation and would be reported to the State Survey Agency. h. During the Exit conference on 04/18/2025 at 1:30 PM, the facility was given the opportunity to provide additional documentation - none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure that physician's orders for wound care were followed for 2 (Resident #17, Resident #18) of 2 sampled residents reviewed for facility acquired pressure ulcer/injuries. The findings include: 1. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #17 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate impaired cognition. Resident #17 was at risk for developing a pressure ulcer/injury, but Resident #17 did not currently have one or more unhealed pressure ulcer/injuries. a. A review of the Care Plan Report revision date 01/30/2024, revealed Resident #17 had diabetes mellitus type 2 with interventions to inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. b. A review of the most recent Skin Only Evaluation dated 03/06/2025, revealed Resident #17 did not have current skin issues. c. A review of the Visit Note from the Family Medicine Podiatry encounter date 04/10/2025, indicated ulcer #1 was noted to left great toe, wound measured 1.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth and was a [NAME] stage 3 pressure ulcer, meaning it displayed full thickness tissue loss with involvement of tendon, ligaments, joints, and even bone. Escar (dying tissue) was absent, and slough (yellow grainy tissue) was present in the wound. d. A review of the Order Summary Report revealed there was an order which indicated monitor right great toe for intact dressing and sign/symptoms of infection. Notify treatment nurse if here of the need for new dressing or apply a new dressing. See TAR for orders. Every day and night shift related to pressure ulcer of other site, stage 4. e. A review of the Treatment Administration Record (TAR) revealed an order which indicated cleanse right great toe with normal saline, pay dry, apply betadine, apply dry dressing and tape; apply clean sock to help keep dressing in place. Every day shift for wound care until 04/14/2025 11:59 PM, start date 04/12/2025 at 700 AM. There was no indication that any dress changes had been completed. This surveyor noted that the Skin Only Evaluation prior to October indicated Resident #17 had an open area on the left great toe not the right. f. On 04/14/2025 at 12:50 PM, this surveyor observed Resident #17 sitting in wheelchair in room eating noon meal. This surveyor noted Resident #17 had a black shoe on the right foot and a yellow sock on the left foot. The dressing to the left foot was visible through the yellow sock. g. On 04/14/2025 at 12:51 PM, during an interview with Resident #17 the resident stated, there was an open wound on the foot, because someone stepped on the foot. h. On 04/17/25 at 4:00 PM, during an interview Medication Administration Certified (MAC) #5 expressed that the facility's staff documented wound care orders on the TAR after completion, but if it was not documented on the TAR, it was likely not done. MAC #5 indicated that Skin Only Evaluations were completed weekly by a nurse on every resident regardless of the presence or absence of a wound. MAC #5 confirmed after record review that there were no signed completions on the TAR for Resident #17 since the order was entered on 4/11/25, and the most recent Skin Only Assessment was completed on 03/06/2025. 2. A review of the annual MDS with an ARD of 12/17/2024, revealed that Resident #18 had a BIMS score of 11, indicating moderately impaired cognition. Resident #18 was at risk for developing pressure ulcer/injuries, and Resident #18 had two stage 4 pressure ulcers. a. A review of the Care Plan Report Revised 03/27/2025, revealed that Resident #18 had actual pressure sores, a stage 4 to the right scrotum fold and stage 4 to scrum-coccyx area. b. A review of the March TAR revealed that there was an order which indicated Stage 4 to sacrum - coccyx area and scrotum: Clean with wound cleanser, pat dry with 4x4, apply calcium alginate to rule slough out of wound. Cover with silicone dressing every day apply abdominal pad and secure with tape every day shift. This surveyor noted 16 of 31 days signed as completed. c. A review of the April TAR , print date 04/14/2025, revealed there was an order which indicated Stage 4 to sacrum - coccyx area and scrotum: Clean with wound cleanser, pat dry with 4x4 apply calcium alginate to rule sloth out of wound. Cover with silicone dressing every day apply abdominal pad and secure with tape every day shift. This surveyor noted 7 of 14 days signed as completed. d. On 04/17/2025 at 4:20 PM, during an interview, Registered Nurse (RN) #6 expressed that the facility's staff documented wound care orders on the TAR after completion, but if it was not documented on the TAR, it was likely not done. RN #6 signified that Skin Only Evaluations were completed weekly by the treatment nurse if she is available, if not the floor nurse assigned the resident was responsible. According to RN #6 Resident #18 had treatment orders to be completed daily. After review of the TAR, RN #6 stated the treatments were not completed daily as ordered per the physician. e. On 04/17/2025 at 4:23 PM, this surveyor requested Director of Nursing (DON) review Resident #17 ' s visit note on 04/10/2025 and examination of ulcer #1. The DON indicated the note revealed the wound had progressed to a [NAME] stage 3 pressure ulcer, meaning it displayed full thickness tissue loss with involvement of tendon, ligaments, joints, and even bone. DON stated necrosis. On 04/18/25 at 9:13 AM, during an interview the Administrator voiced that inadequate staffing was the root cause for the TAR being incomplete potentially indicating wound care was not provided and the Skin Only Evaluations were not up to date. There was no pertinent information in the policies provided by the facility to support the deficient practice.

Based on interviews, record review, and facility policy review the facility failed to ensure that the facility was sufficiently staffed to ensure residents residing in the facility received quality of care. This failed practice had the potential to affect every resident residing in the facility. The finding include: A review of the facility assessment and after an interview with the Administrator it was brought to our attention that the facility staff plan was for a full-time Director of Nursing (DON) and Assistant Director of Nursing (ADON), 2-3 charge nurses for each shift LPN/RN, 15 staff members on the day shift 7a-3p, 9 Certified Nursing Assistants only on the evening shift, and 8 staff members on the night shift. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.5 staff members during these hours. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 of with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 of with 5 staff members for the hours 11 PM-7 AM. Which was an accurate number. A review of the Daily Staffing Log for 01/05/2025, indicated that the facility had a census of 67 with 10 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 8 members during these hours. A review of the Daily Staffing Log for 01/05/2025 indicated that the facility had census of 67 with 6 staff members, which included 3 aides, for the hours 3 PM-7 PM. Which was accurate. A review of the Daily Staffing Log for 01/05/2025, indicated that the facility had a census of 67 with 5 staff members for the hours 7 PM-11 PM, which included four (4) aides, one (1) aide from agency that came in at 7pm. However, after a review of the time sheet provided, it was indicated there were 6 staff members during these hours. A review of the Daily Staffing Log for 01/05/2025, indicated that the facility had a census of 67 with 4 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 4.5 staff members during these hours. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 10 staff members for the hours 7 AM-3 PM which was accurate. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 11 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8.5 staff members, which included one agency nurse and 5 aides, 6 total, aide came in after 9 PM, during these hours. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 8 staff members which included one agency nurse, for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/12/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 01/12/2025 indicated that the facility had a census of 67 with 11 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 01/12/2025 indicated that the facility had a census of 67 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 7 aides, one aide came in at 7pm, during these hours. A review of the Daily Staffing Log for 01/12/2025, indicated that the facility had a census of 67 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/18/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 01/18/2025 indicated that the facility had a census of 67 with 14 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 01/18/2025 indicated that the facility had a census of 67 with 14 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 10 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 01/18/2025, indicated that the facility had a census of 67 with 8 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/19/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 01/19/2025 indicated that the facility had a census of 67 with 11 staff members, which included 6 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 01/19/2025 indicated that the facility had a census of 67 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which include 6 aides, during these hours. A review of the Daily Staffing Log for 01/19/2025, indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/25/2025 indicated that the facility had a census of 68 with 12 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 10.25 staff members during these hours. A review of the Daily Staffing Log for 01/25/2025 indicated that the facility had a census of 68 with 4 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 01/25/2025 indicated that the facility had a census of 68 of with 4 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, they indicated there were 9 staff members which included 7aides, one aide came in at 7pm, during these hours. A review of the Daily Staffing Log for 01/25/2025, indicated that the facility had a census of 68 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 12 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 10 staff members, which included 6 aides, for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.25 staff members during these hours. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 13 after a review of the hours 3p-7 PM. However, after review sheet provided, it was indicated there were 10 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8.25 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/02/2025 indicated that the facility had a census of 68 with 11 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 02/02/2025 indicated that the facility had a census of 68 with 11 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8.25 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/02/2025 indicated that the facility had a census of 68 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/02/2025, indicated that the facility had a census of 68 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/08/2025, indicated that the facility had a census of 67 with 11 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 02/08/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 02/08/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members which included 6 aides, one came in at 7 PM, during these hours. A review of the Daily Staffing Log for 02/08/2025, indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 6 staff members during these hours. A review of the Daily Staffing Log for 02/09/2025, indicated that the facility had a census of 67 with 14 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 02/09/2025, indicated that the facility had a census of 67 with 10 staff members which included 6 aides, for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/09/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members which included 7 aides, one aide came in at 7 PM and 1 nurse stayed until 11 PM, during these hours. A review of the Daily Staffing Log for 02/09/2025 indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 4.5 staff members during these hours. A review of the Daily Staffing Log for 02/15/2025 indicated that the facility had a census of 62 with 14 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 02/15/2025 indicated that the facility had a census of 62 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides during these hours. A review of the Daily Staffing Log for 02/15/2025, indicated that the facility had a census of 62 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/15/2025, indicated that the facility had a census of 62 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/16/2025, indicated that the facility had a census of 63 with 8 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 10 staff members, which included two (2) agency nurses, during these hours. A review of the Daily Staffing Log for 02/16/2025 indicated that the facility had a census of 63 with 6 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/16/2025, indicated that the facility had a census of 63 with 6 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/16/2025, indicated that the facility had a census of 63 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/22/2025 indicated that the facility had a census of 66 with 11 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 02/22/2025, indicated that the facility had a census of 66 with 9 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 02/22/2025 indicated that the facility had a census of 66 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 02/22/2025, indicated that the facility had a census of 66 with 4 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/23/2025, indicated that the facility had a census of 66 with 10 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 02/23/2025, indicated that the facility had a census of 66 with 8 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 4 aides, during these hours. A review of the Daily Staffing Log for 02/23/2025 indicated that the facility had a census of 66 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 5 aides, one aide came in at 7 PM, during these hours. A review of the Daily Staffing Log for 02/23/2025 indicated that the facility had a census of 66 with 7 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 6 staff members during these hours A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 12 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 13 staff members during these hours. A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/02/2025, indicated that the facility had a census unknown with 11 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/02/2025 indicated that the facility had a census unknown with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides during these hours. A review of the Daily Staffing Log for 03/02/2025 indicated that the facility had a census of 66 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 03/02/2025 indicated that the facility had a census of 65 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/08/2025, indicated that the facility had a census of 65 with 11 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/08/2025 indicated that the facility had a census of 65 with 8 staff members which included 5 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/08/2025 indicated that the facility had a census of 65 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 5 staff members, which included 4 aides during these hours. A review of the Daily Staffing Log for 03/08/2025, indicated that the facility had a census of 65 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/09/2025 indicated that the facility had a census unknown with 10 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/09/2025 indicated that the facility had a census unknown with 8 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides during these hours. A review of the Daily Staffing Log for 03/09/2025 indicated that the facility had a census of 65 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 03/09/2025indicated that the facility had a census of 65 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 65 with 11 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 8.5 staff members during these hours. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 65 with 9 staff members which included 5 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 64 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, one aide came in at 7 PM, during these hours. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 64 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 8 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 9 staff members which included 6 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8staff members which included 6 aides, one aide came in at & PM, during these hours. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/22/2025 indicated that the facility had a census of 64 with 8 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/22/2025 indicated that the facility had a census of 64 with 9 staff members, which included 6 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/22/2025, indicated that the facility had a census of 64 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members which included 6 aides, one aide came in at 7 PM, during these hours. A review of the Daily Staffing Log for 03/22/2025 indicated that the facility had a census of 64 with 11 staff members for the hours 11 PM-7 AM, which was accurate. However, after a review of the time sheet provided, it was indicated there were 10.75 staff members during these hours. A review of the Daily Staffing Log for 03/23/2025 indicated that the facility had a census of 64 with 8 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.5 staff members during these hours. A review of the Daily Staffing Log for 03/23/2025 indicated that the facility had a census of 64 with 7 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 4 aides, during these hours. A review of the Daily Staffing Log for 03/23/2025 indicated that the facility had a census of 64 with 7 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, they indicated there were 6 staff members, which included 4 aides, during these hours. A review of the Daily Staffing Log for 03/23/2025, indicated that the facility had a census of 64 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/29/2025 indicated that the facility had a census of 66 with 14 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 03/29/2025, indicated that the facility had a census of 66 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 03/29/2025, indicated that the facility had a census of 66 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 03/29/2025 indicated that the facility had a census of 66 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/30/2025 indicated that the facility had a census of 66 with 9 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.5 staff members during these hours. A review of the Daily Staffing Log for 03/30/2025 indicated that the facility had a census of 66 with 12 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 10 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 03/30/2025, indicated that the facility had a census of 66 with 12 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 03/30/2025 indicated that the facility had a census of 66 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 8 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 5 staff members for the hours 11 PM-7 AM, which was accurate. On 04/07/2025 at 11:30 Certified Nursing Assistant (CNA) #3 stated she was working the hall alone due to a call in. CNA #3 stated she does not provide shower when she works alone. CNA #3 stated she works alone 3-4 times a month. On 04/08/2025 at 2:30 PM, during an interview the Administrator stated, the facility did not have a Director of Nursing (DON) at the current time. According to the Administrator, the DON was expected to start on 04/09/2025. The Administrator stated, I know we just got a tag for it; I am just as frustrated as you are. According to the Administrator the facility has been without a DON since March 14, 2025. On 04/08/2025 at 9:30 AM, during an interview Certified Nursing Assistant (CNA) #9 stated, she was working alone on the hall, which she does often. CNA #9 stated when she was providing care there was no one on the hall to watch the other residents to ensure their safety. On 04/08/25 at 11:14 AM, during an interview Licensed Practical Nurse (LPN) #2 stated, she was responsible for working 2 halls, plus providing wound care to those residents scheduled. On 04/08/2025 at 11:48 AM, during an interview the Maintenance Director stated, he felt there should be two staff members on the secured unit at all time. On 04/09/2025 at 1:10 PM, during an interview with CNA #1 stated, she was working the hall alone. CNA #1 stated when there was one aide on the hall a bed bath can be done but not showers. CNA #1 stated, she was unable to give everyone a bed bath today that was scheduled for a shower. On 04/09/2025 at 2:20 PM, during an interview CNA #4 warned this Surveyor to be cautious due to a resident being aggressive. CNA #4 stated she was working alone and that if she was providing care to another resident, she could not ensure that the aggressive resident would not hit another resident in her absence. On 04/14/2025 at 11:45 AM, during an interview the Administrator explained the staffing plan noted on the facility assessment. The Administrator stated, I will have a full-time Director of Nursing (DON), an RN/LPN as ADON, 15 staff members on day shift, 9 on evening, and 8 on nights. The Administrator stated it was the facility plan to have one to two additional staff members in addition to the minimum. The Administrator stated the numbers listed on the facility ' s assessment were minimum staffing. On 04/18/25 at 9:13 AM, during an interview, the Administrator stated she does not feel that the facility had enough staff. The Administrator indicated that staffing was the root cause analysis to elopements, treatments not being completed, and showers not being completed. A review of policy titled Staffing , revised October 2017, indicated our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services to all residents.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 1 (Resident #265) sampled resident was safe to self-administer medications. The findings include: A plan of care for Resident #265 (Revision on: 09/11/2024) revealed Resident #265 had impaired cognitive function/dementia or impaired thought processes related to history of suicidal ideation. Interventions included to administer medications as ordered, monitor, and document for side effects and effectiveness. On 10/07/24 at 11:14 AM, the Surveyor observed over the counter medications in Resident #265's bathroom. On 10/07/24 at 12:47 PM, the Surveyor observed over the counter medications in Resident #265's bathroom. On 10/08/24 at 9:03 AM, the Surveyor observed over the counter medications in Resident #265's bathroom. On 10/08/24 at 9:30 AM, the Nurse Consultant stated there were no residents on 400 hall (the hall on which Resident #265 resided) who self-administered medications. The Nurse Consultant stated Resident #265 did not have an order for the medications to be kept in the bathroom, and the resident should not have medication accessible. The Nurse Consultant stated Resident #265 had not been assessed to self-administer medications safely and doing so could have a negative impact on the resident. On 10/11/24 at 4:40 PM, the Administrator stated there were no residents residing in the facility assessed to self-administer their own medications, therefore medications should not be accessible to Resident #265 with supervision. The Administrator stated there could be a potential negative outcome from the resident having medications in their room or taking medications the facility was unaware of, such as another resident wandering in the resident's room and getting the medications, or the resident having an interaction with other medication the resident was taking. A policy titled Self-Administration of Medications noted Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on interviews and facility policy review, the facility failed to ensure residents received mail on Saturdays. The findings include: On 10/10/24 at 11:31 AM, during a meeting with the resident council members, the surveyor was informed mail is not delivered on Saturdays. On 10/10/24 at 11:35 AM, the Activity Director stated she delivers mail Monday through Friday, which are the days she works. On 10/14/24 at 4:40 PM, during an interview the Administration stated nobody delivers mail Saturdays. A policy titled Resident Rights noted residents in the facility have the right to send and receive mail promptly.

Deficiency Text Not Available

Based on interviews, record review, and facility policy review, it was determined the facility failed to complete timely quarterly assessments for 1 (Resident #215) of 1 sampled resident reviewed for resident assessments. Findings include: A review of the Minimum Data Set's (MDS) for Resident #215 shows an entry MDS was completed on 03/28/24, as the only one completed for resident. Resident #215 is lacking an admission MDS and a Quarterly MDS. A review of an undated facility policy titled, MDS Error Correction did not address the timeliness of MDS's being completed. On 10/10/24 at 4:32 PM, the Administrator (AD) was asked when was the last time the facility had an MDS Coordinator. The AD indicated they had a Registered Nurse (RN) start July 8 and resign July 25. The AD then indicated another RN started on August 27th and worked 3 days and quit. The AD indicated they have a sister facility in Oklahoma and the Licensed Practical Nurse (LPN) MDS Coordinator has been helping complete the MDS's for the facility. The AD indicated they just contracted with an RN that would be doing the MDS's, the RN would not be coming into the facility but would do everything remotely. On 10/14/24 at 4:58 PM, the AD was asked when an admission MDS should be completed. The AD indicated within 3 to 5 days of admission. The AD was asked when a quarterly MDS should be completed. The AD indicated quarterly from date of admission. The AD was asked if Resident #215 should have had an admission MDS completed by this point in time, his admit date being 03/28/24. The AD indicated yes, and it must have been overlooked, because Resident #215 should have had an admission and a quarterly MDS by now.

Based on record review, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly. The findings are: Review of Resident #16's Order Summary Report dated 5/21/2024 noted a stage 3 wound to left big toe: Cleanse with wound cleanser, pat & dry, apply collagen matrix with silver to affected site, cover with dry dressing, complete nursing assessment/ body audit every week on 7 PM-7 AM shift. Review of Resident #16's Quarterly Minimum Data Set (MDS) with an Assessment Reference date of (ARD) of 08/26/2024 noted in Section M0150 that the resident did not have an unhealed pressure ulcer/ injury. Section M1030 noted the resident did not have any venous or arterial ulcers. Review of Resident #16's Skin Only Evaluation dated 08/19/2024 revealed left great toe wound length 0.4 centimeters (cm), width 0.4 cm, 0.1 cm. Skin Only Evaluation dated 10/12/2024 revealed left great toe wound length 1.5 cm, width 1 cm, depth 0.2 cm. There are no other wound evaluations from 08/19/2024 through 10/12/2024. Skin Only Evaluations: 05/22/2024- Diabetic foot ulcer Length: 1 cm Width: 1 cm Depth: 0.1 cm 07/16/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth 0.126 cm 07/23/2024- Diabetic foot ulcer Length: 0.3 cm Width: 0.3 cm Depth: none recorded 07/24/2024- Other skin issue. No measurements- documented left greater toe area already being treated. 07/25/20240 Diabetic foot ulcer Length: 0.3 Width: 0.3 Depth: not recorded 07/31/2024 Skin. Does Resident have current skin issues? No 08/06/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth: 0.1 cm 08/12/2024 Skin. Does Resident have current skin issues? No 08/19/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth: 0.1 cm 10/12/2024- Pressure ulcer/ injury: Length: 1.5 cm Width: 1 cm Depth: 0.2 cm Review of Resident #16's Care plan dated 9/20/2024 noted the resident has potential/actual impairment to skin integrity of the body related to fragile skin. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of injury. During an interview with Licensed Practical Nurse (LPN) #13 on 10/14/2024 at 3:00 PM, she confirmed Resident #16 should have had weekly skin evaluations completed as indicated on the physician's order. During an interview with Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed Resident #16 should have had weekly skin evaluations completed as indicated on the physician's order. During an interview with the Nurse Consultant by telephone on 10/14/2024 at 6:19 PM, he confirmed Resident #16's pressure ulcer was changed from a diabetic ulcer to a pressure ulcer on 10/12/2024 because it was not a diabetic ulcer as documented on 5/22/2024 it is pressure ulcer. The Nurse Consultant confirmed that weekly skin evaluations were not completed for Resident #16 as ordered by the physician.

Based on observation, record review and interview, the facility failed to ensure a Percutaneous Endoscopic Gastrostomy (PEG) tube was properly checked for placement before fluids and medications were administered, and failed to ensure the enteral feeding rate was set per the physician's orders for 1 (Resident #31) sampled resident reviewed for enteral feeding. The findings are: On 10/07/2024 at 10:36 AM, Resident #31 was lying in bed on the right side with a wedge pillow behind the back and the head of bed (hob) was elevated. [Brand name] enteral feeding was hanging, and the feeding pump rate was set at 95 milliliters/hour (ml/hr) and flush set at 50 ml every (q)1 hr. The feeding bottle was labeled with the resident's name, room number, date and the rate indicated 95 ml/hr. There was not a time to indicate when the bottle was hung or the nurse initials who initiated the feeding. Resident #31's Order Summary Report was reviewed and indicated the resident had a diagnosis of difficulty swallowing (dysphagia) and an encounter for attention to a surgical opening in the abdominal wall for a feeding tube (gastrostomy). An enteral feed order dated 09/16/2024 indicated the resident was to receive [brand name] enteral feeding at 90 ml/hr with 50 ml/hr of water. An enteral feed order dated 05/08/2024 indicated the [feeding] tube was to be checked for placement before starting the enteral feeding, medication administration, or flushing the tube. Resident #31's care plan, dated as last reviewed 08/12/2024, was reviewed and indicated the resident required tube feeding. An intervention indicated the PEG tube would be checked for tube placement and gastric contents/residual volume (fluid from the stomach) per the facility's protocol. Another intervention indicated to see the Medical Doctor's orders for the current feeding orders. On 10/08/2024 at 9:15 AM, Resident #31 was lying in bed awake with hob elevated. The enteral feeding bottle was reviewed, and the label was dated 10-8 [10/08/2024] and indicated a rate of 95 ml/hr. The feeding pump rate was set at 95 ml/hr. On 10/10/2024 at 7:53 AM, Resident #31 was lying in bed on the back with hob up. The enteral feeding tube was disconnected from the resident and hanging on the pole. The enteral feeding bottle was reviewed and dated 10-10 [10/10/2024] and the rate indicated 95 ml/hr. The feeding pump was off at this time. On 10/10/2024 at 9:10 AM, Registered Nurse (RN) #6 drew up 5 ml of air into a 60 ml syringe and placed the bell of a stethoscope on Resident #31's stomach and checked the PEG tube placement by pushing the 5 ml of air through the PEG tube. She administered water, medications, and more water through the PEG tube. She connected the enteral feeding tube to the resident's PEG tube and started the feeding pump. On 10/10/2024 at 9:15 AM, RN #6 was interviewed and asked how she was instructed to check the PEG tube for placement. She stated to draw back 5 ml of air, place the stethoscope on the stomach and then listen for a swoosh sound to indicate tube was intact and in the correct spot. She was asked if she received training or education from the facility on how to check the PEG tube for placement. She stated she had not. An Enteral Feedings-Safety Precautions policy, dated as revised May 2014 and provided by the Assistant Director of Nursing on 10/14/2024, was reviewed and indicated to prevent errors in administration to check the rate of administration (ml/hour). The policy indicated to have the following on the formula label: initials, date, and time the formula was hung/administered. The policy indicated to prevent inhaling fluid into the lungs (aspiration), the enteral tube placement should be checked prior to each feeding and administration of medication but it did not specify how.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure Monthly Medication Regimens (MMR) were completed at least monthly for 1 (Resident #8) sampled resident. The findings include: A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/25/2024 revealed on the Brief Interview of Mental Status (BIMS) Resident #8 scored 11, indicating moderate cognitive impairment. Resident #8 was taking high risk medications used to treat depression, anxiety, and fluid retention. A plan of care for Resident #8 (Revision on: 05/28/2024) revealed Resident #8 used antidepressant medication related to depression. On 10/14/24 at 4:40 PM, during an interview the Administrator stated the facility could not provide any documentation to prove MMRs were completed. A policy titled Medication Regimen Reviews noted the Consultant Pharmacy shall review the medication regimen of each resident at least monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, facility document review, facility policy preview, it was determined the facility failed to ensure residents were provided privacy during care provided for surgically created airway (tracheostomy/trach) care for 1 (Resident #13) of 1 sample mix resident; and to ensure collection bags for resident's indwelling catheters are kept in a privacy bag for 1 (Resident #216) of 1 sample mix residents. The findings are: 1. Review of Resident #13's admission Record revealed the resident was admitted on [DATE] with a diagnoses of tracheostomy complication. Review of Resident #13's Physician Orders, dated 4/19/2024, noted suction tracheostomy (trach) as needed (PRN), every shift, trach care once a day on Thursday, change trach ties one time a day every Thursday, trach care every 24 hours (hrs.) and PRN clean trach site with 1/2 normal saline (NS) and 1/2 Peroxide then rinse with NS and apply dry dressing daily and PRN two times a day related to tracheostomy complications. Review of Resident #13's Care Plan dated 5/6/2024 noted the resident has impaired immunity related to tracheostomy in place. On 10/11/2024 at 2:44 PM, the Surveyor observed Licensed Practical Nurse (LPN) #11 perform tracheostomy care for Resident #13. During trach care LPN #13 re-secured inner cannula with tracheostomy ties and told the resident he would be right back he needed to get more gauze. LPN removed gloves and left the room at 2:58 PM. LPN #11 returned to the room at 3:00 PM with more gauze but did not shut the resident's door and proceeded with tracheotomy care. During an interview with LPN #11 on 10/11/2024 at 3:04 PM, confirmed when he exited Resident #13's room to get more gauze, he did not shut the resident's door when he returned and continued trach care. LPN #11 confirmed it is a resident privacy violation to perform care with the door open. During an interview with Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed that Resident #13's door should have been closed throughout trach care and that it is a dignity concern. 2. Resident #216 has a diagnosis of type 2 diabetes mellitus, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and disorder of prostate. During an observation on 10/07/24 at 2:45 PM, Resident #216's catheter collection bag was hanging on the side of the bed, visible from the door, and not in a privacy bag. During an interview on 10/07/24 at 3:00 PM Certified Nursing Assistant (CNA) #17 confirmed Resident #216's catheter collection bag should be in a privacy bag. During an observation on 10/10/24 at 10:50 AM, Resident #216's catheter bag was hanging on the side of the bed, visible from the door, the catheter collection bag was not in a privacy bag. A privacy bag was hanging on the Resident's walker close to the bed, but the catheter collection bag was not in the privacy bag. A review of Resident #216's Care Plan, initiated on 10/04/24, revealed the resident has an indwelling catheter. Intervention included catheter position which includes the catheter bag and tubing below the level of the bladder and away from entrance and door. During an interview on 10/14/24 at 5:00 PM, the Assistant Director of Nursing (ADON) confirmed a resident with a catheter should have a privacy bag. Facility provided a policy titled Resident Rights with a revision date of December 2016 noted Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; t. privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility document review, facility policy review, it was determined that the facility failed to ensure an incident of an injury of unknown source was reported to the Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures, and in reporting to the Office of Long-Term Care (OLTC) and other agencies in accordance with state law for 2 (Resident #50 and #59) of 2 (Residents # 50, and #59) sample mix residents. The findings are: 1. Review of Resident #50's Progress Note revealed, an Incident Note dated 7/13/2024 at 6:11 PM noted the resident was found on floor with cut to forehead, referring to [hospital] for observation. Review of Resident #50's Progress Note revealed an Alert Note dated 7/14/2024 at 5:56 PM that noted [hospital] called regarding resident and stated that x-ray results from 7/13/2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with Ears Nose and Throat (ENT). Review of Resident #50's Order Summary Report with an order date of 7/15/2024 noted regular diet, mechanical soft texture, regular/thin consistency, [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with ENT. Review of Resident #50's Care Plan dated 7/15/2024 noted the resident had an actual fall on 7/13/24 with serious injury fractured jawbone related to (r/t) poor balance, for no apparent acute injury, determine and address causative factors of the fall. During an interview with Resident #50 on 10/10/24 at 10:38 AM, the Surveyor asked Resident #50 about an unwitnessed fall where they ended up with a fractured mandible and the resident stated they fell out of their chair trying to get into bed. During an interview with the Administrator on 10/10/24 at 11:49 AM, the Administrator confirmed she had no reportable completed for Resident #50's unwitnessed fall on 7/13/2024 that resulted in a major injury with a fracture to the resident's mandible. During an interview with the Nurse Consultant on 10/11/24 at 11:00 AM, he confirmed there was no Incident and Accident Report (I&A) for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in major injury. During an interview with the Administrator on 10/11/2024 at 11:03 AM, she confirmed no Incident and Accident report had been completed for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in a major injury. 2. Review of Resident #59's admission Record showed Resident was admitted with a diagnosis of amputation of two or more toes, cognitive communication deficit, constipation, difficulty walking, muscle wasting, type 2 diabetes mellitus, malnutrition, dehydration, chronic ulcer of left heel and midfoot, dementia, and weakness, Review of a Progress Note dated 09/25/24 at 8:16 PM showed This nurse was called to resident's room resident has rolled out of bed onto fall mat face down and face was off mat hitting right side of face on floor resident able to move all extremities. He has blood all over right side of face and head resident cleaned up with wound cleaner approximately a 2 cm (centimeter) long and .3 wide abrasion across right eyebrow. Eyes reactive to light resident kept quenching his eyes c/o (complaining of) head hurting denies all other sites of pain. Doctor notified by message sending resident out to hospital for evaluation, no family to notify. Resident informed medical transport service contacted for transport. On 10/14/24 at 5:00 PM the Administrator (AD) was asked if she had any reportables for the month of September. The AD indicated she did not have any reportables. The AD was asked if she was aware of Resident #59 being sent to the hospital on [DATE] due to resident falling out of bed. The AD did not reply. Review of a facility policy titled Abuse Investigation and Reporting, with a revision date of July 2017, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident, and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/ her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/ her designee, to the following persons or agencies: a. The State licensing/ certification agency responsible for surveying/ licensing the facility; b. The local/ State Ombudsman; c. The Resident's Representative (Sponsor) or Record; d. Adult Protective Services (where state law provides jurisdiction in long term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR had resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/ written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. 4. Notices will include, as appropriate: a. The name of the resident; b. The number of the room in which the resident resides, c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred, e. The name(s) of all persons involved in the alleged incident, and f. What immediate action was taken by the facility. 5. The Administrator, or his/ her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Review of facility policy titled Accidents and Incidents- Investigating and Reporting with a revision date of July 2017 noted Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/ Charge Nurse and/ or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The Nurse Supervisor/ Charge Nurse and/ or department director or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director or Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility document review, and facility policy review, it was determined the facility failed to ensure an incident of an injury of unknown origin was immediately and thoroughly investigated, failed to ensure protective measures were consistently implemented and maintained for 2 (Resident #50, and #59) of 2 sample mix resident investigated. The findings are: Review of Resident #50's Progress Notes revealed an Incident Note dated 7/13/2024 at 6:11 PM that noted the resident was found on floor with cut to forehead, referring to [hospital] for observation. Review of Resident #50's Progress Note revealed an Alert Note dated 7/14/2024 at 5:56 PM that revealed [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with Ears, Nose, and Throat (ENT.) Review of Resident #50's Order Summary Report revealed an order that indicated, regular diet, mechanical soft texture, Regular/Thin consistency Start Date 7/15/2024, [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with ENT. every shift Start Date 7/14/2024. Review of Resident #50's Care Plan, dated 7/15/2024, noted Resident #50 has had an actual fall on 7/13/24 with serious injury (fractured mandible) related to (r/t) poor balance, for no apparent acute injury, determine and address causative factors of the fall. During an interview with Resident #50 on 10/10/24 at 10:38 AM, the Surveyor asked Resident #50 about an unwitnessed fall where they ended up with a fractured jawbone (mandible) and the resident stated they fell out of their chair trying to get into bed. During an interview with the Administrator on 10/10/24 at 11:49 AM, the Administrator confirmed she had no investigation completed for Resident #50's unwitnessed fall on 7/13/2024 that resulted in a major injury with a fracture to the resident's mandible. During an interview with the Nurse Consultant on 10/11/24 at 11:00 AM, he confirmed there was no I&A for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in major injury. During an interview with the Administrator on 10/11/2024 at 11:03 AM, she confirmed no I&A report had been completed for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in a major injury. Review of an admission Record dated 09/10/2024 revealed Resident # 59 was admitted with the following diagnosis: two toes amputated, trouble communicating difficulty in walking, muscle wasting, type 2 diabetes mellitus, malnutrition, dehydration, high blood pressure chronic ulcer of left heel and midfoot, , dementia, and behavioral disturbance, A review of a Progress Note dated 09/25/24 at 8:16 PM showed This nurse was called to resident's room resident has rolled out of bed onto fall mat face down and face was off mat hitting right side of face on floor. Resident able to move all extremities. He has blood all over right side of face and head. Resident cleaned up with wound cleaner approximately a 2 cm (centimeters) long and .3 wide abrasion across right eyebrow and complains of head hurting. [Doctor] notified by message sending resident out the hospital for evaluation, no family to notify. Resident informed emergency transport service contacted for transport. On 10/14/24 at 5:00 PM, the Administrator (AD) was asked if she had any reportable for the month of September. The AD indicated she did not have any reportable. The AD was asked if she was aware of Resident #59 being sent to the hospital on [DATE] due to a fall, the AD did not reply. A facility policy titled Abuse Investigation and Reporting with a revision date of July 2017 read Policy Statement .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/ her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (if medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 3. The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. a. If the ombud declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. A facility policy titled, Accidents and Incidents- Investigating and Reporting, with a revision date of July 2017, noted Policy Statement .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/ Charge Nurse and/ or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The Nurse Supervisor/ Charge Nurse and/ or department director or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director or Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review and interview, it was determined the facility failed to electronically transmit encoded accurate and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 2 (Residents #215, #47) of 2 sampled residents whose MDS assessments were reviewed. The findings are: On [DATE] the following reviews were made in Resident #47's health record: a. Discharge return anticipated MDS date [DATE] that was exported but not accepted. b. Entry MDS dated [DATE] that was exported but not accepted. The discharge return not anticipated MDS dated [DATE] in progress. Resident #47 discharged from the facility on [DATE] to the hospital and expired at the hospital on [DATE]. Review of Resident #47's Progress Note dated [DATE] at 11:14 AM showed, the resident was transferred to the hospital Review of Resident #47's Progress Note dated [DATE] at 9:54 AM showed family called the facility to inform them that Resident #47 had expired at the hospital. During an interview with the Assistant Director of Nursing on [DATE] at 3:07 PM, she confirmed that facility has no MDS Coordinator, and that Resident #47 should have had a discharge return anticipated MDS completed since the resident was to return to the facility from the hospital on [DATE] when the resident was sent to and admitted to the hospital, and the assessment should have been completed and submitted within 14 days. She also confirmed the exported MDS assessments on [DATE] and [DATE] did not show they were accepted by CMS. Facility policy titled MDS Completion and Submission Timeframes with a revision date of [DATE] noted facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' Qua) Quality Improvement Evaluation System (QIES). Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. 3. Submission of MDS records to the QIES ASAP is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of fifteen (15) months form the date submitted. Facility in-service titled Late MDS/ Care plans dated [DATE] noted please see attached POC (Plan of correction) for catching up all late MDS/ Care plans and for follow up. Review of Resident #215's admission Record showed Resident was admitted to facility on [DATE] with a diagnosis of type 2 diabetes mellitus, high blood sugar, deficiency of vitamins, schizophrenia, acute pain due to trauma, chronic ulcer of skin, and break down of skin. A review of an undated facility policy titled, MDS Error Correction, did not address the timeliness of MDS being completed. On [DATE] at 4:32 PM, the Administrator (AD) was asked when was the last time the facility had an MDS Coordinator. The AD indicated they had a Registered Nurse (RN) start [DATE] and resign [DATE]. The AD then indicated they had another RN start on [DATE] and worked 3 days and quit. The AD indicated they have a sister facility in Oklahoma and the Licensed Practical Nurse (LPN) MDS Coordinator has been helping complete the MDS's for the facility. The AD indicated that they just contracted with an RN that would be doing the MDS's remotely, the RN would not be coming into the facility but would do everything remotely.

Based on record review, interview, facility document review, facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly; to accurately assess the quarterly Minimum Data Set (MDS) to reflect to accurate drug class for the medication Risperdal for 1 (Resident #8) or 1 sample mix residents. The findings are: Review of Resident #16's Order Summary Report dated 5/21/2024 noted a stage 3 wound to left big toe: Cleanse with wound cleanser, pat & dry, apply collagen matrix with silver to affected site, cover with dry dressing, complete nursing assessment/ body audit every week on 7 PM-7 AM shift. Review of Resident #16's Quarterly Minimum Data Set (MDS) with an Assessment Reference date of (ARD) of 08/26/2024 noted in Section M0150 the resident did not have an unhealed pressure ulcer/ injury. Section M1030 noted the resident did not have any venous or arterial ulcers. Review of Resident #16's Skin Only Evaluation dated 08/19/2024 revealed left great toe wound length 0.4 cm (centimeter), width 0.4 cm, 0.1 cm. Skin Only Evaluation dated 10/12/2024 revealed left great toe wound length 1.5 cm, width 1 cm, depth 0.2 cm. There are no other wound evaluations from 08/19/2024 through 10/12/2024. Skin Only Evaluations: 05/22/2024- Diabetic foot ulcer Length: 1 cm Width: 1 cm Depth: 0.1 cm 07/16/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth 0.126 cm 07/23/2024- Diabetic foot ulcer Length: 0.3 cm Width: 0.3 cm Depth: none recorded 07/24/2024- Other skin issue No measurements- documented left greater toe area already being treated. 07/25/20240 Diabetic foot ulcer Length: 0.3 Width: 0.3 Depth: not recorded 07/31/2024 Skin. Does Resident have current skin issues? No 08/06/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth: 0.1 cm 08/12/2024 Skin. Does Resident have current skin issues? No 08/19/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth: 0.1 cm 10/12/2024- Pressure ulcer/ injury: Length: 1.5 cm Width: 1 cm Depth: 0.2 cm Review of Resident #16's Care plan dated 9/20/2024 showed the resident has potential/actual impairment to skin integrity of the body related to fragile skin. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of injury. During an interview with Licensed Practical Nurse (LPN) #13 on 10/14/2024 at 3:00 PM, she confirmed Resident #16 should have had weekly skin evaluations completed as indicated on the physician's order. During an interview with Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed Resident #16 should have had weekly skin evaluations completed as indicated on the physician's order. During an interview with the Nurse Consultant by telephone on 10/14/2024 at 6:19 PM, he confirmed Resident #16's pressure ulcer was changed from a diabetic ulcer to a pressure ulcer on 10/12/2024 because it was not a diabetic ulcer as documented on 5/22/2024 it is pressure ulcer. The Nurse Consultant confirmed that weekly skin evaluations were not completed for Resident #16 as ordered by the physician. A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/25/2024 revealed on the Brief Interview of Mental Status (BIMS) Resident #8 scored 11 indicating moderate cognitive impairment. Resident #8 had a diagnosis of Psychotic Disorder (other than schizophrenia). Resident #8 was taking high risk prescribed medications to treat depression, anxiety, and fluid retention A plan of care for Resident #8 (Revision on: 05/28/2024) revealed Resident #8 used anti-anxiety medications Risperdal 0.5 mg tablet related to anxiety disorder. A review of the Order Summary Report Resident #8 had an order for Risperidone 0.5 milligram (MG) related to psychosis. On 10/14/24 at 4:40 PM, during an interview the Director of Nursing stated Risperdal was an antipsychotic, not an antianxiety medication, therefore should be reflected on the care plan or MDS as an antipsychotic.

Based on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed individualized appropriate care and services for 4 (Resident #45, #13, #35, #21) of 4 sample mix residents reviewed for care plan. The findings are: 1. On 10/07/24 at 9:47 AM, the Surveyor observed Resident #45 lying in bed with eyes closed and unshaven with hair on their face. Review of Resident #45's Care Plan dated 5/8/2024 did not note the resident's Activities of Daily Living (ADL) requirements. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/2024 revealed the resident is dependent on staff for shower/bath. Review of Resident #45's shower log from 9/27/2024 through 10/12/2024 revealed the resident received a shower/bath on: 9/27/2024 9/28/2024 10/11/2024 10/12/2024 On 10/10/24 at 11:12 AM, the Surveyor observed Resident #45 lying in bed, remaining unshaven, with hair on their face. 2. On 10/08/24 at 11:04 AM, the Surveyor observed Resident #13 sitting in their wheelchair in dayroom. Resident #13's right arm is flaccid and right hand is contracted with no device present. Review of Resident #13's admission Record with an admission date of 5/4/2024 revealed a diagnosis of paralysis/weakness affecting the right dominant side. Review of Resident #13's Care Plan, dated 5/8/2024, revealed it did not address the resident's flaccid right arm or contracted right hand. Review of Resident #13's Quarterly MDS with an ARD of 8/17/2024 Section GG0115.functional limitation in range of motion impairment on one side of upper extremity. On 10/09/24 at 2:37 PM, the Surveyor observed Resident #13 sitting outside in the smoking area. Resident's right arm is flaccid and right hand is contracted with no device present. On 10/11/24 2:44 PM, the Surveyor observed Resident #13 in their room with Licensed Practical Nurse (LPN) #11. No device or intervention was observed in Resident #13's right hand that is contracted. On 10/11/2024 at 3:03 PM, the surveyor interviewed LPN #11, who confirmed Resident #13's right arm is flaccid and right hand is contracted with no device present. LPN #11 confirmed the resident is not care planned for flaccid right arm or contracted right hand. 3. During an interview with Resident #35 on 10/08/2024 11:14 AM, the resident said, I have issues with my legs. Review of Resident #35's admission Record with a date of 6/8/2022 revealed the resident had a diagnosis of over active muscle activity for a paralyzed person with cerebral palsy. Review of Resident #35's Care plan with an initiation date of 6/3/2024 noted the resident has limited physical mobility related to contractures. Review of Resident #35's annual MDS with an ARD of 8/25/2024 noted in Section GG0115 that the resident has impairment on one side. On 10/9/2024 at 2:24 PM, the Surveyor asked Resident #35 if Certified Nursing Assistant (CNA) #12 could pull back the resident's blanket so the surveyor could see their legs and the resident agreed. CNA #12 pulled back the resident's blanket and surveyor observed resident's legs were not contracted. Both legs were in a locked position straight out. During an interview with CNA #12 on 10/9/2024 at 2:26 PM, the CNA confirmed Resident #35 could not bend either of their legs. During an interview with Resident #35 on 10/10/2024 at 2:43 PM, the resident confirmed not being able to bend their legs and that they stay in a straight position. Facility provided a polity titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 that noted Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/ her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. b. Include an assessment of the resident's strengths and needs. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/ or functional levels. 10 Identify problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plans were revised to reflect the most recent care needs for 3 (Residents #13, #16, and #21) sampled residents whose care plans were reviewed. The findings are: 1. On 10/07/2024 at 10:07 AM, Certified Nursing Assistant (CNA) #9 was observed propelling Resident #21 in the hall using a mechanical lift with no other staff member assisting her. CNA #10 was heard telling CNA #9 the resident had to be in a shower chair and was not supposed to be in the lift. CNA #9 propelled the resident to the resident's room in the lift without assistance of another staff member. CNA #10 entered the room with a shower chair and closed the resident's door. Resident #21's Medical Diagnosis health record was reviewed and indicated the resident had diagnoses of a condition of rigidity of the joint (contracture) of the left hip and a decline (atrophy) in the muscle and decrease in size (wasting) of multiple sites, difficulty in making decisions for everyday life (dementia) and a change in how the brain works (metabolic encephalopathy). An Order Summary Report was reviewed and indicated Glargine insulin 100 units per milliliter (unit/ml) and to inject 20 units under the skin (subcutaneously) at bedtime with an ordered date of 06/16/2024. Risperidone (antipsychotic) 0.5 milligrams (mg) included instructions to take 1 tablet twice a day every other day and was ordered on 02/19/2024. An annual Minimum Data report, with an Assessment Reference Date of 07/20/2024, was reviewed and indicated Resident #21 had a Brief Interview for Mental Status score of 7, which indicated severely cognitively impaired, an impairment in the lower extremity and required substantial/maximal assist with a shower/bath, received insulin injections during the last 7 days or since admission/entry or re-entry and was taking an antipsychotic, high-risk drugs. A care plan, dated as reviewed 07/29/2024, was reviewed and had no indication of how Resident #21 was to be transferred, how many staff were required to assist with the transfer, or the resident was taking insulin and antipsychotic high-risk medications. On 10/14/2024 at 1:34 PM, CNA #9 was interviewed and stated she didn't know much about the resident's care needs and started working at the facility on 09/21/2024. She stated the resident could not walk or propel self in the wheelchair. She stated staff used a lift to get the resident from the bed to the shower chair for showers and baths. She stated she did not know the mechanical lift required two people when she used the mechanical lift Monday, 10/07/2024, to transport the resident. 2. Resident #13's Order Summary Report was reviewed and indicated the resident had diagnoses of a disease affecting the body's blood sugar level (diabetes mellitus type 2) and high blood pressure (hypertension). The order summary report indicted the following orders: a. Apixaban 5 mg, take 1 tablet by mouth twice a day and it was ordered on 01/29/2024. b. Furosemide 40 mg, take 1 tablet by mouth twice a day and it was ordered on 01/29/2024; c. Tresiba 100 UNIT/ML, inject 15 units under the skin (SQ) at bedtime every night and it was ordered on 07/24/2024. The quarterly Minimum Data Set with an ARD of 08/17/2024 indicated Resident #13 had a Brief Interview for Mental Status score of 4, which indicated the resident was severely cognitively impaired, was taking an anticoagulant, a diuretic, and the box to indicate the days the resident received insulin injections was blank. Review of Resident #13's care plan, dated as last revised 07/29/2024, was reviewed and did not address the resident's use of an anticoagulant, insulin or address the signs and symptoms to monitor for the use of a diuretic. 3. Review of Resident #16's admission Record revealed the resident was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, and an unstageable pressure ulcer. Review of Resident #16's Skin Only Evaluation dated 05/22/2024, 7/16/2024, 7/23/2024, 7/24/2024, 7/25/2024, 7/31/2024, 8/6/2024, and 8/19/2024 revealed Resident #13 had a diabetic foot ulcer. Review of Resident #16's Progress notes dated 8/19/2024 revealed a late entry skin issue that noted the resident with a diabetic foot ulcer to the left great toe. Review of Resident #16's Care plan dated 9/20/2024 noted the Resident had potential/actual impairment to skin integrity of the body related to fragile skin. Follow facility protocols for treatment of injury. The care plan was not revised to note current pressure wound and interventions. During an interview with the Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed Resident #16 has had a left great toe wound since 5/22/2024 and that the care plan should have been revised to reflect current wound and interventions. Facility provided a policy titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 that noted Policy Interpretation and Implementation13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition.

Based on observation, interview, record review, facility document review, facility policy review, the facility failed to ensure female residents had hair removed from their face for 1 (Resident #35) of 1 sample mix resident to promote good hygiene; ensure male residents had been kept clean shaved for 1 (Resident #45) of 1 sample mix residents to promote good grooming; and to ensure that 1 (Resident #32) of 1 sample mix residents received regular scheduled baths and/or showers . The findings are: 1. On 10/7/24 at 12:30 PM, the Surveyor observed Resident #35 sitting in a wheelchair in dining room. The resident observed to have hair on their chin. Review of Resident #35's admission Record with an admission date of 6/8/2022 noted the resident has diagnoses of a paralyzed person with cerebral palsy and high pressure in the eyes (Primary angle glaucoma bilateral.) Review of Resident #35's Care plan, initiated date of 6/3/2024, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to (r/t) confusion. Bathing/ showering: Provide sponge bath when a full bath or shower cannot be tolerated. Review of Resident #35's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 08 (08-12 indicates moderately impaired) and is dependent for personal hygiene that includes shaving. Review of Resident #35's tub/shower transfer log for the past thirty (30) days documents from 9/17/2024 through 10/12/2024 and revealed the resident was bathed on 9/27/2024, 10/10/2024, 10/11/2024; 10/12/2024. On 10/7/24 at 2:12 PM, the Surveyor observed Resident #35 in their room in bed with hair still present on chin. Resident #35 confirmed wanting hair removed from their chin. On 10/8/2024 at 9:03 AM, the Surveyor observed Resident #35 in the day room near the nurses' station with hair still present on chin. On 10/9/2024 at 10:23 AM, the Surveyor observed Resident #35 being wheeled to the cafeteria by a staff member with hair visible on Resident's chin. 2. On 10/07/24 at 9:47 AM, the Surveyor observed Resident #45 lying in bed with facial hair that appears to be unshaved. Review of Resident #45's Care Plan with an initiate date of 6/4/2024 does not reveal the Resident is care planned for ADL care. Review of Resident #45's quarterly MDS with an ARD of 07/24/2024 revealed the resident has a Staff Assessment for Mental Status (SAMS) score of 3 (indicates moderately impaired) and is dependent for hygiene that included shaving. Review of Resident #45's shower log for the past thirty (30) days showed from 9/27/2024 through 10/12/2024 the resident received a shower/ bath on 9/27/2024, 9/28/2024, 10/11/2024, 10/12/2024. On 10/10/2024 11:12 AM, the Surveyor observed Resident #45 lying in bed with facial hair that appears to be unshaved. During an interview with Certified Nursing Assistant (CNA) #12 on 10/14/2024 at 2:56 PM, she confirmed both Resident #35 and Resident #45 have hair on their face that needs removing and it's good hygiene and dignity to shave the residents. During an interview with the Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed both Resident #35 and Resident #45 have hair on their face that needs removing and that both residents have not been showered/ bathed as scheduled. She also confirmed that is part of good hygiene to shave the residents. Facility policy titled Shaving the Resident with a revision date of 6/1/2012 noted Purpose the purpose of this procedure is to promote cleanliness and to provide skin care. Reporting 1. Notify the supervisor if the resident refuses the procedure. A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/3/2024 revealed Resident #32 had memory problems, severely impaired cognition, never or rarely made decisions. Resident #32 had diagnoses of bacteremia ( bacteria in the bloodstream), cough, and wound infection. A plan of care for Resident #32 (revision on: 05/29/2024) revealed Resident #32 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) cognitive deficits. On 10/09/2024 at 3:40 PM, the Surveyor was provided with the Bath Schedule for 7-3 shift and 3-11 shift which revealed Resident #32 received a bath Monday, Wednesday, and Friday. On 10/10/24 at 3:17 PM, A review of Skin Monitoring: Comprehensive CNA Shower Review for the months of September and October revealed Resident #32 had a bed bath on 09/18/2024, 9/19/2024, 09/27/2024 and 10/07/2024 and a wash up by hospice on 09/23/2024 and 09/25/2024. On 10/10/2024 at 4:40 PM, the Administrator stated if Resident #32 only received 6 baths in the past two months that likely means Resident #32 has not been getting baths/showers. The Administrator stated it was the facility's responsibility to take care of their residents and Resident #32 cannot refuse a bath/shower because the resident does not talk.

Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure residents who have physician orders for weekly skin evaluations had their skin evaluated for 4 (Resident #13, #35, #63, #366) of 4 sample mix residents with orders for weekly skin evaluations; and to ensure residents with a contracture had a treatment in place to prevent further decline in accordance with professional standards of practice for 1 (Resident #13) of 1 sample mix residents. The finding are: 1. On 10/8/2024 at 11:03 AM, the surveyor observed a dressing on Resident #13's right lower leg. Resident #13 told the surveyor it was covering an open spot. Review of Resident #13's Order Summary Report dated 5/20/2024 noted weekly nursing assessment and body audit on Wednesdays, right lower leg swelling with small cluster of blisters: cleanse with wound cleanser, pat & dry, paint with betadine, apply abdominal (ABD) pads and wrap with gauze one time a day every Monday, Wednesday, Friday for wound care and every 24 hours as needed for wound care. On 10/9/2024 at 10:36 AM, skin assessments section Skin Only Evaluation reviewed and revealed skin assessments conducted on: 5/30/2024 6/7/2024 7/8/2024 7/15/2024 7/18/2024 7/22/2024 7/25/2024 7/30/2024 10/8/2024 Review of Resident #13's Care Plan, dated 7/26/2024, noted staff were to monitor/ document location, size and treatment of skin injury and to report abnormalities, failure to heal, signs and symptoms of infection, or maceration to the physician. Weekly treatment documentation is to include measurement of each area of skin breakdown's width, depth, type of tissue and drainage and any other notable changes. Review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/2024 documented Resident #13 was not at risk of pressure ulcer/ injuries and that there were no unhealed pressure ulcers/ injuries. The MDS showed the resident had no other ulcers, wounds, or skin problems. 2. Review of Resident #35's Order Summary, dated 5/21/2024, noted weekly nursing assessment and body audit one time a day. Review of Resident #35's Skin assessments section Skin Only Evaluation reviewed and revealed skin assessments conducted on: 6/5/2024 7/7/2024 7/16/2024 7/16/2024 7/25/2024 3. Review of Resident #63's Order Summary Report, dated 5/20/2024, noted complete nursing assessment/ body audit every week on 7 PM-7 AM. Review of Resident #63's Skin assessments section Skin Only Evaluation reviewed and revealed skin assessments conducted on: 7/2/2024 7/2/2024 7/9/2024 4. Review of Resident #366's Order Summary Report dated 7/24/2023 noted weekly summary and body audit once a week on Saturday, 7 AM to 3 PM shift. Review of Resident #366's Skin assessments section Skin Only Evaluation reviewed and revealed skin assessments conducted on: 7/6/2024 7/13/2024 7/20/2024 7/27/2024 5. On 10/8/2024 at 11:04 AM, the Surveyor observed Resident #13's right arm to be flaccid and right hand is contracted with no device present. Review of Resident #13's admission Record revealed a diagnosis of hemiplegia affecting right dominant side. Review of Resident #13's Care Plan dated 5/9/2024 does not have the resident care planned for a flaccid arm or contracted right hand. Review of Resident #13's Quarterly MDS with an ARD of 8/17/2024 noted in section GG0115.functional limitation in range of motion impairment on one side of upper extremity. On 10/9/2024 at 2:37 PM, the Surveyor observed Resident #13 sitting outside in the smoking area. Resident #13's right hand was contracted with no device present. On 10/11/24 at 2:44 PM, the Surveyor observed Resident #13 in room with LPN #11 who was getting ready to perform tracheostomy care and the surveyor observed no device in resident #13's right hand that appears contracted. During an interview with Certified Nursing Assistant (CNA) #12 on 10/14/2024 at 2:56 PM, she confirmed Resident #13 has a right-hand contracture and no device has been present in the right hand. During an interview with Licensed Practical Nurse (LPN) #11 n 10/11/2024 at 3:03 PM, he confirmed Resident #13's right arm is flaccid (complete lack of voluntary movement in a limb) and right hand is contracted with no device present. LPN #11 confirmed the resident is not care planned for flaccid right arm or contracted right hand. A facility policy titled Treatment of Contractures indicated, Elders of this facility will be provided care to prevent formation of progression of contractures and deformities. Contractures are joint deformities caused by immobility. Contractures develop rapidly and are difficult or impossible to reverse without surgery. When muscles are week, contractures place the muscles in a position of mechanical disadvantage and weakness and muscle wasting from lack of use leads to atrophy. Procedure: Contracture treatment: Restorative staff, nursing staff and therapy staff will work closely to prevent the progression of contractures. Contractures treatment will include slow, gentle stretching and massage. Range of Motion (ROM) exercises will be provided following the facility's Range of Motion Exercise Policy and Procedure. Contracture plans will be developed and supervised by a skilled therapy and the Restorative Nurse Coordinator. Restorative nursing staff will report any changes in ROM to the Restorative Nurse Coordinator immediately for further assessment and revision to the restorative care plan. Use of handrolls to prevent hand/ finger contractures: Handrolls should be considered part of routine care of all dependent elders. May be applied based on nursing assessment and nursing judgement orders and no physician order is required unless elder has severe deformities/ contractures of hand(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure a mechanical lift was properly used to for 1 (Resident #21) sampled resident reviewed for mechanical lift transfer, and failed to ensure residents were assessed to smoke during the facility designate smoke break times for 1 (Resident #13) of 1 sample mix resident reviewed for smoking. The findings are: 1. Resident #21's Medical Diagnosis health record was reviewed, which indicated the resident had diagnoses of a condition of rigidity of the joint (contracture) of the left hip and a decline (atrophy) in the muscle and decrease in size (wasting) of multiple sites. An annual Minimum Data report, with an Assessment Reference Date of 07/20/2024, was reviewed and indicated Resident #21 had a Brief Interview for Mental Status score 7, which indicated severely cognitively impaired and an impairment in the lower extremity and required substantial/maximal assist with a shower/bath. A care plan, dated as reviewed 07/29/2024, was reviewed and had no indication of how Resident #21 was to be transferred or how many staff were required to assist with the transfer. On 10/07/2024 at 10:07 AM, Certified Nursing Assistant (CNA) #9 was observed propelling Resident #21 in the hall using a mechanical lift with no other staff member assisting her. CNA #10 was heard telling CNA #9 the resident had to be in a shower chair and was not supposed to be in the lift. CNA #9 propelled the resident to the resident's room without assistance of another staff member. CNA #10 entered the room with a shower chair and closed the resident's door. On 10/14/2024 at 1:34 PM, CNA #9 was interviewed and stated she didn't know much about the resident's care needs, and had started working at the facility on 09/21/2024. She stated the resident could not walk or propel self in the wheelchair. She stated staff used a lift to get the resident from the bed to the shower chair for showers and baths. She stated she did not know the mechanical lift required two people when she used the mechanical lift Monday, 10/07/2024, to transport the resident. She stated resident safety was an important reason to have the right amount of staff for transferring residents using the mechanical lift. She stated a CNA walked her through using the mechanical lift regarding the education she received on how to transfer residents. A Safe Lifting and Movement of Residents policy, dated as revised July 2017 and provided by the Assistant Director of Nursing (ADON)on 10/14/2024, was reviewed and indicated the facility uses appropriate techniques and devices to lift and move residents to protect the safety and well-being of staff and resident and to promote quality of care. The policy indicated the residents' individual needs for transfer assistance would be assessed and staff would document resident transferring and lifting needs in the care plan. The owner's manual for the [brand name] lift, with no date, and provided by the ADON on 10/14/2024, was reviewed. The manual indicated on page 5 the lift should be used solely for transferring a user/patient from one utility (beds, bathtubs, toilets, etc. [etcetera]) to another. The patient lift should not be used for transporting or moving any patient from one location to another location. 2. Review of Resident #13's admission Record revealed the resident was admitted on [DATE] with a diagnosis of cognitive communication deficit, chronic respiratory failure with low oxygen, paralysis/ weakness affecting right dominant side, chronic obstructive pulmonary disease (COPD), and surgically created airway/tracheostomy complication. A review of quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/2024 revealed a score of 4 (indicates severe cognitive impairment) on the Brief Interview for Mental Status (MDS). On 10/08/2024 at 10:08 AM, the Surveyor observed a smoke break where Resident #13 was present and smoking with no smoking apron. One staff member was present supervising the smoke break, CNA #18, who was asked if all residents were assessed for smoking, and she said yes. Review of Resident #13's Assessments did not reveal the resident was assessed for smoking. Review of Resident #13's Care Plan revealed the resident is a smoker, had a goal stating the resident will not suffer injury from unsafe smoking, and direction for staff to instruct the resident about the facility's smoking policy and safety concerns, and observe clothing and skin for signs of cigarette burns. During an interview with Resident #13 on 10/08/2024 at 11:05 AM, Resident #13 revealed they do not wear a smoking apron while smoking. On 10/09/2024 at 10:13 AM, the Surveyor observed Resident #13 outside smoking during smoke break. Resident does not have on a smoking apron. During an interview with Licensed Practical Nurse (LPN) #13 on 10/14/2024 at 3:00 PM, she confirmed residents should be assessed prior to being able to smoke to ensure residents safety and confirmed Resident #13 has no smoking assessment. During an interview with, the Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed residents should be assessed prior to being able to smoke to ensure residents safety and confirmed Resident #13 has no smoking assessment. A facility policy titled Smoking Policy- Residents with a revision date of 2017 noted Policy Statement This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (standard cigarettes; electronic cigarettes, pipe, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. The resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.

Based on observation, interviews, record reviews, and facility policy reviews the facility failed to ensure incontinence care was provided in a clean and sanitary manner to promote cleanliness for 2 (Resident #32 and #33) sampled residents. The findings include: 1. A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/01/2024 revealed Resident #33's Brief Interview of Mental Status (BIMS) score was 14, indicating the resident was cognitively intact. Resident #33 was occasional incontinent of bowel and bladder. a. A plan of care (Revision on: 06/10/2024) revealed Resident #33 had episodes of occasional incontinence related to (r/t) impaired mobility. b. On 10/03/2024 at 9:30 AM, the Surveyor observed Certified Nursing Assistant CNA #14 improperly cleaning Resident #33 genital area by wiping in a back-and-forth motion with one wipe, a practice that can spread germs and cause urinary tract infections. c. On 10/03/2024 at 9:40 AM, the Surveyor asked CNA #14 if they were trained to wipe more than once with one wipe without folding. CNA #14 stated no ma'am. 2. A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/3/2024 revealed Resident #32 had memory problems, severely impaired cognition, never or rarely made decisions. Resident #32 had diagnoses of bacteremia, cough unspecified, and wound infection. a. A plan of care for Resident #32 (revision on: 05/29/2024) revealed Resident #32 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) cognitive deficits. b. On 10/07/2024 at 1:03 PM, the Surveyor noted Resident #32 was lying in the bed with a wet ring around the buttock area. c. On 10/08/2024 at 2:30 PM, Surveyor observed CNA #15 provide incontinence care to Resident #32. CNA #15 improperly cleaned the resident by not cleaning all of the genital area which had been exposed to urine and potentially feces. Resident #32 was incontinent of urine during care and CNA #15 did not clean the resident a second time. d. On 10/08/2024 at 2:50 PM, CNA #15 stated she did not clean all of the genital area because it was too hard due to the Resident's contracture. CNA #15 stated she did not clean Resident #32 after the incontinence episode during care. e. On 10/10/2024 at 4:40 PM, the Administrator stated if the sheet under the resident's buttock was wet, that indicated lack of care, staff not doing rounds every 2 hours, and/or we do not care about our residents. The Administrator stated when providing incontinence care the entire genital area should be cleaned to prevent Urinary Tract Infection (UTI), yeast infections, poor wound healing. f. A policy titled Perineal Care Protocol noted perineal care would be provided every shift as needed based on the individual needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure surgically created airway/ tracheostomy care was provided as physician ordered to prevent possible respiratory infections for 1 (Resident #13) of 1 residents with a tracheostomy; to ensure respiratory supplies were properly stored and readily available for 2 (Resident #13, #32) for 2 sample mix residents. The findings are: On 10/08/2024 at 11:07 AM, the Surveyor observed gauze around Resident #13's tracheostomy to be light brown in color with what appears to be dried blood. During an interviewer with Resident #13 the resident confirmed the gauze hasn't been changed and when asked how often they change it she said sometimes. Review of Resident #13's admission Record revealed the resident was admitted on [DATE] with a diagnoses of Tracheostomy complication. Review of Resident #13's Order Summary Report with an order date of 4/19/2024 noted tracheostomy (trach) care every 24 hours and as needed (PRN), clean trach site with half normal saline (NS) and half peroxide then rinse with NS and apply dry dressing daily and PRN two times a day related to tracheostomy complications. Review of Resident #13's Care Plan with an initiated date of 5/6/2024 noted the resident has impaired immunity related to (r/t) trach in place, use universal precautions as appropriate, the resident has a tracheostomy r/t impaired breathing mechanics, tube out procedures: Keep extra trach tube and tube inserted into trachea (obturator, a device used to insert a tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy tube as it is being inserted) at bedside. Review of Resident #13's Treatment Administration Record (TAR) with a start date of 5/20/2024 noted trach care two times a day at 8:00 AM and 8:00 PM. Resident had trach care performed on 10/2/2024 at 8:00 PM, 10/3/2024 at 8:00 PM, 10/4/2024 at 8:00 AM, 10/7/2024 at 8:00 AM resident refused, 10/7/2024 at 8:00 PM. Physician order was changed to reflect trach care every day shift starting on 10/10/2024. Resident did not receive trach care until 10/13/2024. Review of facility procedure titled Performing Tracheostomy Care Using Sterile Technique noted Step by Step perform hand hygiene and put on appropriate PPE as indicated; auscultate lung sounds and assess respiratory rate. Assess pain level and need for pain medication; place a liquid-absorbing towel across the client's chest to help prevent bacteria and other organisms form transmitting onto the clients linen; Hyper-oxygenate the client using 100% oxygen for at least 30 seconds or by having the client take five or six deep breaths. On 10/11/2024 at 2:44 PM, the Surveyor observed Resident #13's tracheostomy care performed by Licensed Practical Nurse (LPN) #11. The surveyor entered Resident #13's room and LPN #11 had already donned surgical gloves prior to surveyor entering. The surveyor did not observe an obturator at the bedside. LPN #11 closed the Resident's door with his surgical gloves on and did not change them. Surveyor observed LPN #11 removing items from the trach kit and placing the items on the sterile field on the overbed table without sanitizing the table first. LPN #11 placed sterile gloves, cotton tipped swab, fenestrated gauze, neck ties, pipettes, bristled brush and 0.9% sodium chloride irrigation containers on sterile field. LPN #11 poured fluid in the tracheostomy supply tray. LPN #11 attempted to remove the obturator from the resident's tracheostomy but appeared to have a hard time getting it removed. LPN was able to remove obturator and placed it in 0.9% sodium chloride solution and used bristled brush to clean for approximately two (2) minutes. The obturator was observed full of green/ brown mucus. While holding the obturator the LPN opened another container of 0.9% Sodium Chloride solution and poured it into another tray within the tracheostomy tray kit. LPN #11 changed his surgical gloves, did not sanitized hands. LPN #11 placed obturator on sterile field. LPN #11 removed old fenestrated gauze. Trach site appears to have dried blood, area is red. LPN #11 cleansed trach site with 0.9% sodium chloride solution on gauze. LPN #11 unhooked trach ties and cleansed around trach are removing copious amounts of brown/ green mucus. Resident #13 refused to have trach ties changed. Resident #13 began coughing up mucus. LPN #11 re-secured inner cannula with tracheostomy ties and told the resident he would be right back he needed to get more gauze. LPN #11 removed gloves and left the room at 2:58 PM with obturator left on sterile field. LPN #11 returned to the room at 3:00 PM with more gauze but did not shut the Resident's door. LPN #11 did not sanitize hands before donning surgical gloves. LPN #11 recleaned trach area with gauze and recleaned obturator with bristled brush. LPN #11 replaced fenestrated gauze with new fenestrated gauze, placed obturator with visible mucus still on it back in Resident's tracheostomy site. LPN #11 did not put on personal protective equipment (PPE) while performing tracheostomy care. During an interview with LPN #11 on 10/11/2024 at 3:04 PM, he confirmed he should have worn sterile gloves while performing tracheostomy care because it is a sterile procedure, that he should have worn PPE and that he should've sanitized his hands before putting on and changing gloves for infection control purpose. LPN #13 was unable to answer when the Surveyor asked where the spare obturator was located. Resident #13 pulled it out of the dresser drawer. LPN #11 said the extra respiratory supplies should be stored in the medication room. During an interview with the Nurse Consultant n 10/11/2024 at 3:11 PM, he confirmed LPN #11 should have sanitized his hands, sanitized bedside table prior to sterile field being placed on it, worn sterile gloves while performing trach care, should have worn PPE during trach care, and replaced obturator with a new one for infection control purposes. The Nurse Consultant confirmed the spare obturator should be kept at the head of Resident #13's bed not in the medication room. The Nurse Consultant also confirmed tracheostomy care has not been performed as ordered according to Resident #13's TAR. During an interview with the Assistant Director of Nursing (ADON)on 10/14/2024 at 3:07 PM, she confirmed LPN #11 should have sanitized his hands, sanitized bedside table prior to sterile field being placed on it, worn sterile gloves while performing trach care, should have worn PPE during trach care, and replaced obturator with a new one for infection control purposes. The ADON confirmed the spare obturator should be kept at the head of Resident #13's bed not in the medication room. The ADON also confirmed tracheostomy care has not been performed as ordered according to Resident #13's TAR. A facility policy titled Tracheostomy Care noted, Policy This facility will minimize risks of infection and other complications associated with tracheostomy care at all times. Clean technique, using sterile supplies will be used for care of non-established and established tracheostomies. Procedure Non-Established & Established Tracheostomy Stoma: Stoma care is provided every 24 hours or as needed; if elder is immunocompromised or with acute infective illness, sterile techniques will be utilized; tracheostomy stoma will be cleansed with sterile normal saline. Tracheostomy Tube Changes tracheostomy tubes with inner cannula will be changed every thirty (30) days and as needed; Supplies for tracheostomy care and emergent tracheostomy tube replacement/ change must be available at the bedside or in a readily accessible location at all times. Stoma Care using sterile cotton-tipped applicators, gauze and sodium chloride clean the tracheostomy stoma starting at the stoma site under faceplate extending 5-10 centimeters (cm) in all directions from the stoma; using dry gauze or dry cotton tipped applicators, pat lightly at skin and exposed outer cannula surfaces.

Based on interviews and facility policy review the facility failed to ensure the facility had full-time Director of Nursing (DON) coverage. The findings include: On 10/08/2024 at 3:35 PM, the Surveyor was provided a calendar for the months of July, August, September, and October. The Surveyor noted there was not a DON employed, nor an interim filling in for role of DON, at the facility from August 10, 2024-August 18, 2024. On 10/14/2024 at 1:00 PM, the Surveyor was provided check stubs of the Director of Nursing's which did not reflect fulltime hours consistently during a two-week timeframe. On 10/14/2024 at 4:40 PM, the Administrator stated sometimes we had DON coverage sometimes we did not. A policy titled Staffing noted the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the facility assessment.

Based on observations, interviews, and facility policy review, the facility failed to ensure daily staffing was posted visible for resident and visitor with all the required components. The findings include: On 10/10/2024 at 9:00 AM, the Surveyor noted there was no posting of the daily staffing and resident census visible for visitors and residents to see. The Surveyor noted on previous sign in sheet there was no tally of actual hours worked per shift for direct care staff. On 10/10/2024 at 2:00 PM, Licensed Practical Nurse #7 the facility's Staff Coordinator stated she did not know it was required to have a visible posting which included the facility name, date, census, nursing staff responsible for director care, and a tally of actual hours worked per shift. On 10/14/2024 at 04:40 PM, the Administrator stated there was not a daily posting for staffing which included all the required components. A policy titled Posting Direct Care Daily Staffing Numbers noted the facility would post daily for each shift the number of nursing personnel responsible for providing direct care to residents. The Information on the form shall include the facility name, date, census, category of licensed and unlicensed staff working each shift, and actual time worked that shift for each category.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to accurately account for a controlled medication after administration for 1 (Resident #50) resident who was reviewed for pharmaceutical services and failed to ensure pharmaceuticals available for the residents during medication administration were dispensed with the accurate dosage for 1 (Resident #63) sampled resident reviewed for medication dosages. The findings are: Resident #50's Order Summary Report was reviewed and indicated the resident had a diagnosis of a disorder associated with mood swings from depressive lows to manic highs (bipolar). Clonazepam 0.5 milligram (mg) was ordered 08/31/2024 to give 1 tablet by mouth every 8 hours as needed for anxiety. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/2024 was reviewed and indicated Resident #50 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated moderately cognitively impaired and was taking antipsychotic medications. Review of a care plan, dated as last reviewed 06/19/2024, showed Resident #50 used psychotropic medications and to monitor/ document any adverse reactions such as frequent falls loss of appetite or behavior symptoms not usual to the person. The September 2024 electronic Medication Administration Record (eMAR) was reviewed and indicated a dose of Clonazepam 0.5 mg was administered on the 7th at 2144 (9:44 PM) and on the 8th at 0057 AM (12:57 AM) and the follow-up code, E, was documented with each dose and indicated the medication was effective. The narcotic log for the secured unit was reviewed and on page 38, indicated Clonazepam 1 mg was ordered to be taken three times a day. On 09/07/2024 at 220 (10:00 PM) a dose was documented as wasted due to an order change and there was only one signature on the line. On page 45 of the narcotic log, Clonazepam 0.5 mg was ordered every 8 hours as needed and the page was started on 10/05/2024. The page did not indicate if the order was moved from another page. The balance remaining was 60 tablets, and no medication had been signed out on this page. On 10/14/2024 at 6:30 PM, Licensed Practical Nurse (LPN) #7 was interviewed with concurrent observations. She was asked to show this surveyor the prior page of Clonazepam 0.5 mg for September 2024 which reflected the September eMAR. LPN #7 after reviewing all the folded pages for Clonazepam 0.5 mg, she stated she did not see another page for Clonazepam 0.5 mg, only Clonazepam 1 mg tablets. She stated the process of signing out controlled substances was the nurse signs the medication out when punched out of the medication cart. She stated if an error/discrepancy was identified in the controlled substance log, the nurses were instructed to call the Director of Nursing and Administrator. On 10/14/2024, this surveyor informed the ADON and Administrator of a discrepancy for Resident #50's Clonazepam 0.5 mg documentation for September 2024. Review of Resident #63's admission Record revealed the resident was admitted on [DATE] with a diagnosis of Essential Hypertension. Review of Resident #63's Care Plan with an initiation date of 5/9/2024 noted the resident has high blood pressure issues and prescribed Nifedipine extended release (ER) 60 milligrams (mg). Review of Resident #63's Order Summary Report noted Nifedipine Tab ER 24 hour (HR) 60 mg give 1 tablet orally two times a day related (r/t) to high blood pressure with a start date of 5/20/2024. Review of Resident 63's Medication Administration Record (MAR) for May 2024, June 2024, and July 2024 noted the resident was prescribed Nifedipine tab ER 24 HR 60 MG give 1 tablet orally two times a day related to Essential Hypertension with a start date of 5/20/2024 at 8:00 AM. Review of Resident #63's [Pharmacy] prescription order summary dated 10/11/2024 revealed Nifedipine ER 90 MG was dispensed to the facility on 7/17/2023 quantity (QTY) 60; 12/22/2023 QTY 60; 1/25/2024 QTY 60; 2/27/2024 QTY 62; 3/25/2024 QTY 60; 4/25/2024 QTY 62; 5/22/2024 QTY 60; 6/20/2024 QTY 62; 6/21/2024 QTY 60; 9/13/2024 QTY 60. During an interview with the Nurse Consultant on 10/11/2024 at 2:55 PM, he confirmed that Resident #63 did not receive the physician ordered dose of Nifedipine ER 60 mg two times a day for hypertension, however the resident was ordered and received Nifedipine ER 90 mg two times a day from 5/20/2025 through Resident #63's discharge on [DATE]. During an interview with the Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed Resident #63 did not have their correct dosage of Nifedipine ordered from the pharmacy from 5/9/2024 through discharge on [DATE] and that the resident continued to receive 90 milligrams versus the ordered 60 milligrams and that the pharmacy should have been notified immediately about the change. Facility policy titled Pharmacy Services Overview with a revision date of April 2007 noted Policy Interpretation and Implementation f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescribers. Facility policy titled Medication and Treatment Orders with a revision date of July 2016 noted Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 9. Orders for medications must include: a. Name and strength of the drug.

Based on record review and interview, the facility failed to ensure a pharmacist recommendations for psychotropic medications were addressed for 3 (Residents #8, #50 and #57) sampled residents reviewed for medication regimen review recommendations. The findings are: 1. Resident #50's Order Summary Report was reviewed and indicated the resident had a diagnosis of a disorder associated with mood swings from depressive lows to manic highs (bipolar). Trazodone (psychotropic medication) 50 milligrams (mg) take one tablet by mouth at bedtime was ordered on 01/30/2024. The order summary report indicated the resident should be observed closely for side effects of antipsychotic medications including disorientation and increased agitation. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/2024 was reviewed and indicated Resident #50 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated moderately cognitively impaired, and the resident was taking antipsychotic medications. A Care Plan, dated as last reviewed 06/19/2024, was reviewed and indicated Resident #50 used psychotropic medications and to monitor/document any adverse reactions such as frequent falls loss of appetite or behavior symptoms not usual to the person. A pharmacy medication regimen review (MRR) form, dated 08/17/2024, was reviewed and indicated the resident had been taking Trazodone since 01/2024 and to evaluate the current dose and consider a dose reduction. As of 10/08/2024, the recommendation had not been addressed by the physician. 2. Resident #57's Order Summary Report was reviewed and indicated the resident had a diagnosis of a type of disorder affecting a person's movements, ability to communicate, think, feel and behave clearly (catatonic schizophrenia). Resident #57's admission Minimum Data Set, with an Assessment Reference Date of 08/21/2024, was reviewed and indicated the resident had a Staff Assessment for Mental Status score of 3, which indicated severely cognitively impaired and received antipsychotic medication. Haloperidol (antipsychotic) solution inject 5 mg/ml intramuscularly every 8 hours as needed (PRN) for agitation was ordered 09/06/2024. A pharmacy MRR form dated 09/12/2024, was reviewed and indicated a PRN psychotropic order needed a 14 day stop day and the physician would need to re-evaluate the need for Haloperidol. The recommendation indicated a duration greater than 14 days would need a physician rationale. As of 10/08/2024, the recommendation had not been addressed. A Tapering Medications and Gradual Drug Dose Reduction policy, dated as revised April 2007 and provided by the Assistant Director of Nursing (ADON), was reviewed and indicated after medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. The policy indicated residents who use antipsychotic drugs shall receive gradual dose reductions, unless clinically contraindicated, to discontinue the use of such drugs. 3. A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/25/2024 revealed on the Brief Interview of Mental Status (BIMS) Resident #8 scored 11 indicating moderate cognitive impairment. Resident #8 had a diagnosis of Psychotic Disorder (other than schizophrenia). A plan of care for Resident #8 (Revision on: 05/30/2024) revealed Resident #8 was at low risk for falls related to psychoactive drug use. A review of the Order Summary Report Resident #8 had an order for Risperidone 0.5 milligram (MG) related to psychosis. An unaddressed Consolidated Report to DON (Director of Nursing) and Medical Director dated 7/28/2024 noted Resident #8 has been taking risperidone O, mirtazapine 7.5 mg, and duloxetine 30 mg since 12/2023. Please evaluate the current dose and consider a dose reduction. An unaddressed Recommendations Pending Response dated 8/18/2024 noted Resident #8 has been taking risperidone 0.5 mg, mirtazapine 7.5 mg, and duloxetine 30 mg since 12/2O23. Please evaluate the current dose and consider a dose reduction. On 10/14/24 at 4:40 PM, during an interview the Administrator stated the Medical Director did not provide a rationale or reason as to why he was not going to attempt the (GDR) with the medication. The Administrator stated the Gradual Dose Reduction (GDR) suggestion for Resident #8's Risperdal was not addressed or attempted.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 4 (Residents #31, #36, #37 and #54) of 4 sampled residents who received medications from 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). 29 opportunities of medication administration were observed and 7 of the 29 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 24.14%. The findings are: 1. On 10/10/2024 at 8:08 AM, RN #6 entered Resident #36's room to administer medication she had prepared. She obtained the resident's blood pressure and heart rate and indicated the heart rate was 58 and she was going to hold the resident's Coreg (Carvedilol) 25 milligram (mg) tablet. She administered Albuterol Sulfate 90 micrograms (mcg) inhaler, 2 puffs, to the resident. Resident #36's Order Summary Report was reviewed and indicated the resident had diagnoses of an irregular heartbeat (atrial fibrillation) and a lung condition which causes difficulty breathing (chronic obstructive pulmonary disease). Carvedilol 25 mg was ordered to take 1 tablet by mouth two times a day and no parameters were indicated on the order. Albuterol Sulfate inhalation (90 Base) mcg was ordered to inhale 2 puffs orally four times a day. The electronic Medication Administration Record (eMAR) was reviewed and indicated the Albuterol inhalation solution was last administered at 0600 (6:00 AM) and was not scheduled to be administered again until 1200 (12:00 PM). On 10/11/2024 at 2:23 PM, Registered Nurse (RN) #6 was interviewed with concurrent observations, and she was asked to review Resident #36's orders for Carvedilol and Albuterol inhalation 90 mcg. She stated she had not notified the provider that she administered the resident's Albuterol inhalation 90 mcg 2 hours early or that she held the Carvedilol because she thought there were parameters but observed there were none. 2. On 10/10/024 at 8:52 AM, RN #6 was preparing medications for Resident #31 and stated Zinc Gluconate was ordered but Zinc Sulfate was available on the medication cart, and this was not the correct medication. She stated she would have to call the provider. The medication was omitted during the 8 AM medication administration for this resident. On 10/10/2024 at 2:45 PM, RN #6 informed this surveyor she had spoken with the Nurse Practitioner and the Zinc Gluconate order was changed to Zinc Sulfate. 3. On 10/10/2024 at 9:44 AM, Licensed Practical Nurse (LPN) #7 was preparing medications for Resident #37 and after she administered the resident's medications and refreshed her screen, she stated another medication was showing as due, Phenobarbital, and she would give it later. On 10/10/2024 at 11:47 AM, this surveyor reviewed Resident #37's eMAR and observed Phenobarbital 64.8 mg tablet was documented as administered. This surveyor reviewed the narcotic log, and the medication was signed out at 10:30 AM by LPN #7. The eMAR indicated Phenobarbital was to be administered at 0800 (8:00 AM) and 2000 (8:00 PM). The medication was administered 2 and a half hours late. 4. On 10/10/2024 at 11:01 AM, LPN #7 had prepared medications for Resident #54. She administered Apixaban 5 mg tablet, Gabapentin 300 mg capsule and Metoprolol Tartrate 50 mg tablet with the other scheduled medications. Resident #54's Order Summary Report was reviewed and indicated the resident had diagnoses of a coagulation defect (the blood will not clot as it should), high blood pressure (hypertension) and fibromyalgia (a condition causing widespread body pain and tiredness). Apixaban 5 mg was ordered to take twice a day, Gabapentin 300 mg was ordered to take 2 capsules three times a day, and Metoprolol Tartrate 50 mg was ordered to take 1 tablet twice a day. Resident #54's eMAR was reviewed and indicated Apixaban was scheduled at 0800 and 2000 and was administered 3 hours late. Metoprolol Tartrate was ordered at 0800 and 1600 (4:00 PM) and was administered 3 hours late. Gabapentin was ordered at 0800, 1300 (1:00 PM) and 2000 and was given 3 hours late, leaving 2 hours between the administered and next scheduled time. An Adverse Consequences and Medication Errors policy, dated as revised April 2014, was reviewed and indicated a medication error was defined as the preparation or administration of drugs or biologicals which was not in accordance with the physician's orders, manufacture's specifications, or accepted professional standards of the professional providing services. Examples of medication errors included: a drug ordered but not administered, wrong drug, and wrong time.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. The week 3-day lunch menu for 2024 to 2025 specified for the residents on regular diets, and mechanical soft diets to receive 3 ounces of ham and 1/2 cup of white beans and for the residents on pureed diets to receive a #8 scoop (1/2 cup) of pureed ham and a #8 (1/2 cup) of pureed white beans. 2. On 10/7/24 at 8:57 AM, Dietary [NAME] (DC) #1 used a 4-ounce spoon to place 7 servings of black-eyed peas from a container dated 10/04/2024 into a blender and pureed. When asked during an interview if black eyed peas were on the menu, DC #1 stated we are having lima beans for lunch, and using leftover black-eyed peas for the pureed. 2. On 10/07/24 at 11:09 AM, ten small pieces of ham weighed 3 ounces, which is the amount each resident should have received. DC #1 used tongs to place 30 small pieces of ham into a blender, resulting in 3 servings, although 4 servings were needed. To achieve the correct number of servings, DC #1 should have used 40 pieces of ham, instead of 30. DC #1 #1 added 7 dinner rolls plus 3 more slices of bread, added broth and pureed. Total of 3 servings, instead of 4 servings. At 11:16 AM, he poured the pureed meat mixture into a pan and placed it on a pan of hot water on the stove to be served to the residents on pureed diets. 3. On 10/7/24 at 11:30 AM, ten small pieces of ham weighed 3 ounces, which is the amount each resident should have received. DC #1 used a tong to place 60 small pieces of ham into a blender, resulting in 6 servings, although he needed 13 servings instead. To achieve the correct number of servings, DC #1 should have used 130 pieces of ham, instead of 60 4. On 10/07/24 at 12:51 PM, one small slice of ham weighed 1.4 ounces was served to the residents on regular diets, instead of 3 ounces. 5. On 10/07/24 at 12:54 PM, DA#4 weighed the same pieces of ham used in preparation of the mechanical soft diet's meat and the pureed diets meat and stated all 10 small pieces of the meat weighed 3 ounces. DA #4 weighed the same amount of ham served to the residents who required regular diets and stated the meat weighed 1.4 ounces.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The findings are: 1. On 10/07/24 at 8:57 AM, Dietary [NAME] (DC) #1 used a 4-ounce spoon to place 7 servings of black-eyed peas from a container dated 10/04/2024 into a blender and pureed. When asked during an interview if black eyed peas were on the menu, DC #1 stated we are having lima beans for lunch, and using leftover black-eyed peas for the pureed. DC #1 poured the pureed black-eyed peas into a pan, covered it with foil and placed it in the oven. The consistency of the pureed black-eyed peas was mushy and not formed. 2. On 10/7/24 at 10:56 AM, DC #1 used a 4 ounce ladle spoon to place 9 servings of turnip greens into a blender, and pureed. At 11:01 AM, DC #1 poured the pureed turnip greens into a pan and placed it in pan of hot water on the stove. The consistency of the pureed turnip green was watery and not formed. 3. On 10/7/24 at 11:09 AM, the DC#1 used tongs to place 30 small pieces of ham into a blender, added 7 dinner rolls plus 3 more slices of bread, added broth and pureed. Total of 3 servings, instead of 5 servings. On 10/07/24 11:16 AM, he poured the pureed meat into a pan and placed it on a pan of hot water on the stove. The consistency of the pureed meat was thick with visible pieces of ham skins in the mixture. 4. On 10/7/24 at 11:41 AM, DC #1 placed 5 servings of hot was cornbread into a blender, added milk and pureed. At 11:47 AM, DC#1 poured the pureed hot water cornbread into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed cornbread was thick. 5. On 10/7/24 at 1:06 PM, when asked during an interview, Dietary Aide #2 stated the pureed turnip greens were not real smooth, but not clumpy; the black-eyed peas were smooth and looked like a milk shake; pureed ham was thick like mashed potatoes with the skin on them; pureed corn bread looked like raw dough.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure enhance barrier precautions were consistently implemented during care for 1 (Resident #31) sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube; failed to ensure a water management program included the necessary components; failed to ensure laundry was transported in a manner to decrease the potential for contamination; failed to ensure the required personal protective equipment (PPE) was used during a resident care activity for 2 (Residents #33 and #35) sampled residents: Resident #33, during incontinent care and Resident #35, during care of and opening in the neck leading to the wind pipe (Tracheostomy); failed to perform appropriate hand hygiene during a resident care activity for 2 (Residents #33 and #35) sampled residents and failed to maintain a technique of remaining free of germs (aseptic) during a resident care activity for 1 (Resident #35) sampled resident reviewed for tracheostomy care. The findings are: 1. On 10/07/24 at 10:36 AM, Resident #31 was observed lying in bed with eyes closed on the right side with a wedge pillow behind the back and the head of bed was elevated. An EBP sign was posted on the wall to the left side of the doorway and an isolation cabinet was outside of room. A feeding pump was in the room and a bottle of [brand name] enteral feeding and a bag of clear fluids were hanging on the pole with the feeding pump. The enteral feeding rate was set at 95 milliliters/hour (ml/hr), and the flush rate was set at 50 ml every (q) 1 hr on the feeding pump. Resident #31's Order Summary Report was reviewed and indicated the resident had a diagnoses of difficulty swallowing (dysphagia) and an encounter for attention to a surgical opening in the abdominal wall for a feeding tube (gastrostomy). An enteral feed order dated 09/16/2024 indicated the resident was to receive [brand name] enteral feeding at a rate of 90 ml/hr with a rate of 50 ml/hr of water. Resident #31's care plan, dated as last reviewed 08/12/2024, was reviewed and there was no indication to use enhanced barrier precautions during care/use of the resident's PEG tube. On 10/10/2024 at 9:15 AM, RN #6 was interviewed and asked if she was familiar with enhance barrier precautions. She stated she was. She was asked what personal protective equipment (PPE) was required for a resident on EBP. She stated she would have to follow up on the answer because she was not sure at this time. She was asked if she put on a gown [isolation] and gloves before administering the medications through the resident's feeding tube. She stated she put on gloves and confirmed she did not put on a gown. She stated she could not recall if she had received any education or training on EBP. A Policies and Practices-Infection Control policy, dated as revised October 2018 and provided by the Assistant Director of Nursing (ADON), was reviewed and indicated all personnel would be trained on the facility's infection control policies and practices upon hire and periodically thereafter, which would include where and how to find and use pertinent procedures and equipment related to infection control. On 10/24/2024, the ADON was asked to provide a policy for enhanced barrier precautions. Prior to the survey team's exit on 10/14/2024, no EBP policy was provided. 2. On 10/10/2024 at 4:50 PM, the Maintenance Supervisor provided information for the facility's water management program. He was interviewed about the water management program. He stated the water management program did not include any information on Legionella monitoring. He stated he would be attending a meeting at a local hospital next month to find out about water management and get more information from the local hospital's program to incorporate at the facility. On 10/10/2024, the water management information provided by the Maintenance Supervisor was reviewed and did not include a description of the building's water system using text and flow diagrams to indicate where Legionella and other opportunistic waterborne pathogens could grow and spread, measures to prevent the growth of Legionella and other opportunistic waterborne pathogens or established ways to intervene when control limits were not met. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and she stated Maintenance, and the Housekeeping Supervisor were part of the water management team. She stated the Maintenance Supervisor oversaw the water management program. She was asked to provide a policy for the water management program. She stated she had not seen an actual policy for water management program. A Water Supply Program policy, dated as revised November 2009 and located in the Water Saving Program binder provided by the Maintenance Supervisor, was reviewed and indicated the facility handled and maintained their water supply according to the recommendations of the Centers for Disease Control (CDC), the Healthcare Infection Control Practices Advisory Committee and the Food and Drug Administration (FDA). The policy indicated the purpose was to maintain a sanitary water supply and control the spread of waterborne microorganisms. 3. On 10/09/2024 at 2:53 PM, the Housekeeping Supervisor was observed pushing a rack of hanging laundry in the 500 hallway with a green sheet only covering the top portion of the laundry. She stopped in the hall near a resident's room, pulled back the green sheet, removed clothing from the rack and left one side of the laundry rack with clothes uncovered and entered a resident's room, leaving the rack unattended. There was a housekeeper with a housekeeping cart in the hall at this time cleaning resident's rooms. On 10/14/2024 at 8:39 AM, Laundry Technician (Tech) #8, was interviewed and was asked how linens were transported to the residents. She pointed to a hanging rack and stated on the clothing rack covered with a sheet. 4. On 10/08/2024 at 11:07 AM, the Surveyor observed gauze around Resident #13's tracheostomy to be light brown in color with appears to be dried blood. During interview Resident #13 Resident confirmed the gauze hasn't been changed and when asked how often staff change the gauze Resident #13 said sometimes. Review of Resident #13's admission Record revealed the resident was admitted on [DATE] with a diagnoses of Tracheostomy complication. Review of Resident #13's Order Summary Report with an order date of 4/19/2024 noted tracheostomy (trach) care every 24 hours and as needed (PRN), clean trach site with half normal saline (NS) and half peroxide then rinse with NS and apply dry dressing daily and PRN two times a day related to tracheostomy complications. Review of Resident #13's Care Plan with an initiated date of 5/6/3034 noted the resident has impaired immunity related to (r/t) trach in place, use universal precautions as appropriate, the resident has a tracheostomy r/t Impaired breathing mechanics. On 10/11/2024 at 2:44 PM, the Surveyor observed Resident #13's tracheostomy care performed by Licensed Practical Nurse (LPN) #11. The surveyor entered Resident #13's room and LPN #11 had already donned surgical gloves prior to surveyor entering. The surveyor did not observe an obturator at the bedside. LPN #11 closed the Resident's door with his surgical gloves on and did not change them. Surveyor observed LPN #11 remove items from trach kit and place the sterile field on the overbed table without sanitizing the table first. LPN #11 placed sterile gloves, Q-Tip's, fenestrated gauze, neck ties, pipettes, bristled brush and 0.9% sodium chloride irrigation containers on sterile field. LPN #11 poured fluid in tracheostomy supply tray. LPN #11 attempted to remove the obturator (The obturator is used to insert a tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy tube as it is being inserted) from the Resident's tracheostomy but appeared to have a hard time getting it removed. LPN #11 was able to remove the obturator and placed it in 0.9% sodium chloride solution and used a bristled brush to clean for approximately two (2) minutes. Obturator was observed to be full of green/brown mucus. While holding the obturator the LPN opened another container of 0.9% sodium chloride solution and poured it into another tray within the tracheostomy tray kit. LPN #11 changed his surgical gloves but did not sanitized hands. LPN #11 placed the obturator on sterile field. LPN #11 removed old fenestrated gauze. Trach site appears to have dried blood, area is red. LPN #11 cleansed trach site with 0.9% Sodium Chloride solution on gauze. LPN #11 unhooked trach ties and cleansed around trach are removing copious amounts of brown/ green mucus. Resident #13 refused to have trach ties changed. Resident #13 began coughing up mucus. LPN #11 re-secured inner cannula with tracheostomy ties and told the resident he would be right back he needed to get more gauze. LPN #11 removed gloves and left the room at 2:58 PM with obturator left on sterile field. LPN #11 returned to the room at 3:00 PM with more gauze but did not shut the Resident's door. LPN did not sanitize hands before putting on surgical gloves. LPN #11 re-cleaned trach area with gauze and recleaned obturator with bristled brush. LPN #11 replaced fenestrated gauze with new fenestrated gauze, placed obturator with visible mucus still on it back in Resident's tracheostomy site. LPN #11 did not put on PPE while performing tracheostomy care. During an interview with LPN #11 on 10/11/2024 at 3:04 PM, he confirmed he should have worn sterile gloves while performing tracheostomy care because it is a sterile procedure, and he should have worn PPE, and sanitized his hands before putting on and changing gloves for infection control purpose. During an interview with the Nurse Consultant on 10/11/2024 at 3:11 PM, he confirmed LPN #11 should have sanitized his hands, sanitized bedside table prior to sterile field being placed on it, worn sterile gloves while performing trach care, should have worn PPE during trach care, and replaced obturator with a new one for infection control purposes. The Nurse Consultant also confirmed tracheostomy care has not been performed as ordered according to Resident #13's Treatment Administration Record (TAR) for October 2024. During an interview with, the Assistant Director on 10/14/2024 at 3:07 PM, she confirmed LPN #11 should have sanitized his hands, sanitized bedside table prior to sterile field being placed on it, worn sterile gloves while performing trach care, should have worn PPE during trach care, and replaced obturator with a new one for infection control purposes. The ADON also confirmed tracheostomy care has not been performed as ordered according to Resident #13's TAR for October 2024. Review of Resident #13's (TAR with a start date of 5/20/2024 noted trach care two times a day at 8:00 AM and 8:00 PM. Resident #13 had trach care performed on 10/2/2024 at 8:00 PM, 10/3/2024 at 8:00 PM, 10/4/2024 at 8:00 AM, 10/7/2024 at 8:00 AM resident refused, 10/7/2024 at 8:00 PM. The physician order was changed to reflect trach care every day shift starting on 10/10/2024. Resident did not receive trach care until 10/13/2024. Facility policy titled Tracheostomy Care noted Policy This facility will minimize risks of infection and other complications associated with tracheostomy care at all times. Clean technique, using sterile supplies will be used for care of non-established and established tracheostomies. Procedure Non-Established & Established Tracheostomy Stoma: Stoma care is provided every 24 hours or as needed; if elder is immunocompromised or with acute infective illness, sterile techniques will be utilized; tracheostomy stoma will be cleansed with sterile normal saline. Tracheostomy Tube Changes tracheostomy tubes with inner cannula will be changed every thirty (30) days and as needed; Stoma Care using sterile cotton-tipped applicators, gauze and sodium chloride clean the tracheostomy stoma starting at the stoma site under faceplate extending 5-10 centimeters (cm) in all directions from the stoma; using dry gauze or dry cotton tipped applicators, pat lightly at skin and exposed outer cannula surfaces. Facility procedure titled Performing Tracheostomy Care Using Sterile Technique noted Step by Step perform hand hygiene and put on appropriate PPE as indicated; place a liquid-absorbing towel across the client's chest to help prevent bacteria and other organisms form transmitting onto the client's linen. Facility policy titled Policies and Practices- Infection Control with a revision date of July 2014 noted Policy Statement The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payer source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter. 5. A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/01/2024 revealed Resident #33's Brief Interview of Mental Status (BIMS) score was 14, indicating the resident was cognitively intact. Resident #33 was occasional unable to control bowel and bladder Review of the plan of care for Resident #33 (Revision on: 06/10/2024) Resident #33 had episodes of occasional incontinence related to (r/t) impaired mobility. On 10/03/2024 at 9:30 AM, the Surveyor observed Certified Nursing Assistant (CNA) #14 and #15 providing incontinent care to Resident #33. The Surveyor observed CNA #15 removed the incontinence pad and place on the floor. The Surveyor observed CNA #14 and #15 apply a clean brief and clothing then placed Resident #33 onto the wet sheet. CNA #15 handled the mechanical lift with the same gloves used to provide incontinence care. The Surveyor observed another CNA take the mechanical lift off the hall prior to cleaning. On 10/03/2024 at 9:40 AM, during an interview CNA #15 stated she did not change gloves during the process of providing care or transferring the resident. CNA #15 stated by handling the mechanical lift with dirty gloves and the lift was taken to another hall for potential use she cross contaminated and potentially cross contaminated to another hall. CNA#14 stated she placed the dirty linen on the floor and by doing so cross contaminated. On 10/10/2024 at 4:40 PM, the Administrator stated by staff placing a clean brief and clothing on the resident then placing the resident on top of a sheet wet with urine caused wet clothing and cross contamination. A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/3/2024 revealed Resident #32 had memory problems, severely impaired cognition, and never or rarely made decisions. Resident #32 had diagnoses of bacteremia (a condition in which bacteria gets in the blood stream, cough, and wound infection). A plan of care for Resident #32 (revision on: 05/29/2024) revealed Resident #32 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) cognitive deficits. On 10/08/2024 at 2:30 PM, the Surveyor observed Licensed Practical Nurse (LPN) #16 toss dirty linen on the floor while providing care to Resident #32. The Surveyor observed LPN #16 reconnected Resident's PEG tube feeding with the same gloves used to provide incontinence care. On 10/08/2024 at 2:50 PM, LPN #16 stated she cross contaminated when she reconnected the PEG tube with dirty gloves and tossed dirty linen on the floor. On 10/10/2024 at 4:40 PM, the Administrator stated dirty linen should always be placed in a bag when staff are providing care. A policy titled Standard Precautions noted standard precautions will be used in the care of all residents. Standard Precautions presume that all blood, body fluids, secretions, and excretions, non-intact skin, and mucous membranes may contain transmissible infectious agents.

Based on record review, interview, and facility policy review, the facility failed to ensure a pneumococcal vaccine was provided for 1 (Resident #59) of 5 (Resident's #13, #16, #31, #33, and #59) sampled residents and failed to provide documentation of education provided to a resident after an influenza vaccination was declined for 1 (Resident #33) of 5 (Resident's 13, #16, #31, #33, and #59) sample residents reviewed for immunizations. The findings are: Resident #59's admission Record was reviewed and indicated the Resident's original admission date was 06/22/2023. The admission record indicated the resident had no know drug allergies and diagnoses of difficulty in the ability to think which interferes with daily living (dementia) and a disease affecting the body's blood sugar level (type 2 diabetes mellitus). Resident #59's electronic health record was reviewed and there was no indication if the resident consented to or declined the pneumococcal vaccine. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 was reviewed and indicated Resident #59 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated cognitively intact, and a pneumococcal vaccine was not offered. On 10/14/2024, the Assistant Director of Nursing (ADON) was asked to provide documentation that Resident #59 had received or declined the pneumococcal vaccine. At 1:00 PM, the ADON stated she could not provide any information regarding the pneumococcal vaccine for this resident. Resident #33's immunization screen was reviewed and indicated the resident refused the influenza vaccine, but it did not indicate the date of the refusal. Resident #33's Order Summary Report was reviewed and indicated the resident had a diagnosis of a disease which causes an abnormally high blood sugar level (type 2 diabetes mellitus with hyperglycemia). A significant change MDS with an ARD of 06/01/2024, was reviewed and indicated Resident #33 had a BIMS of 14, which indicated cognitively intact and had refused the influenza vaccine, but no date was indicated for the refusal. On 10/14/2024, the ADON was asked to provide documentation of Resident #33's declination consent and the education provided to the resident. At 1:00 PM, the ADON provided a copy of the resident's immunization screen which only indicated the resident refused the influenza vaccine and no date was indicated for the refusal. A Pneumococcal Vaccine policy, with a revision date of October 2019, provided by the Administrator on 10/07/2024, was reviewed and indicated all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy indicated the pneumococcal vaccine would be offered within 30 days of admission to the facility unless medically contraindicated, the resident refused, or the resident has already been vaccinated. An Influenza Vaccine policy, with a revision date of October 2019, provided by the Administrator on 10/07/2024, was reviewed and indicated all residents would be offered annually to promote the benefits associated with the vaccination against influenza. The policy indicated the significant risks and benefits would be provided to the residents and the resident's refusal would be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.

Based on observation and interview, the facility failed to ensure the kitchen was free of pests; kitchen floor was free of dirt and, grease; food items stored in the refrigerator and freezer were covered, sealed, and dated; leftover foods were used in a manner to maintain food quality; expired dairy products was promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; ice machine was maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment when contaminated, dairy product was maintained at 41 degrees Fahrenheit or below and hot food items were maintained at above 135 degrees Fahrenheit on the steam table. The findings are: 1. On 10/07/24 at 8:59 AM, the following observations were made in the kitchen: a. One roach was crawling around the hand washing sink, and one-half dead around the food preparation sink. The surveyor pointed them out the half dead roach to Dietary Aide (DA) #2, who removed the roach. b. The floor around the oven and grill had an accumulation of grease and food crumbs. c. The body of the grill and oven had a build-up of grease with caked in greasy foods on them. d. DA #2 stated if it is constantly cleaned like it supposed to be cleaned, it will not look like it is now. There was loose foil and food crumbs on the floor behind the oven and grill. e. An opened bottle of grape jelly was on the counter. The manufacturer's specification on the bottle indicated to refrigerate after opening. DA #2 stated jelly should not be left out, they supposed to be refrigerated. 2. On 10/7/24 at 9:10 AM, the following observations were made on a shelf in the walk-in refrigerator: a. An opened container of diced tomatoes with a sage colorization. DA #2 stated it's starting to turn bad. b. One leftover container of pasta sauce dated 9/24/24. DA #2 stated they supposed to store it for only 3 days. b. A plastic bag that contained leftover scrambled eggs and a plastic bag that contained pureed sausage and whole sausage, were on a shelf in the refrigerator. c. On 10/7/24 at 9:11 AM, when asked during an interview what were in the plastic bags and what are they used for, DA #2 stated they are scrambled eggs and pureed sausage and sausage patties. They use them the next day for the residents on mechanical and pureed diets. The quality of the food is gone when reheating them the next day, the sausage will feel rubbery. d. Two containers of cottage cheese with an expiration date of 9/22/2024. e. One container of sour cream with an expiration date 10/5/2024. c. There were 15 bags of bread, 12 bags of hot dog buns and 4 bags of hamburger buns with the received date of 9/22/2024. The manufacturer specification on the box indicated to keep frozen at 0 or below. 3. On 10/07/24 at 9:31 AM, the following observations were made on a shelf in the freezer: a. An open box of diced chicken. The box was not covered or sealed. b. An opened box of hamburger patties. The box was not covered or sealed. c. An opened box of corndog. The box was not covered or sealed. d. An opened box of turkey sausage. The box was not covered or sealed. e. An opened box of marinara sauce with 150 counts of marinara sauce with an expiration date of 6/24/2024. f. An opened bag of chicken tenders. The box was not sealed. g. An opened box of corn on the knob. The box was not covered or sealed. h. An opened box of cookie dough. The box was not covered or sealed. On 10/07/24 at 9:42 AM, the following observations were made in the cabinet in the kitchen: a. An opened bag of grits. The was no indication of when it was opened. b. An opened bag of oatmeal. The bag was not sealed. 4. On 10/7/24 at 9:43 AM, the following observations were made in the storage room: a. An opened bag of salt was on a shelf. The bag was not sealed. b. An opened box with 150 counts of marinara sauce was on a shelf with an expiration of date of 6/26/24. c. An opened bag of rice. The box was not covered, and the bag was not sealed. 4. On 10/7/24 at 10:11 AM, the ice machine in the nourishment room behind the nurses' station for 300 hall had a wet, reddish-pink, slimy residue on the panel. It was pointed out to DA #2 and asked if the residue build up could be wiped off. She used a tissue and wiped it off. The reddish-pink residue easily transferred to the tissue. DA #2 during interview stated that was slimy wet reddish pink residue. She doesn't know who uses the ice from ice machine. The receptionist stated the ice is used by the Certified Nursing Assistant to fill the water pitchers in the resident's rooms. On 10/8/24 7:45 AM, the maintenance supervisor, stated he cleaned the ice machine every month. 5. On 10/7/24 at 11:05 AM, DC #1 turned on the hand washing sink, washed his hands, turned off the hand washing sink faucet with his bare hands, contaminating his hands. Without rewashing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who required pureed diets. 6. On 10/7/24 at 11:20 AM, (Dietary Cook) DC #1 turned on the hand washing sink, washed his hands, turned off the hand washing sink faucet with his bare hands, contaminating his hands. Without rewashing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who required pureed diets. DC #1 stated he should have washed his hands. 7. On 10/7/24 at 11:23 AM, the DA #3 lifted a trash can lid and threw away tissue paper. Without washing his hands, he picked up glasses by the rims and poured beverages in them to serve to at the lunch meal. DA #3 stated he should have washed his hands. 8 On 10/7/24 at 11:56 AM, DA #5 wore gloves on her hands when she was preparing ham and cheese sandwiches. She turned on the food preparation sink and rinsed off a spatula, turned off the sink faucet with her gloved hands, contaminating the gloves. Without changing gloves and washing her hands, she removed slices of bread from the bread bag and placed them on the liner on the counter, removed slices of bologna from the packet and placed them on top of a slice of bread. DA #5 stated she should have washed her hands. 9. On 10/7/24 at 12:10 PM, the temperature of the steak fingers of the food items when checked on the steam table by the DC #1. The steak fingers were 125 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 10. On 10/7/24 at 2:25 PM, the temperature of the egg salad sandwich in a paper plate at bottom shelf of the food cart by the steam table was checked by the DA #2 and was 47.2 degrees Fahrenheit. DA #2 stated they should have been in the refrigerator. 11. On 10/07/24 at 12:33 PM, DA #2 was asked if she could check the temperature of the ham sandwiches in in a paper plate at the bottom shelf of the food cart by the steam table. The DA #2 stated it was 58 degrees Fahrenheit. DA #2 was asked if the sandwiches were not cold enough, where should they be stored. DA #2 indicated the sandwiches would be closer to temperature if they weren't sitting out for an hour. DC #1 stated to toss them. 12. On 10/7/24 at 1:14 PM, the surveyor observed DA #4 taking a food cart that contained left over cup of milk from lunch in the walk-in refrigerator. DA #4 was asked if she could check the temperature of the leftover milk in the cup. DA #4 stated it was 54.2 degrees Fahrenheit. 13. A facility policy titled, Hand Washing and Glove Usage, undated and provided by the Administrator, indicated hands should be washed before starting work and after touching anything else dirty.

Based on interview, the facility failed to develop and implement a facility assessment. This failed practice had the potential to affect all the residents residing in the facility. The total census was 63. The findings are: On 10/07/2024 the survey team entered the facility. The Administrator provided documents for review, but there was no facility assessment included in the information provided. On 10/11/2024 at 8:43 AM, the Nurse Consultant was informed by this surveyor the facility assessment was needed for review. The nurse consultant returned and stated he had spoken with the Administrator, and she informed him the facility did not have a facility assessment in place. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and asked who was responsible for completing the facility assessment. She stated the Administrator and had no explanation why the facility assessment had not been completed. She informed this surveyor she became the Administrator at the facility on 11/23/2023. She was asked what the purpose of the facility assessment was. The following were some of the reasons she stated: to see where the facility's strengths and weaknesses were, if a performance improvement plan (PIP) was needed, and to see if someone needed to assess the building. On 10/14/2024, the Assistant Director of Nursing (ADON) provided a Facility Assessment Tool, dated 08/18/2017, which was reviewed and included no information for the facility. The facility assessment tool indicated the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents required.

Based on record review, interview, and facility policy review, the facility failed to ensure the antibiotic stewardship program was consistently implemented for 1 (Resident #13) sampled resident who was taking an antibiotic. The findings are: On 10/11/2024 at 5:00 PM, the Nurse Consultant was interviewed and stated he had been at the facility only a few days but managed to catch up 4 months of the infection control tracking logs. He stated he would train the next Infection Preventionist once someone was hired. On 10/14/2024, the Assistant Director of Nursing (ADON) provided the antibiotic stewardship infection mapping and an Order Listing Report for June 2024, July 2024, August 2024 and September 2024. There was no information provided for October 2024. The information was reviewed and did not include a tracking log to indicate what signs/symptoms the resident had, the start date of the symptoms, if the condition required lab tests such as a urine sample/culture, and no criteria to indicate if the antibiotic was necessary. The September Order Listing Report was reviewed and indicated Resident #13 was taking Doxycycline 100 milligrams (mg) tablets one by mouth twice a day for a skin infection in the right lower leg. The medication order indicated a revised date of 09/11/2024. There was no duration of therapy or stop date indicated on the order. An Antibiotic Stewardship policy, dated as revised December 2016 and provided by the Administrator on 10/07/2024, was reviewed and indicated the purpose of the facility's antibiotic stewardship program was to monitor the use of antibiotics in the residents. The policy indicated the prescriber would provide complete antibiotic orders to include the drug name, dose, frequency of administration, duration of treatment (start and stop date or number of days of therapy), route of administration, and indication for use.

Based on record review, interview, and facility policy review, the facility failed to ensure an individual was designated as the Infection Preventionist (IP), who had time to monitor and manage the infection prevention and control program. The findings are: On 10/07/2024, the survey team entered the facility. The Administrator provided a document titled Number 21, which was reviewed and indicated the facility did not have an IP. On 10/11/2024, the facility's in-service binder was reviewed and there were no in-services/trainings on any infection control topics from October 2023 to October 14, 2024. On 10/14/2024, the Assistant Director of Nursing was informed the in-service binder did not include any infection control in-services/trainings for the staff. She stated she would investigate the matter. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and stated she had not designated a staff member to fill in as IP until someone was hired. An Infection Preventionist policy, dated as revised on July 2016 and provided by the Administrator on 10/07/2024, was reviewed and indicated the IP was responsible for coordinating the carrying out and updating of the established infection prevention and control policies and practices. The policy indicated the IP would collect, analyze, and provide infection and antibiotic usage data to nursing staff and health care practitioners and provide education and training. On 10/14/2024, prior to the survey team's exit from the facility, no in-services/training information on infection control was provided for review.

Based on interview and record review the facility failed to ensure a discharge summary was completed on 1(Resident #3) of 4 (Resident #3, Resident #4, Resident #5, and Resident 8) discharged sampled residents. The findings are: A review of Resident #3's Medical Diagnosis List indicated the resident had a diagnosis of type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene. A review of Resident #3's Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 04/01/2024 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score or 15, which indicated the resident was cognitively intact. The resident required maximum assistance with activities of daily living (ADL's). The discharge MDS indicated Resident #3 was discharged on 04/01/2024. On 07/01/2024 at 2:20 PM, Resident #3's medical records were reviewed. There was not a discharge summary in the medical records. On 07/02/2024 at 8:45 AM, during an interview, Registered Nurse (RN) #9 indicated the nurses are responsible for completing the discharge summary when a resident discharges. On 07/02/2024 at 12:30 PM, during an interview the Administrator confirmed a discharge summary wasn't completed for Resident #3. She indicated that a discharge summary should be completed by the nurse within 24-48 hours after a resident discharge, and that the facility doesn't have a policy for discharges.

Based on observations, interviews, record review, and the facility failed to ensure care and services were provided to prevent pressure ulcer development for 2 (Residents #10 and #11) of 3 sampled residents reviewed for pressure ulcers and/or skin concerns. Specifically, the facility failed to monitor the resident's skin by not following physician orders for dressing changes. The findings are: On 07/02/2024 at 10:54 AM, the Surveyor asked for a wound care policy, or guideline. The Administrator informed the surveyor the facility did not have a policy for Wound care or a Guideline. 1. Review of Resident #10's Medication Administration Record noted the resident had diagnoses of unspecified dementia, pressure ulcer of back, buttock, and hip, stage 4, type 2 diabetes, acquired absence of left below the knee amputation, encounter for aftercare following surgery on skin and subcutaneous tissue, and unspecified open wound right leg. a. Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/2024 documented Resident #10 scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had one Stage 4 pressure ulcer. b. Review of the Physician Orders dated 05/30/2024 noted Resident #10 had the following pressure ulcer/wound cleaning orders: i. Sacrum wound to be clean with normal saline, apply collagen to wound bed then cover with border foam dressing one time a day. ii. Left Below the Knee Amputation to be cleaned with normal saline. Apply petroleum based gauze and cover with foam border dressing. Change every Monday, Wednesday, and Friday. iii. Right Below the Knee Amputation to be cleaned with normal saline. Apply petroleum based gauze and cover with foam border dressing. Change on Monday, Wednesday, and Friday. c. On 07/02/2024 at 8:21 AM, the Surveyor asked Certified Nursing Assistant (CNA) #13 accompany the surveyor to Resident #10's room to observe the dates of the dressings on Resident #10. CNA #13 verified the dressings to both leg amputation wounds were dated 06/28/2024. CNA #13 verified the sacral dressing was dated 06/28/2024. d. On 07/02/2024 at 12:41 PM, the Surveyor observed through record review that the last skin audit for Resident #10 was dated 05/22/2024. 2. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/2024 documented Resident #11 scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. Review of the Physician Orders dated 05/10/2024 noted Resident #11 was to have the sacral wound cleanse with wound cleanser, packed with collagen, then covered with bordered foam dressing, every day and as needed. The Care Plan with revision date of 05/23/2024 noted the resident had potential/actual impairment to skin integrity of the Sacral related to fragile skin. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On 07/01/2024 at 11:39 AM, the Surveyor accompanied the Assistant Director of Nursing (ADON) to do Resident #11's sacral wound dressing. Resident #11 was turned to the side and the Surveyor had the ADON verify the date on the dressing that she was removing. The ADON replied it was dated 6/28/2024. The ADON discarded the soiled dressing into a red bag and proceeded to perform wound care. The Surveyor asked the ADON to again verify the date on the dressing. The ADON replied, Yes, it was dated 6/28/2024. The Surveyor asked the ADON to read the order to the surveyor. The ADON verified the order cleanse wound with wound cleanser and pack with collagen gauze and cover with bordered foam dressing every day and as needed. The Surveyor asked who is responsible for assuring the wound care gets done as ordered. The ADON replied the treatment nurse does, or the charge nurses do wound care on their hall if the treatment nurse isn't here. The Surveyor asked where are the supplies kept for wound care. The ADON replied in the treatment nurse's office and some of them are in central supply. The Surveyor asked if the nurses have access to the treatment nurse's office. The ADON replied yes, the treatment nurse's keys are left at the nurse's station for them when she isn't here and on weekends. On 07/01/2024 at 11:49 AM, the Surveyor asked Licensed Practical Nurse (LPN) #8 who was responsible for doing wound care for the residents. LPN #8 replied the treatment nurse was. The Surveyor asked if the treatment nurse isn't here who is responsible. LPN #8 replied the charge nurses are. The Surveyor asked do the nurses have keys to the treatment nurse's office to get supplies needed to do wound care. LPN #8 replied no, we don't have access to the treatment nurse office or central supply. On 07/01/2024 at 11:52 AM, the Surveyor asked Licensed Practical Nurse (LPN) #15 who was responsible for doing wound care for the resident's when the treatment nurse isn't here. LPN #15 replied the charge nurses are. The Surveyor asked how do you get supplies to do the wound care. LPN #15 replied the treatment nurse leaves her cart outside of her office when she isn't here. The Surveyor asked if you need something out of her office, how do you get it. LPN #15 replied there is always someone who has the key. The Surveyor asked what if there was not anyone with a key. LPN #15 replied she would call the treatment nurse or Administrator. On 07/02/2024 at 10:44 AM, the Surveyor asked the Administrator who was responsible for making sure resident wound care is performed per physician orders. The Administrator replied, the treatment nurse is. The Surveyor asked who was responsible for doing the wound care when the treatment nurse is not here. The Administrator replied, the charge nurses do them on their halls. The Surveyor asked who was responsible for doing the wound care on the weekends. The Administrator replied, the charge nurses are. The Surveyor asked what negative outcome could occur if wound care isn't performed according to physician orders. The Administrator replied, I cannot answer that, I am not a nurse. On 07/02/2024 at 11:50 AM, the Surveyor observed through record review the last skin audit performed on Resident #11 was dated 05/28/2024.

Based on observation and interview, the facility failed to ensure a Director of Nursing (DON) was employed full-time. The findings are: On 07/01/2024 at 9:15 AM, the Administrator provided a list of the key personnel. The list did not have a DON named. On 07/01/2024 at 12:30 PM, the Administrator indicated the facility has not had a DON since March 20, 2024. The Administrator indicated the facility doesn't have a policy for DON coverage. On 07/01/2024 at 2:30 PM, the Administrator indicated the facility should have a fulltime DON.

Based on observations, interviews, document review, and policy review, the facility failed to maintain an effective pest control program throughout the entire facility and in one of one kitchen as evidenced by the presence of flies in the kitchen, dining room, resident rooms, as well as hallways. The findings are: On 07/01/2024 at 2:42 PM, during review of the policy titled, Pest Control, the policy noted, Policy Interpretation and Implementation. 1. The facility maintains an on-going pet control program to ensure that the building is kept free of insects and rodents. On 06/30/2024 at 9:32 AM, while the surveyor was rounding, the surveyor observed flies on the 200, 400, and 500 hallways, and common areas where residents sit, and in the resident rooms. On 06/30/2024 at 12:05 PM, the surveyor observed flies sitting on the resident's food, mashed potatoes and gravy, while they were attempting to eat. Residents and staff were waving them off the food for the entire meal. On 06/30/2024 at 12:21 PM, the surveyor went back into the kitchen and observed flies in the kitchen area where staff were working on the food line preparing the trays for the halls. There were flies on the food line and landing on the food. On 07/01/2024 at 12:07 PM, the surveyor observed flies on resident food in dining room. On 07/01/2024 at 2:08 PM, on the 200, 400, and 500 hallways, the surveyor observed flies in the hallways, the common areas, and the resident rooms. During interview conducted on 06/30/2024 at 1:19 PM, Certified Nursing Assistant (CNA) #1 revealed the facility does have a big problem with flies throughout the facility, but has never seen a mouse in the facility, however, there is a problem with roaches in the kitchen area where food is prepared and in the dining area where the residents eat. On 07/01/2024 at 9:18 AM, the surveyor went into the kitchen and dishwashing area. The surveyor had Dietary Aide #3 verify what the small brown insect was on the floor in the dish washing area. Dietary Aide #3 replied that is a roach and that roaches are spotted at times in the kitchen, but they report them to management and the pest control will come and spray. On 07/01/2024 at 2:52 PM, during an interview Housekeeping/Floor Aide #2 revealed there were roaches in the rooms on the 500 Hall and the I the hallway. Housekeeping/Floor Aide #2 revealed there are flies throughout the building but especially in the dining room where the residents eat. Housekeeping/Floor Aide #2 denied seeing any mice in the facility. During an interview conducted on 07/01/2024 at 2:57 PM, Registered Nurse (RN) #5 revealed there was a problem with flies in the facility and roaches at the nurse ' s station. RN #5 revealed it is reported to maintenance when she sees the roaches. During an interview on 07/01/2024 at 3:02 PM, Certified Nursing Assistant (CNA) #6 revealed roaches were seen in the resident rooms, and there are flies everywhere in the facility. During an interview on 07/02/2024 at 8:09 AM, the Administrator revealed she was aware of the roaches and flies in the facility and the facility signed a new contract with a pest control company on 12/4/2023. She continued to say that they came out weekly for a few months and are now coming out monthly. The pest control serviceman is getting us a price contract to control the fly problems that the facility is having.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure food was served in a timely manner for 1 (Resident #5) of 2 (Residents #5 and #6) sampled residents observed in the dining room. The findings are: A review of an Order Summery Report indicated Resident #5 had a diagnosis of unspecified protein-calorie malnutrition. The Quarterly Minimum Data Set with an Assessment Reference Date of 03/01/2024 revealed Resident #5's cognitive skills for daily decision making were severely impaired per a Staff Assessment for Mental Status. On 05/22/2024 at 12:00 PM, Resident #5 was sitting at the feed assist table. Resident #5 hadn't received the resident's meal tray, and most of the residents in the dining room had finished their meal. During an interview on 05/22/2024 at 12:19 PM, the Dietary Manager was asked, Can you tell me why [Resident #5] hasn't been served a lunch tray? She stated, I don't know how [Resident #5] got missed. During an interview on 05/22/2024 at 12:19 PM, the Assistant Director of Nursing (ADON) was asked, Can you tell me why [Resident #5] hasn't been served a lunch tray? She stated, I don't know how [Resident #5] got missed. On 05/22/2024 at 12:20 PM, Restorative Aide #2 sat at the feeding table in front of Resident #5. Restorative Aide #3 stated, I just made it back from taking a resident to an appointment. On 05/23/2024 at 2:42 PM, the ADON indicated that Resident #5 should not have to wait long periods of time to be fed. On 05/23/2024 at 2:58 PM, the Administrator indicated that the facility doesn't have a policy on passing food in a timely manner.

Based on observations, interviews, and record review, the facility failed to keep smoking materials secured and provide adequate supervision during all smoke breaks to prevent potential injury for one (Resident #1) of one sampled resident reviewed for smoking. The findings include: The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #1 had a Brief Interview for Mental Status [BIMS] score of 14 which indicated the resident was cognitively intact and had diagnoses of Dementia and Chronic obstructive pulmonary disease [COPD]. During an observation on 04/02/2024 at 9:57 AM, Resident #1 was lying in bed on his/her side with back to the door, the over bed table was parallel to the right side of the bed, and a blue package of cigarettes and a white disposable lighter was sitting on top of table. During an observation on 04/03/2024 at 11:03 AM, Resident #1's bedside table drawer was open and two blue packages of cigarettes were in the drawer. A review of Resident #1's April Physicians Orders did not address residents smoking. A review of Resident #1's Care Plan initiated, 02/12/2024 did not address smoking status but did indicate the resident received prn (when necessary) oxygen. On 04/02/2024, no smoking assessment was located in Resident #1 ' s health record. On 04/03/2024 at 01:45 PM, Licensed Practical Nurse [LPN] #1 was asked if any residents keep their own smoking supplies, LPN #1 stated , Not supposed to, but you see residents out in smoking area unsupervised smoking when it's not smoke break time. During an interview on 04/03/2024 at 2:10 PM, Certified Nursing Assistant (CNA) #1 was asked who is responsible for supervising resident smoke breaks? CNA #1 responded that the activity person is supposed to do smoke breaks but whoever has time does it. They were then asked if they were aware of any resident that keep their own smoking supplies, they stated, They are not supposed to, but there are some residents that try to sneak. On 04/03/2024 at 10:30 AM, the Surveyor asked LPN #2, Who supervises smoke breaks? LPN #2 stated, The activity person is supposed to, but whoever has time. I've done it lots of times. The Surveyor asked where cigarettes and lighters were kept. LPN #2 said, In a lock box in the medication room. The Surveyor asked if any residents keep their own smoking supplies. LPN #2 stated, They are not supposed to but I've seen some residents smoke when it's not smoke break time. A review of a facility policy titled, Smoking Policy-Residents obtained from the Administrator on 04/04/2024 at 02:37 PM documented, .The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption: b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Smoking Evaluation) .Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure activities were regularly provided, resident activity participation was regularly evaluated and documented, and plans for activities were revised to meet residents' individual interests and needs to promote quality of life for 1 (Residents #2) of 14 residents who required 1:1 activities. The findings are: On 11/27/23 at 11:30 AM Resident #2 was in bed, no TV, or other activity related item in room. On 11/27/23 at 05:14 PM Resident #2 was lying in bed window shades were closed and there was no TV or activity in room. On 11/28/23 at 08:15 AM Resident #2 was lying in bed with no TV or other activities observed. On 11/29/23 at 04:08 PM, Resident #2 was lying in bed and did not get any activities in the room. Resident #2 does not have a TV in her room. Resident #2's Activity Comprehensive assessment dated [DATE] documented the resident listens to music. A review of Resident #2 Care Plan showed a care plan for psychosocial well-being, last updated on 12/23/22 which showed the resident has a history of depression and anxiety. There was no care plan or interventions related to activities. On 11/29/23 at 12:43 PM, Certified Nursing Assistant (CNA) # 4 was asked about the activities for resident #2. CNA #4 stated she doesn ' t get up she don't do any activities. On 11/29/23 at 1:03PM housekeeper # 1 was asked if she had witnessed Resident #2 being provided with activities. Housekeeper # 1 stated, I try to talk to her, but she can't do any activities. On 11/30/23 at 3:21 PM, the Certified Activities Director (AD) was asked about the activities provided for in room residents and AD stated, I do different things with them. The Surveyor asked the AD to provide documentation showing the in-room activities for the past month. On 11/30/23 the AD supplied a form titled Progress Note documented activities were provided on 10/31/23, 11/3/23, 11/10/23,11/14/23 and 11/22/23. There was no activity documented for the week of 11/27/23-11/30/23. On 12/1/23 at 08:16 AM the Administrator was asked if she expected all residents to be offered an activity. The Administrator stated, absolutely. On 12/01/23 at 5:29PM, the Administrator provided a form titled Activities Attendance .The Activity Department records activities attendance and participation of all residents .on a daily basis .

Based on observation, interview, and record review the facility failed to ensure oxygen tubing, nasal cannulas, and humidified water were properly changed, dated, and bagged in a closed container to prevent infections for 1 resident (#239) who received oxygen, and the facility failed to ensure nebulizer mask was contained and bagged properly. The findings are: On 11/27/2023 at 11:53 AM, surveyor observed R #239 was receiving oxygen therapy via nasal cannula with the humidified water dated 11/18/23. On 11/28/2023 at 9:47 AM, surveyor observed R #239 was receiving nebulizer treatment with tubing dated 11/14/23. On 11/28/2023 9:47 AM, surveyor observed a nebulizer mask not bagged or contained lying on the bed for R #239. On 11/28/23 at 9:54 AM Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for taking care of the resident's oxygen? She stated, The nurses are responsible for the oxygen. When are the oxygen tubing, humidified water and nebulizers changed? LPN #1 stated, on Sunday nights. Should the nebulizer be bagged. LPN #1 replied, Yes, it should. On 12/01/23 at 09:33 AM Surveyor asked Registered Nurse (RN) #1, when do you change your oxygen tubing and equipment. RN #1 replied, every week. How should your tubing be stored. RN #1 replied, in a plastic bag to keep them clean. On 12/1/23 at 9:40 AM the Administrator said there was no Oxygen policy.

Based on interview, the facility failed to ensure a policy was developed regarding use and storage of foods that were brought to residents by family and other visitors, to ensure safe and sanitary storage, handling, and consumption for the residents who resided in 1 of 1 facility. This failed practice had the potential to affect 11 residents who had food brought in by family. The findings are: 1. On 11/28/2023 at 1:00 PM, the Administrator was asked to provide the facility's policy regarding use and storage of foods that were brought to residents by family and other visitors. The administrator stated they have no policy. 2. On 11/28/2023 at 10:01 AM, a list provided by the Certified Nursing Assistant/Receptionist #2 documented there were 11 residents currently residing in the facility who had food brought in by family members. 3. On 11/27/23 1:08 PM, an opened bottle of sweet tea was on a shelf in the refrigerator in the nourishment room behind the nurse's station facing 300 Hall. There was no name to whom it belongs to, no opened or received date on the bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide appropriate/comfortable water temperatures in two (Hall 400 and Hall 600) of four (Hall 200, Hall 400, Hall 500, and Hall 600) bathing areas. The failed practice had the potential to affect 67 residents who have the potential to be bathed/showered on Hall 400 or 600. The findings are: On 11/27/23 3:15 PM the surveyor checked the water temperature in the shower room on 400 halls, the warmest it registered on the thermometer after 5 minutes was 91 degrees Fahrenheit. At 03:20 PM the water temperature in the whirlpool on the 500-hall registered 103 degrees Fahrenheit and at 03:25 PM the water temperature in the whirlpool room on 200 hall registered at 102 degrees Fahrenheit. The temperature of the water in the 400-hall shower room was checked again on 11/30/2023 at 1:30 PM and registered 91.2 degrees Fahrenheit. On 11/30/2023 at 1:20 the Maintenance Director was asked, What is an appropriate temperature range for bath water for the residents? The Maintenance Director responded, between 105 and 110 degrees. When asked how the water temperatures were regulated, he responded he adjusted the water heater at the boiler. On 11/30/2023 at 1:25 PM the Maintenance Director accompanied the surveyor to the 400 Hall shower room and tested the temperature of the water. The water temperature was 91.2. On 11/30/2023 at 1:55 PM the surveyor asked Resident #174, if she had been having a problem with the temperature of her bath water, and she answered yes. Resident #174, stated, it was too cold. The resident was then asked which area do you bathe in and Resident #174 answered, on 600 Hall. When asked how long the water temperature being too cold had been a problem, Resident #174 responded it had been an ongoing problem since September and they had worked on it, but it didn't fix it. When asked if resident had told anyone resident stated, told the Certified Nursing Assistant [CNA] every time they were bathed on Tuesdays, Thursdays, and Saturdays. On 11/30/2023 at 2:07 PM the Maintenance Director accompanied the surveyor to the 600 Hall shower room and checked the temperature of the water and found it to be 92 degrees Fahrenheit. The Maintenance Director and surveyor went into room [ROOM NUMBER] and the water temperature was measured at 105 degrees. On 11/30/2023 at 2:04 PM the surveyor asked Resident #6 if they had a problem with the water temperature in the shower and Resident #6 said that it was too cold. Resident #6 said it has been too cold for a long time. And that they had told the CNA and nurse. On 11/30/2023 at 2:05 PM Resident #182 told the surveyor the water in the 400 Hall shower was usually kind of cool and Monday it was cold. On 11/30/2023 at 2:08 PM CNA #5 was asked if they had given any showers in the 400 Hall shower room. CNA #5 said, All the time. The Surveyor asked if the water temperature had been cool. CNA #5 said, all the time, that's why residents refuse showers. When asked if residents had notified anyone about the cool temperatures, CNA #5 stated, Yes, I have told the nurse and Maintenance Director. On 11/30/2023 at 2:55 PM Registered Nurse (RN) #1 provided a document titled, .Shower room [ROOM NUMBER] Hall . dated 10/24/2023 which documented, .Do not use shower on 400 Hall until the water temperature is corrected .Do not ever give a resident a cold lukewarm shower .Anytime water is too hot/too cold notify nurse so maintenance can be notified of problem . On 11/30/2023 at 2:55 PM the Maintenance Director provided January 2023 to 11/27/23 water temperature logs which documented water temperatures within normal limits and a water mixer valve purchase order for Halls 400 and 600 shower areas dated 09/14/2023. On 12/01/2023 at 9:28 AM the facility policy for Maintenance Service obtained from the administrator documented, .The Maintenance Department is responsible for maintaining the building .and equipment in a safe and operable manner .maintain plumbing in good working order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents were assessed for smoking, that oxygen was maintained securely in a safe manner and hazardous chemicals were secured in a locked container. The findings are: On 11/27/23 at 11:29 AM observed Resident #178 drop a used (unlit) cigarette from her lap. On 11/30/23 02:11 PM, the Surveyor asked resident # 178 if she smoked. Resident #178 stated, Yes, all my life. Resident #178 was asked if the facility kept her cigarettes and lighter. Resident #178 stated, No I keep them on me or in my pillow. On 11/30/23 at 12:00 PM during smoking schedule resident #178 pulled out a lighter and a cigarette and lit the cigarette. On 11/30/23 at 12:22, the Activities Director (AD) was asked who oversees the residents during smoke times. The AD stated, I do. The AD was asked if she was aware of resident #178 having smoking paraphernalia on her person. The AD was asked if residents were allowed to keep their cigarettes and lighters. The AD stated, no mam, I keep them. On 11/30/23 at 12:31 PM unable to locate Resident #178 smoking assessment. The Administrator was asked to provide a smoking assessment for resident #178. On 11/30/23 at 3:18 PM, the Administrator stated that there was not a smoking assessment found for Resident #178. On 11/30/23 at 5:29 PM the Administrator provided a form titled Smoking Policy-Residents This facility shall establish and maintain safe resident smoking practices .6. The resident will be evaluated on admission to determine if he or she is a smoker .If a smoker the evaluation will include the ability to smoke safely . On 11/29/2023 at 12:52 PM observed Housekeeper #2 spray a rag in the hallway outside room [ROOM NUMBER] with a disinfectant cleaner and then placed cleaner on top of cart. Housekeeper #2 went in the resident room and left the cart and chemical unattended while 1 resident wheeled past it in wheelchair and one walked past the cart. Housekeeper #2 noted cleaning furniture in room not paying attention to the chemical unsecure in the hallway. On 11/29/2023 at 12:55 PM, observed Housekeeper #2 spray a rag in the hallway outside room [ROOM NUMBER] with a disinfectant cleaner and then placed cleaner on top of cart. Housekeeper #2 went into the resident ' s room and left cart and chemical unattended while cleaning furniture in room not paying attention to the chemical unsecure in the hallway. On 11/29/2023 at 12:59 PM observed Housekeeper #2 cleaning cart parked outside room [ROOM NUMBER]. Housekeeper #2 was observed cleaning furniture in the room not paying attention to the chemical unsecure in the hallway. On 11/29/2023 at 12:59 PM Surveyor asked Housekeeper #2, How should this disinfectant chemical be stored? Housekeeper #2 stated, Don't leave out if unattended. The Surveyor asked, What does the front of the bottle state in bold letters? Housekeeper #2 stated, Danger keep out of reach. On 11/29/2023 at 3:49 PM Housekeeping Supervisor was asked, How should chemicals be stored when not in use? The Housekeeping Supervisor stated, They should be locked up in closets and on carts. On 11/29/2023 at 4:48 PM, the Housekeeping Supervisor provided a safety data sheet for product [named] Disinfectant Cleaner Concentrate that stated .Hazardous statements . Harmful if swallowed. Causes severe skin burns and eye damage .Storage . Store locked up First Aid .If swallowed: Call poison control center or doctor immediately for treatment advice . On 12/01/23 at 2:20 PM, a policy titled Storage Areas, Environmental Services provided by the administrator states, .3. Cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. On 11/28/2023 at 9:47 AM, Surveyor entered room [ROOM NUMBER] and observed Oxygen E-tank standing upright on floor unsecure by empty bed in room. On 11/28/2023 at 9:54 AM, Licensed Practical Nurse (LPN) #1 asked, what was wrong with the E-tank in room? LPN #1 stated, It's not secure. I can take it out. I didn't know anything about this. On 11/28/2023 at 10:13 AM, Resident #239 was asked by the surveyor, How long was the green Oxygen tank in your room for? Resident stated, Since yesterday when I got back from the hospital. On 11/28/2023 at 10:20 AM Certified Nursing Assistant (CNA) #3 When asked, Have you been in room [ROOM NUMBER] today? CNA #3 stated, Yes about 9:30 AM. Surveyor asked, Was a green top Oxygen E-tank cylinder in the room? CNA #3 stated, Yes, it has been in her room since yesterday around 2:00 PM. Surveyor asked, What is the residents assist level? CNA #3 states, The resident walks with a walker, but does almost everything herself.

Based on observation record review, and Interview, the facility failed to ensure Psychotropic medications had an appropriate diagnosis for 1 of 1 sampled Resident (#20 and #185). The findings are: a. Resident #20 was prescribed Trazodone 50 mg 1 po @bedtime Psychophysiological Insomnia, Depakote 125 mg (milligrams) 1 po (by mouth), (without diagnosis) Depakote 500 mg 1 po (without diagnosis), Seroquel 25 mg 1 po (without diagnosis.) and on resident #185 who was prescribed on Trazadone 100 mg 1 po, Divalproex 125 mg, escitalopram 10 mg for anxiety, olanzapine 5 mg all without a diagnosis. a. On 11/30/23 at 9:23 AM, the Surveyor asked Registered Nurse (RN) #1 for diagnoses for these medications on resident # 20 and #185. RN #1 stated, I'll have to look for the diagnoses. b. On 11/30/23 at 12:56 PM, the Administrator provided a written statement that documented, After chart audit and EHR (Electronic Health Records) and admission documentation there was not a physician's order for Psychotropics for resident # 20 [named]or Resident # 185. [named]. d. On 12/01/23 at 2:25 PM, the Administrator was asked for a policy on ensuring diagnoses were appropriate for the medication required. e. On 12/01/23 at 2:30 PM, the Administrator stated, We don't have one.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. These failed practices had the potential to affect 6 residents who received mechanical soft diets and 8 residents who received pureed diets and residents who received fortified foods from the kitchen according to a list provided by the Assistant Dietary Supervisor (DS). The findings are: The cycle Day 9 lunch menu for 2023 specified for the residents on meglazedcal soft diets to receive a-6 scoop (2/3) cup of ground maple glaze fish with 2 ounces of gravy, residents on pureed diets were to receive a #8-scoop (1/2) cup of pureed maple glazed fish and a #16 -scoop (1/4) cup of pureed lemon cheesecake bar. On 11/27/23 at 11:53 AM, Dietary Employee (DE) #1 used 4 ounces (oz) spoon to place 6 servings of diced chicken into a blender, added 5 slices of cream chicken soup and pureed. At 11:56 AM, he poured the pureed chicken into a pan and placed it on the steam table to be served to the residents on pureed diets, instead of maple glazed fish. On 11/27/23 at 12:31 PM, residents on mechanical soft diets were served whole fried fish, instead of ground maple glazed fish. At 11:34 AM, the surveyor immediately asked DE #1 the reason residents on mechanical soft diets are being served whole fish. DE #1 stated, That's how we have been given it to them. 11/27/23 12:36 PM, Residents on pureed diets were served pureed peaches, instead of pureed lemon cheesecake bar. The surveyor immediately asked DE #3 the reason residents on pureed diets did not receive pureed lemon cheesecake bar. DE #3 stated, I did not have enough. The cycle Day: 9 Dinner menu for 2023 specified for the residents on pureed diets were to receive a 6-ounce(oz) spoon of pureed cabbage soup with crackers and a #10 -scoop (3/8) cup of pureed beets. On 11/27/23 at 5:46 PM, the following observations were made during dinner meal service. DE #3 used a 4 -ounces spoon (1/2) cup to serve a single portion of cabbage soup to the residents on pureed diets, instead of 6-ounce ladle spoon (3/4 cup). DE #3 used a #16 scoop (1/4) cup to serve a single portion of pureed beets, instead of ½ cup. The surveyor immediately asked DE #3 how many servings he gave to each resident on pureed diets. He stated, I gave them one each. On 11/28/23 at 12:30 PM, the surveyor asked DE #3 what scoop size he used to serve pureed beets and the spoon size he used to serve pureed cabbage soup at the supper meal on 11/27/23. DE #3, stated, I used the green spoon the (4 oz) for the soup and the blue scoop (#16) for the beet.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 8 residents. The findings are. 1. On 11/27/23 at 11:17 AM, the following observations were made during the lunch meal preparation: a. Dietary Employee (DE) #1 used a 4 ounces spoon to place 10 servings of broccoli into a blender and pureed. At 11:20 AM, he poured the pureed broccoli into a pan. He covered the pan with foil and placed it on the steam table. The consistency of the pureed broccoli was runny and not formed. b. On 11/27/23 at 11:35 AM, DE #1 used a #8 scoop to place 8 servings of garden rice blend into a blender, added cream of chicken soup and pureed. At 11:42 AM, he poured the pureed rice into a pan and placed it on the steam table. The consistency of the pureed rice was lumpy, sticky and not smooth. There were pieces of black food particles visible in the mixture. c. On 11/27/23 at 11:53 AM, DE #1 used a 4-ounce (oz) spoon to place 6 servings of diced chicken into a blender, added 5 slices of cream chicken soup and pureed. At 11:56 AM, he poured the pureed chicken into a pan, covered the pan with foil and placed it on the steam table. The consistency of the pureed chicken was gritty, thick, and not smooth. d. On 11/27/23 at 12:08 PM, DE #1 placed 15 slices of bread, added whole milk and pureed. He poured the pureed bread with milk into a pan. He covered the pan of bread with foil and placed it on the steam table. The consistency of the pureed bread was thick, lumpy, and not smooth. e. On 11/27/23 at 1:11 PM, the surveyor asked Dietary Supervisor and DE #2 to describe the consistency of the pureed food items served to the residents on pureed diets. DE #2 and the Dietary Supervisor stated, Pureed meat was gritty, not smooth. Pureed rice was lumpy, not smooth. Pureed bread was runny with crumbs in it and pureed broccoli was runny. 2. On 11/27/23 at 5:44 PM, the following pureed food items were on the steam table. a. A pan of pureed cabbage soup. The consistency of the pureed soup was lumpy, thick, and not smooth. b. A pan of pureed roast beef with bread. The consistency was lumpy, thick, and not smooth. There were pieces of meat in the mixture. c. On 11/27/23 at 5:48 PM the surveyor asked Certified Nursing Assistant #1 to describe the consistency of the pureed food items served to the residents. She stated, Pureed meat and pureed roast beef with bread had lumps and they were both, thick. 3. On 11/28/23 at 7:37 AM, the pureed sausage served to the residents on pureed diets was lumpy not smooth. Pieces of sausage were still visible in the mixture. At 07:50 AM the surveyor asked Dietary Supervisor to describe the consistency of the pureed sausage. She stated, It was not pureed right. It has pieces of sausage in it.

Based on observation, record review and interview, the facility failed to ensure resident received physician ordered Fortified foods for 1 (Resident #21) sampled resident who were to receive fortified foods. This failed practice had the potential to affect 22 residents, who required fortified foods with all meals, as identified by a list provided by the Certified Supervisor on 11/28/2023 at 10:01 AM. The findings are: a. Resident #21's Physician's Order dated 03/28/2023 documented, .fortified foods TID [three times a day] with meals . b. On 11/27/2023 at 12:30 PM, Resident #21 was not given fortified foods. c. On 11/28/23 at 12:30 PM, the surveyor asked Dietary Employee #3 what was prepared for the residents on fortified foods. He stated, I forgot to do it. I gave regular oatmeal to every resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide influenza and/or pneumococcal immunizations as required or appropriate for residents. This failed practice had the potential to affect all 70 residents who reside in the facility. The findings are: On 11/29/2023 at 3:30 PM RN #1 stated, they did not have documentation for any influenza or pneumococcal education, or immunizations given. They were unable to document the flu vaccines given due to the lot number and expiration dates being discarded. The Facility Influenza Vaccine policy documented, All residents .who have no medical contraindication to the vaccine will be offered the influenza vaccine annually .Between [DATE]st and March 31st each year Prior to vaccination the resident (or resident legal representative) will be provided with information and education regarding the benefits and potential side effects .Provision of such education shall be documented in the residents medical record . the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical record. The facility Pneumococcal Vaccine policy documented, .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine .and offered the vaccine series within thirty days of admission .before receiving a pneumococcal vaccine the resident or legal representative shall receive information and education regarding the benefits and potential side effects .Provision of such education shall be documented in the residents medical record .the date of vaccination, lot number, expiration date, person administering and the site of the vaccination will be documented in the residents medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure an effective pest control program was maintained to keep the facility free of pests. This failed practice had the potential to affect 69 residents according to the list provided by the Dietary Supervisor on 11/28/2023. The findings are: 1. On 11/27/2023 at 11:00 AM Resident #184 stated, I sleep with the light on so roaches dont crawl in my bed. 2. 11/27/23 01:08 PM A roach was crawling inside the top door of the refrigerator in the nourishment room behind the nurse's station facing 300 Hall. The surveyor pointed it out to the Dietary Supervisor who pushed it out of the refrigerator and killed it. 3. On11/28/23 at 12:38 PM A roach was crawling on the counter where microwave and the food blender were located. The surveyor showed it to the Dietary Supervisor pushed it down and killed it. 4. On 11/28/23 at 12:39 PM Another roach was crawling Do we know it was crawling, maybe it was walking on the floor in the kitchen. The surveyor showed it to the Dietary Supervisor who stepped on it and killed it. The surveyor asked the Dietary Supervisor how long they have had problems with roaches. She stated, I just saw them last month and that was the only time. 5. Pest Sighting Log for September 2023 provided by the Dietary Supervisor on 11/28/2023 at 01:10 PM documented, . date of sighting 9/1/2023, contact person or area pest was seen .a. 200 Hall wing- Rooms 201 through 216. Type of pest Ants and roaches. b. All rooms on 300 Hall wing. Type Bugs, ant and ECT. Activity office. Type Bug. c. North complete lounge and south nourishment room roaches. d. 400 Hall wing- rooms 402 to 418. Type Ants and roaches. e. room [ROOM NUMBER] -closet and drawers. Type roaches. f. Front lobby area. Type Bugs. G. 9/13/2023 . 500 Hall wing-502 to 516. Type roaches. 9/19/2023 Kitchen and laundry room area . Type Roaches. 6. Pest Sighting Log for October 2023 provided by the Dietary Supervisor on 11/28/2023 at 01:10 PM documented, . date of sighting 10/1/2023, contact person or area pest was seen .a. Dining room and kitchen area. Type roaches. b. 10/3/2023 . 500 Hall wing- All rooms- 502 through 516.c. 10/3/2023 .400 Hall wing- All rooms -402- 418. Type roaches. d. 10/4/2023 . South nourishment room. Type Roaches. e. 10/4/2023 Employee lunge. Type. Bugs. f. 10/4/2023 North Nurses station. Type Roaches. g. 10/8/2023 200 wing- All rooms- 201 through 216 .Type water bugs and roaches. h. 10/9/2023 soiled utility - Trash room- Roaches. i. 10/9/2023 300 and 400 Hall Janitors closets. Type Roaches. j. 10/9/2023 Laundry washer and Dryer area- Roaches. k. 10/16/22023 . 400 wing- All rooms . Type Roaches. l.10/23/2023 and 10/24/2023 500 all rooms. Type .Roaches. 10/24/2023 on 300 Hall wing. 7. Ecolab Pest Elimination Division] Service report provided by the Dietary Supervisor on 11/28/2023 at 01:10 PM documented, .10/18/2023 No rodent and no cockroach activity were noted during the inspection and or service. No findings noted during service. Location . Patient/Guest rooms-interior. Finding . Food debris found. Food debris and open food in most rooms all through facility. Action needed taken .Please clean regularly.

Based on record review and interview, the facility failed to ensure residents who had Medicaid coverage with Trust Funds managed by the facility were able to have funds available on the weekends and after hours. The failed practice had the potential to affect 52 residents. The findings are: 1. On 11/27/23 at 11:06 AM, Resident #14 was interviewed by the surveyor. The surveyor asked are you able to get your money after hours or on the weekends? The resident said, no there isn't anyone here on the weekends to give it to us. 2. On 11/29/23 at 2:48 PM, the surveyor interviewed the Business of Manager (BOM), and asked, do you leave money for the residents to have access to on the evenings or weekends when you are not available? The BOM stated, absolutely not . 3. On 12/01/23 at 2:05 PM, the surveyor asked the Administrator for a policy addressing a resident ' s personal funds. The Administrator stated, We do not have a Personal Fund Policy.

Based on record review and interview, the facility failed to ensure residents who receive Medicaid benefits and/or their responsible parties were notified when the amount in their resident Trust Fund account was within $200 of the maximum Medicaid limit for 12 Residents sampled. The findings are: 1. On 11/29/23 at 2:48 PM, The Surveyor asked for October Trust account balances. Business Office Manager (BOM) provided the month of November account balances. 2. On 12/01/23 at 11:25 AM, the Surveyor asked the BOM manager to provide the documentation regarding the Medicaid notification letters for Resident #2, who had a balance of $2,183.69, Resident #5, who had a balance of $1891.67, Resident #11 with balance of $2,070.19. Resident #13 with balance of $ 1,850.59, Resident #18 with Balance of $2,376.59, Resident #19 with Balance of $2,040.17, Resident #128 with balance of $4,658.45, Resident # 129 with balance of $1,964.10, Resident # 130 with balance of $2,248.42, resident # 136 with balance of $2,129.28, Resident #175 with balance of $4,657.62, Resident #228 with balance of $4,616.09. The BOM informed the Surveyor that she was new and had not sent out the notification letters. The Surveyor asked BOM, how do you let residents/ family know that they are approaching the maximum amount allowed by Medicaid. The BOM stated, I didn't know that I was supposed to. 3. On 11/30/23 at 5:29 PM, The Administrator provided a policy titled, Management of Residents' Personal Funds .the policy showed, Our facility shall manage the personal funds of residents who request the facility to do so . 4. Should our facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds will be managed in accordance with established policies outlined in this chapter that relate to financial management .6. A copy of all financial transactions will be filed in the resident's permanent record .

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, 7 days a week, each week. The failed practice has the potential to affect 69 residents in the facility. The findings are: 2. On 11/28/23, the Surveyor reviewed the staffing documentation provided by the Business Office Manager (BOM), and noted the following information: a. On 11/16/23, 11/17/23, and 11/18/23 there was no Registered Nurse (RN) that worked as the Director of Nurses (DON). b. On 11/19/23 and 11/20/23 both RNs. worked on the floor. There was no RN who worked as the DON. c. On 11/22/23 and 11/23/23 The RN worked the floor both days. d. On 11/24/23 and 11/25/23, 11/26/23 There was no RN working. e. On 11/27 and 11/28/23 the RN worked the floor. f. On 11/29/23, the RN worked as the DON from 12:59-21:30. 2. On 11/28/23 at 2:01 PM, the Surveyor asked the Administrator, since there is no DON and the Assistant Director of Nurses is on vacation, who is working as the RN in charge? The Administrator stated, I have RNs here Named {RN #1}. We are short on RNs. 3. On 12/01/23 at 8:11 AM, the Surveyor asked the Administrator, what does the facility do when there is no RN to work 8 consecutive hours? Administrator stated, We normally get with an agency or piece together our RNs. The Surveyor asked are you made aware by the facility if you do not have RN coverage for 8 consecutive hours? The Administrator stated, yes. 4. On 11/29/2023 at 8:25 AM, the Surveyor asked the Administrator for a staffing policy. The Administrator provided a form titled, Hours of Work showed the following: 2. Our standard workday consists of 8 (of 8) consecutive hours of work, with a 30-minute paid meal break.

Based on observation, interview, and record review the facility failed to ensure completion and follow up on the pharmacy medication regimen review [MRR] recommendations for four (Resident #17, #18, #20, and #185) of four (Resident #17, #18, #20, #185) sampled residents. The findings are: On 12/1/2023 at 9:30 AM The facility was only able to locate the Monthly Regimen Reviews for Resident #17 for the following months, August 2023, and November 2023. According to Registered Nurse #1 the following months were not to be found November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, September 2023, and October 2023. Resident #18 had a diagnosis of dementia with behavior disturbance, depression, and post-traumatic stress disorder [PTSD]. Minimum data set [MDS] with an assessment reference date [ARD] of 06/20/2023 documented no potential indicators of psychosis, no behavior symptoms observed, no rejection of care and no wandering observed. Resident #18's Physician's Orders for 11/01/2023 to 11/30/2023 documented, .Cymbalta 60 mg 1 tablet once a day; 08:00 AM (start date 03/12/2023) . Zyprexa tablet 2.5 mg (milligram) 1 tab once a day every other day (reduced start date 03/08/2023) . Resident #18's care plan with a revision date of 12/23/2022 documented, .At risk for side effects from use of anti-depressant and antipsychotic medication .observe/document target behaviors, extrapyramidal symptoms. Observe for adverse side effects. Notify MD/family of any concerns/problems . On 08/29/2023 the pharmacist who performed the MRR recommended R#18's Zyprexa and Cymbalta be reduced, on 09/29/2023 and 11/16/23. On 11/30/2023 at 2:50 PM RN #1 said, the responses to the MMR ' s are unable to located. Per record review, Resident #20 was prescribed Trazodone 50 mg 1 po (by mouth) at bedtime for Psychophysiological Insomnia, Depakote 125 mg 1 po, Depakote 500 mg 1 po, and Seroquel 25 mg 1 po. On 07/31/23, the Pharmacist did a review on Trazadone reduction. There was no follow up done from the facility or the Physician. On 10/20/23 the Pharmacist reviewed the medication Depakote and recommended a reduction. There was no follow up from the facility or the Physician. Per record review, Resident #185 was prescribed Trazadone 100 mg 1 by mouth, Divalproex 125 mg, escitalopram 10 mg for anxiety, olanzapine 5 mg without a diagnosis. On 11/16/23 the Pharmacist reviewed the medications escitalopram & Trazadone and recommended a reduction. This recommendation was not followed up. On 11/30/23 at 9:23 AM, the Surveyor asked Registered Nurse (RN) #1 for the diagnoses for these medications and the follow up behind the pharmacist. The RN stated, I don't think they have been done since June and I'll have to look for the diagnoses. On 11/30/23 at 9:40 AM, the Surveyor asked RN #1 to explain the reasoning behind the process of the MRR. RN #1 said the Pharmacist visits once a month and looks at the meds and makes recommendations. On 11/30/23 at 12:56 PM, the Administrator provided a written statement that documented, After chart audit and EHR (Electronic Health Records) and admission documentation there was not a physician's order for Psychotropics for resident #20 [named] or Resident #185. [named]. On 11/30/23 at 5:29 PM, the Administrator provided a form titled Pharmacy Services Overview Help establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility .

Based on observation and interview, the facility failed to ensure food item stored in the refrigerator and freezer were covered, sealed, and dated; leftover foods were used in a manner to maintain food quality; expired dairy products was promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; kitchen ceiling tiles were free of peeling, floors, dish washer and kitchen walls, and baseboards were free of chipped debris, dirt, grease, grime, rust, stains, and spills, ice scoop holder and ice machine were maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 60 residents who received meals from the kitchen. The findings are: 1. On 11/27/23 10:13 AM, the following observations were made in the cabinet. a. An opened bag of grits was on a shelf in the cabinet by the door leading to the serving area. b. An opened bottle of lemon juice on a shelf in the cabinet. Some of the juice has been used from it. The manufacture specification on the bottle documented, Refrigerate after opening. 2. On 11/27/23 at 10:17 AM, the following observations were made in the walk-in refrigerator. a. A plastic bag that contained leftover scrambled eggs and a plastic bag that contained both ground and whole sausage, were on a shelf in the refrigerator. At 4:00 PM, the surveyor asked Dietary Employee (DE) #2 what were in the plastic bags and what they are for. DE #2 stated, They are scrambled eggs and ground and whole sausage. They use them the next day for the mechanical and pureed. b. A gallon of whole milk on a shelf in the refrigerator had an expiration date of 11/25/2023. 3. On 11/27/23 at 10:19 AM, water was standing in front of the ice machine. Dietary Supervisor stated, It leaks out water from the tube. The left inside of the ice machine panel had wet brown/gray residue on it. The surveyor asked the Dietary Surveyor to wipe off what was observed on the panel. The brown residue easily transferred to the white rag. The surveyor how often they cleaned the ice machine. She stated, We clean it two times a week The Surveyor asked, Who uses the ice from the ice machine? She stated, We use it to fill the residents' beverages at mealtimes. 4. On 11/27/23 at 10:20 AM, an opened plastic bag used as a scoop holder was inserted into a metal rack attached on the left side of the counter where tea and coffee makers were kept had water standing. There was black sediment at the bottom of it, and the ice scoop was in direct contact with the sediment. The surveyor asked the Dietary Supervisor what was inside the plastic bag. She said there is black residue. 5. On 11/27/23 at 10:22 AM, the following observations were made on a shelf in the walk-in refrigerator. a. An opened plastic bag of white cheese. The bag was not sealed. There was no storage date. b. An opened bag of shredded cheese. The bag was not sealed. The was no date when the cheese was stored. c. An opened bag of flour tortillas. The bag was not sealed. There was no date when the bag was opened. d. A container of leftover pull pork. There was no date when it was stored. 6. On 11/27/23 at 10:30 AM, the following observations were made in the walk-in freezer. a. An opened box of beef patties. The box was not covered, and the bag was not sealed. b. An opened box that contained an opened bag of loose dinner rolls. The box was not covered, and the bag was not sealed. c. An opened box that contained an opened bag of chicken stripes. The box was not covered, and the bag was not sealed. d. An opened box of sausage. The box was not covered, and the bag was sealed. e. An opened box of cookies. The box was not covered, and the bag was not sealed. f. An opened box that contained a bag of biscuits. The box was not covered, and the bag was not sealed. 6. On 11/27/23 at 10:37 AM, the following spices were on a shelf in the cabinet, there were no dates when the spices were opened: a. Chili powder. b. Ground oregano. c. Onion powder. d. Taco Cajun style seasoning. e. Ground nutmeg. f. Poultry seasoning. g. Black pepper. h. Garlic powder. i. Ground Cinnamon. j. Ground fine sage. k. Seasoning salt. 7. On 11/27/23 at 10:41 AM, the following observations were made in the kitchen areas. a. The ceiling tile between the door leading to the walk-in freezer was peeling, exposing the cement. b. The ceiling tile from the kitchen entrance close to the steam table to the support bin that holds the ceiling was cracked, exposing the cement. c. The floor between the conventional oven, stove, the deep fryer, and grill, had accumulation of caked on black greasy residue, dirt, and debris. d. The grease trap had an accumulation of black cake on food burnt in it. e. There were thick accumulation of black caked food burnt in the conventional oven. f. The ceiling tile covering, and the area that was patched had brown stains on them. g. The wall above the counter on the clean side of the dish machine was peeling and exposing the cement. h. The were food stains on metal between the dish washing machine and the wall where clean dish racks were kept. i. The facing above the clean side of the dish washing machine was loose, exposing the cement. j. The ceiling tiles were peeling between the dirty area of the dishwashing machine and the clean side. The areas that were peeled expose the cement. k. The ceiling tiles above the dirty dish machine had different areas that were cracked and exposing the cement. The areas that were exposed had brown stains on them. l. The floor below the water hose sink had water wet brown stains on it. m. The floor under the 3-compartment sink had water standing on it. n. The wall leading to the janitor's closet and baseboard around the wall were chipped exposing the cement. 8. On 11/27/23 at 11:27 AM, Dietary Employee (DE) #1 picked up the water hose with bare hand and used it to spray leftover food from inside of the blender. He placed the dirty blender and blade in the dirty rack and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on who required pureed food diets. When DE #1 was ready to scoop food items into the blender to puree, the Surveyor asked what you should have done after touching dirty objects or before handling clean equipment? He stated, I washed my hands. 9. On 11/27/23 at 12:01 PM, DE #3 picked up the water hose with gloves on his hands and used it to spray leftover food from inside of the blender. He placed the dirty blender/blade in the dirty rack and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up clean the blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed dirty. At 12:03 PM, then D) #1 placed to scoop food items into the blender to puree. The Surveyor immediately stopped DE #1 from putting food into the blender and asked what you should you have done after touching dirty objects or before handling clean equipment? She stated, Changed gloves and washed my hands. 10. ON 11/27/23 at 12:28 PM, the temperatures of the food items when checked on the steam table by the DE #2 showed the following: A. Pureed bread with milk 101 degrees Fahrenheit. B. Pureed chicken 125 degrees Fahrenheit. The above food items were not reheated before being served to the residents. The Dietary Supervisor stated, They should have been heated up.

Based on interview and policy review, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI), plan that includes identification of problems, implementation of corrective actions, documentation, review, analyze and tracking of the data. The findings include: Interview on 12/1/2023 at 2:17 PM the facility Administrator stated, I have nothing as far as no QAPI Plan or QAA meeting notes. On 12/1/2023 at 2:39 PM review of the facility policy QAPI Committee, (July 2016), documented, .The administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program .The committee will meet monthly at an appointed time .The committee shall maintain minutes of all regular and special meetings that include at least the following information: .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure that staff wore Personal Protective Equipment (PPE) in the transmission-based precaution rooms for 2 residents (#184, #226); the facility failed to have proper signage on isolation room [ROOM NUMBER] and failed to clean the glucometers according to the manufactures guidelines on hall 200 which had the ability to effect (11) residents who reside on the hall. The findings are: 1. On 11/27/2023 at 11:10 AM Certified Nursing Assistant (CNA) #6 walk into R (#226) room without donning PPE. 2. On 11/27/23 at 11:15 AM, observed CNA (#6) go into R #226 room without donning PPE. 3. On 11/28/23 at 8:02 AM, observed CNA (#4), go into R (#184), room to deliver breakfast tray without donning PPE. 4. On 11/28/23 at 08:43 AM, observed Housekeeper going into R (#184) room without donning PPE. 5. On 11/29/23 at 12:22 PM, observed CNA (#5) go into R (#184) room to deliver lunch tray without donning PPE. 6. On 11/28/23 at 8:05 AM surveyor asked CNA (4), are you aware this is an isolation room. CNA (4) replied no I didn't. If it is an isolation room, what should you do. CNA (4) replied wear my PPE. 7. On 11/28/23 at 8:47 AM, surveyor asked Housekeeper (HK) #1, can you tell me why this resident is in isolation. HK #1 replied I don't know What should you do before going into an isolation room. HK (#1) replied put on my PPE. 8. On 11/29/23 at 12:22 PM, surveyor asked CNA #(5), did you know this resident was on isolation. CNA #(5) replied, I realized after I got in the room and saw the barrels. What should you do before going into an isolation room. Put on my PPE. 9. On 11/28/23 at 8:02am surveyor observed that there was no door signage identifying that room [ROOM NUMBER] was an Isolation Room. 10. On 12/1/23 at 9:30 AM, surveyor interviewed registered Nurse (RN) #1, How would an employee or visitor identify an isolation room. RN #(1) stated, there should be signage on the door. What should you do before going into an isolation room. RN #(1), replied, put on your PPE. 11. On 11/29/23 at 11:27 AM, observed RN#(1), use glucometer on R #(224), RN cleaned the glucometer for 7 seconds with Bleach Wipes. 12. On 11/29/23 at 11:58 AM, observed RN #(1), use a glucometer on R #(19), RN #1 used Bleach Wipe for 8 seconds and then took another glucose reading on R #(17). 13. On 11/29/23 at 3:44 PM, surveyor interviewed RN #(1), how long do you clean your glucometer after using it. RN #(1) stated, for one minute. How long should it be cleaned for. RN #(1), stated to the best of my knowledge 1 minute. I should be cleaning it according to Manufacture Guidelines. 14. On 11/29/23 at 4:01 PM, surveyor Interviewed Licensed Practical Nurse (LPN#3), How long do you wipe your glucometer after use. LPN (#3) stated 4 minutes is what that towelettes say. The Surveyor asked what type of wipe do you use? LPN (3) stated, bleach. 15. On 11/29/23 at 3:46 PM, surveyor observed towelette being used to disinfect reads, Use wipe thoroughly to wipe surface. Surface must remain wet for a full 4 minutes. Use additional wipes to ensure there is a complete 4 minutes of wet time on surface. 16. On 12/01/23 at 9:24 AM, administrator provided policy titled Infection Prevention and Control Committee . 1.b. Provide facility guidelines for a safe and sanitary environment .d. Develop isolation precaution protocols for when control of an infectious or communicable disease or disease [NAME] is required in accordance with current CDC guidelines and recommendations; e. Identify situations that may result in employees' exposure to blood, body fluids, or other potentially infectious materials .g. Develop infection prevention and control orientation and in -service training programs for all levels of facility personnel. H. Develop policies and procedures for the surveillance and monitoring of infection control practices .

Based on interview and record review the facility failed to screen, educate, and offer Covid-19 immunization and to maintain documentation for facility staff and residents. This failed practice had the potential to affect all residents who reside in the facility and all staff employed by this facility. On 11/29/2023 at 3:30 PM RN #1 stated they did not have documentation for Covid 19 immunizations given to any of the residents. On 11/29/23 03:47 PM when asked about Covid 19 education and vaccine for staff, the Administrator stated, We have not been doing this, we were unaware this was still a requirement since the pandemic is over. When asked for a Covid 19 vaccine policy RN#1 stated she was unable to find it.

Based on interview and record review, the facility failed to ensure regulated in-services were provided. The findings are: 1. On 11/2/23 at 4:00 PM, the Surveyor requested In-service trainings for Abuse/Neglect/Exploitation, Resident Rights, Dementia Care, Infection Control, Communication, Behavioral Health, and Special resident needs such as Pain, Trach care, Medication side effects, Hospice, and Changes in Condition. The Administrator provided a form documenting after an exhausting search of the facility there were No Inservices to be located. 2. There was no Director of Nurses (DON)/Acting DON employed. The Assistant Director of Nursing was on vacation. 3. The Administrator was asked if she knew which in-services are required yearly. The Administrator stated, The Administrator was asked to explain the purpose behind In-service training. The Administrator stated, To educate your staff on Policies and Procedures, rules and regulations, changes of conditions, and any communication needed. 4. The Administrator was asked for a policy on in-servicing/educating on 12/01/23 at 03:00 PM with no policy received.

Based on observation, interview and record review, the facility failed to update resident assessments for three (R#1, #2 and #3) of three (R#1, #2 and #3) sampled residents. The findings are: 1. On 11/08/2023 at 12:00 PM the surveyor was unable to locate the Minimum Data Set [MDS] in the paper medical record for Residents #1, #2 and #3. 2. On 11/08/2023 at 12:05 PM the DON was asked, where would the MDS be found on R#1, #2 and #3, the DON, stated, I will check on that for you, I believe the MDS coordinator has them in her office. 3. On 11/08/2023 at 1:00 PM, the MDS coordinator was asked to provide a copy of Resident #1, #2 and #3's MDS. The MDS coordinator replied, Do you want the most recent? The surveyor replied, Yes, please. At 4:30 PM they still had not provided a copy of the MDS. 4. On 11/09/2023 at 9:30 AM the MDS coordinator provided a Quarterly MDS, which was the most current, for Resident #1 with an assessment reference date [ARD] of 04/12/2023, and a Quarterly MDS, most current, with an ARD of 04/19/2023 for Resident #2. 5. On 11/09/2023 at 9:59 AM when the surveyor asked about the timing of the MDSs for Resident #1, #2, and #3 The MDS coordinator stated, I know. I've been trying to get them caught up, but I just started the beginning of August and have not been able to. 6. On 11/09/2023 at 11:00 AM the MDS coordinator provided an admission MDS, with an ARD of 05/03/2023, for Resident #3. 7. On 11/09/2023 at 11:15 AM, the Administrator was asked, do you know that the MDS are not being submitted in a timely manner? The Administrator stated, I know some are late and have spoken with the MDS coordinator, and explained they have got to be submitted, because that's how we get paid.

Based on observation, interview and record review, the facility failed to develop and implement an individual care plan for three (Resident #1, #2 and #3) of three (Resident #1, #2 and #3) sampled residents. The findings are: 1. On 11/08/2023 at 12:03 PM, the surveyor was unable to locate the residents care plan in the paper medical record for Residents #1, #2 and #3. 2. On 11/08/2023 at 12:05 PM the DON was asked, where would the MDS be found on R#1, #2 and #3, the DON, stated I will check on that for you, I believe the MDS coordinator has them in her office. 3. On 11/08/2023 at 1:00 PM, the MDS coordinator was asked to provide a copy of Resident #1, #2, and #3's MDS. The MDS coordinator replied, Do you want the most recent? The surveyor replied, Yes, please. At 4:30 PM they still had not provided a copy of the MDS 4. On 11/09/2023 at 9:59 AM, when the surveyor asked about the care plan for Resident #3, the MDS coordinator stated she was unable to find it. 5. On 11/09/2023 at 11:29 AM, CNA (Certified Nursing Assistant) #1 was asked, how do you know how to properly care for the residents? replied, I asked my nurse, they can let me know if they need to have a gait belt, two persons assist

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents. This failed practice had the potential to affect 8 residents in the facility who were at risk for elopement as documented on a list provided by the Assistant Director of Nursing (ADON) on 07/19/23 at 12:00 PM. The findings are: 1. Resident #1 had a diagnosis of Dementia with Behavioral Disturbance. The Discharge Return Not Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was independent with supervision for ambulating in the hallway and exhibited daily wandering behaviors. a. On 07/19/23 at 9:30 AM, Resident #1 was in the common area near the front Nurses Station, ambulatory with a Wanderguard bracelet on his right ankle. b. On 07/19/23 at 10:00 AM, Resident #1 was in his room sitting on the bed. A Wanderguard bracelet was intact to the right ankle. A staff member was present in the room with 1:1 (one on one) documentation on the overbed table. c. An Incident and Accident Report provided by the ADON on 07/19/23 at 10:55 AM did not have a date or a time of the incident. The report documented, .Nurse was on hall passing meds [medications]. Another res [resident] came and got me and told me the res was walking off. Myself and two CNA [Certified Nursing Assistant] staff observed res on the side of the building . uninjured. Res was directed to come back inside . d. Resident #1's General Flowsheet provided by the ADON on 07/19/23 at 10:55 AM documented daily nurse initials at 8:00 AM from 07/11/23 to the current date for 1:1 monitoring x [times] 72 hours for exit seeking behavior . There were no nurse initials documenting monitoring for the evening shift or the night shift. e. Resident #1's Elopement Risk Assessment provided by the ADON on 07/19/23 at 10:55 AM documented the following: i) 07/11/23 - a score of 8 (total score of 8 or higher is at risk for elopement) with no history of elopement and 1:1 x 72 hours. ii) 07/15/23 - a score of 8 with no history of elopement and continue 1:1. iii) 07/16/23 - a score of 11 with elopement and cont [continue] 1:1 monitoring was documented. f. A Telephone Order dated 07/15/23, provided by the ADON on 07/19/23 at 10:55 AM from Medical Director (MD) #1 documented Continue 1:1 monitoring. g. An Inservice Training dated 07/11/23 provided by the ADON on 07/19/23 at 10:55 AM documented, .Resident #1 . Hx [history] of exit seeking behaviors . Resident is to be 1:1 for a minimum of 72 hours from admission or until 1:1 is discontinued by MD . 1:1 staff member is to be with [Resident #1] at all times. When staff member needs to take a break/go to lunch that staff member MUST notify the nurse and pass off 1:1 to another staff member. When this occurs Both staff members are to sign on the1:1 documentation sheet and indicate who is leaving and who is assuming responsibility of resident . Staff member assigned to resident must document on 1:1 form provided to reflect resident was not left alone at any time . h. An Inservice Training dated 07/11/23 provided by the ADON on 07/19/23 at 10:55 AM documented, Title of Inservice: 1:1 with [CNA #1] . When you're assigned to 1:1 you cannot leave assignment until someone relieves you . Do not ever leave a resident who [is on] 1:1 unattended for any reason . i. The Continuous Monitoring documentation from 07/12/23 to 07/18/23 provided by the ADON on 07/19/23 at 10:55 AM did not document 1:1 monitoring on 07/16/23 at 3:00 and 4:00 PM and at 5:00 PM, Assisted back in facility was documented. j. The Temporary admission Care Plan dated 07/11/23 provided by the ADON on 07/19/23 at 11:30 AM documented, .7/11/23 1:1 monitoring x 72 hours . 7/15/23 continue 1:1 monitoring per MD #1 . 7/16/23 eloped out of facility continue 1:1 monitoring after return from ER [Emergency Room] . k. A Progress Note dated 07/16/23 provided by the ADON on 07/19/23 at 1:40 PM documented, .Res left building without permission was found walking in between trees on the side of the building . 1754 [5:54 PM] ADON and DON [Director of Nursing] notified . l. A Progress Note dated 07/16/23 at 1930 (7:30 PM) provided by the ADON on 07/19/23 at 1:40 PM documented, Assumed 1:1 resident at this time . m. A facility policy titled, Elopement/Wandering Policy, provided by the Business Office Manager (BOM) on 07/19/23 at 9:50 AM documented, .The facility maintains a process to assess all residents for risk of elopement, implement risk reduction strategies, and conduct a coordinated resident search in the event of a missing resident. 1. Definitions Elopement is the ability of a . resident . to successfully leave the facility unsupervised and unnoticed . B. Risk Reduction Measures 1. Interventions that may be used for residents identified as high risk for elopement could include: a. frequent monitoring of the resident's whereabouts to assure he/she remains in the facility . n. A facility policy titled, One to One Policy, provided by the ADON on 07/19/23 at 1:40 PM documented, Purpose: To maintain safety for resident/residents/staff . 2. Staff are to document whereabouts/behaviors every hour . o. On 7/19/23 at 10:00 AM, the Surveyor asked Resident #1, Do you remember going outside on Sunday? Resident #1 answered, I don't remember. I may have. The Surveyor asked, What door did you go out of ? Resident #1 answered, I don't remember. The Surveyor asked, Where were you going? Resident #1 answered, I don't know. The Surveyor asked, The Surveyor asked, Do they take good care of you? Resident #1 answered, Yes. p. On 07/19/23 at 10:50 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Were you here Sunday evening when [Resident #1] went outside? LPN #1 answered, Yes. It was about 5:00 PM and I was on my med pass. I was in a resident's room and when I came out, [Resident #4] came up and told me the resident had gone outside. The resident always sets off the alarms but usually when that happens, the resident closes the door and doesn't go out. The resident is always in 1:1 supervision. I got some help, and we went out and found the resident around the side of the building. We think the resident went out the front door. That's the only one the resident could have gone out of. The Surveyor asked, How long was the resident outside? LPN #1 answered, Maybe 2 to 3 minutes. Just long enough to walk around the corner. The Surveyor asked, Was the resident in 1:1 supervision when he got outside? LPN #1 answered, Probably not. We were shorthanded that day and we had to pull the aide to the floor. Sometimes we have to do that. The Surveyor asked, What happened when the resident came back inside? LPN #1 answered, I am not sure. The ADON came in and I think she sent the resident to the hospital, but it was after shift change. We work 7a/7p [7:00 AM to 7:00 PM]. The Surveyor asked, You said the front door is the only door the resident can go out. What do you mean? LPN #1 answered, It's an automatic sliding door. The Wanderguard is supposed to keep it from opening but it can be manually opened. After that happened, I locked the door and turned off the automation. If a visitor came after that we would have to let them in. The Surveyor asked LPN #1 to mark on the facility floor plan/map the area where the resident was located outside. LPN #1 marked an x on the right side of the building about 1/3 of the way down the building and around the corner from the front entrance. The Surveyor asked, Did you complete a witness statement? LPN #1 answered, No. I just did an I&A [Incident and Accident Report]. q. On 07/19/23 at 11:02 AM, the Surveyor asked the Administrator, How did [Resident #1] get outside if the staff was doing 1:1 monitoring? The Administrator answered, A CNA who was monitoring on the day shift left at 3:00. The CNA's relief called in. There was a period of time when the resident was not in 1:1. We provided you a copy of the inservice that we held with the CNA instructing that they cannot leave a resident who is on 1:1 monitoring until there is relief. The Surveyor asked, How long was the resident outside? The Administrator answered, Not long. Maybe a few minutes. Just long enough to walk around the corner of the building. r. On 07/19/23 at 11:30 AM, the ADON was shown the I&A report that was not dated or timed by the Surveyor and was asked, What is this? The ADON answered, That is the I&A from Sunday. The Surveyor asked, How do I know that since there is no date or time? The ADON answered, I will have the nurse complete the date and time. s. On 07/19/23 at 12:10 PM, the Surveyor asked CNA #1, Are you familiar with an incident when [Resident #1] went outside? CNA #1 answered, I found out about it the next day. The Surveyor asked, What do you know about it? CNA #1 answered, I was doing 1:1 on Sunday. I knew something was about to happen. All day the resident kept telling me I didn't have to stay and watch his every move. The resident was saying, 'I've got to get out of here. I need to go to Memphis.' I told the other CNA on the hall that something was about to happen. The Surveyor asked, What time did you leave on Sunday? CNA #1 answered, I left at 3:00 [PM]. The Surveyor asked, Did anyone relieve you at 3:00? CNA #1 answered, I saw the next shift coming in. I didn't know I was supposed to wait until someone said they were taking over. Now I know. The Surveyor asked, What could happen if a resident went outside with no staff member present? CNA #1 answered, They could leave the property. They could get overheated. It could be really bad. t. On 07/19/23 at 2:20 PM, the Surveyor asked the ADON how long Resident #1 was outside. The ADON answered, I wasn't here but the staff told me it was less than ten minutes. The Surveyor asked what could happen if a resident went outside with no staff supervision. The ADON answered, They could easily have a heat stroke.

Based on interview and record review, the facility failed to ensure the residents who have authorized the facility in writing to manage their personal funds have ready and reasonable access to those funds. The failed practice had the potential to affect the 60 residents who have a trust account managed by the facility according to a list provided by the Business Office Manager on 8/31/22 at 9:10 AM The findings are: 1. Resident #4 has a diagnosis of Diabetes, Type II, Congestive heart failure and chronic kidney failure. On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. On 08/29/22 at 1:45 PM, Resident #4 asked, .Why can't I get my money . Resident reported that he has a trust account that is managed by the facility and that he is made to wait when he requests money. Resident #4 stated, .They always tell me I'll have to wait till they go to the bank. Sometimes it's all day . The Surveyor asked Resident #4 how often this situation occurs, and he stated, .it's all the time . when I do get money, they will only give me 20 or 30 dollars to try and get me to hush. The Surveyor asked Resident #4 if he was able to access his money on the weekend. Resident #4 stated, .I don't even try cause there would have to be someone in the office and they ain't never here on the weekends. The Surveyor asked Resident #4 if he was aware of his balance. He stated, .No . Per request of Resident #4, the Surveyor accompanied the resident to the Business Office Manager's office. Resident #4 requested to know his balance. The BOM stated, .Let me print that off for you . As the BOM left the area, the resident stated, .Why can't she do that all the time . The BOM returned with the balance written on a piece of paper. Resident #4 stated, .I can't read that . The BOM requested permission to read the number out loud and permission was granted. She stated, .Your balance is $2,533.66 . The Surveyor asked if he had received a statement. Resident #4 stated, .No ., and the BOM stated, .Well, we do pass them out . The BOM was asked to reprint Resident #4's statement. Resident #4 stated, .They are trying to make me think I'm crazy, that I just don't remember but that's not true . The BOM returned with the copy of the statement and asked the resident if he would like her to read the information to him. Resident #4 stated, .Yes, every line of it . Resident #4 stated that he had problems reading due to cataracts. The Business Office Manager reported that the statements are passed out to the residents in the facility and mailed. 2. Resident #43 had diagnoses of Diabetes Type II and Cerebral Infarction due to Embolism. The Quarterly MDS with an ARD of 06/08/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS. a. On 08/29/22 at 1:47 PM, Resident #43 over heard Resident #4 express his dissatisfaction with his inability to gain access to his money upon request. Resident #43 reported that she too was unable to withdraw her money at any time. The Surveyor asked Resident #43 about her concerns. She stated, .They're aways putting me off . The Surveyor asked if she was aware of the balance of her trust account. Resident #43 stated, .No . The Surveyor asked if she received a quarterly statement. Resident #43 stated, .I do not . Resident #43 stated she did not know her balance and could not obtain money on the weekend. 3. Resident #73 had a diagnoses of Hypothyroidism, Unspecified Convulsions and Diabetes Mellitus Type II. The Quarterly MDS with an ARD of 07/21/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS. a. On 08/29/22 at approximately 3:00 PM, during a Resident Council Meeting, the Surveyor asked Resident #73 if she had a trust account. She stated, .Yes . Resident #4 and Resident #43 described how they did not receive quarterly statements, Resident #73 stated, .Did you ask? .you know you aren't going to get one unless you ask . The Surveyor asked the Social Director, who was leading the meeting, if there was a process for the residents to obtain money from their accounts on the weekend. She stated, .No, they can't get money on the weekend .

Based on record review and interview, the facility failed to provide quarterly trust fund statements to the residents or their legal representatives who had trust fund accounts. The failed practice had the potential to affect the 60 residents who had a trust account managed by the facility according to a list provided by the Business Office Manager (BOM) on 8/31/22 at 9:10 AM. The findings are: 1. Resident #4 has a diagnosis of Diabetes, Type II, Congestive heart failure and chronic kidney failure. On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. On 08/29/22 at 1:45 PM, Resident #4 asked, .Why can't I get my money . Resident reported that he has a trust account that is managed by the facility and that he is made to wait when he requests money. Resident #4 stated, .They always tell me I'll have to wait till they go to the bank. Sometimes it's all day . The Surveyor asked Resident #4 how often this situation occurs, and he stated, .it's all the time . when I do get money, they will only give me 20 or 30 dollars to try and get me to hush. The Surveyor asked Resident #4 if he was able to access his money on the weekend. Resident #4 stated, .I don't even try cause there would have to be someone in the office and they ain't never here on the weekends. The Surveyor asked Resident #4 if he was aware of his balance. He stated, .No . Per request of Resident #4, the Surveyor accompanied the resident to the Business Office Manager's office. Resident #4 requested his balance. The BOM stated, .Let me print that off for you . As the BOM left the area, the resident stated, .Why can't she do that all the time . The BOM returned with the balance written on a piece of paper. Resident #4 stated, .I can't read that . The BOM requested permission to read the number out loud and permission was granted. She stated, .Your balance is $2,533.66 . The Surveyor asked if he had received a statement. Resident #4 stated, .No ., and the BOM stated, .Well, we do pass them out . The BOM was asked to reprint Resident #4's statement. Resident #4 stated, .They are trying to make me think I'm crazy, that I just don't remember but that's not true . The BOM returned with the copy of the statement and asked the resident if he would like her to read the information to him. Resident #4 stated, .Yes, every line of it . Resident #4 stated that he has problems reading due to cataracts. The Business Office Manager reported that the statements were passed out to the residents in the facility and mailed if there is a family member involved. 2. Resident #43 had diagnoses of Diabetes Type II and Cerebral Infarction due to Embolism. The Quarterly MDS with an ARD of 06/08/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS. a. On 08/29/22 at 1:47 PM, Resident #43 heard Resident #4 express his dissatisfaction with his inability to gain access to his money upon request. Resident #43 reported that she too was unable to withdraw her money at any time. The Surveyor asked Resident #43 about her concerns. She stated, .They're aways putting me off . The Surveyor asked if she was aware of the balance of her trust account. Resident #43 stated, .No . The Surveyor asked if she received a quarterly statement. Resident #43 stated, .I do not . Resident #43 stated she did not know her balance and could not obtain money on the weekend. 3. Resident #73 had a diagnoses of Hypothyroidism, Unspecified Convulsions and Diabetes Mellitus Type II. The Quarterly MDS with an ARD of 07/21/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS. a. On 08/29/22 at approximately 3:00 PM, during a Resident Council Meeting, the Surveyor asked Resident #73 if she had a trust account. She stated, .Yes . Resident #4 and Resident #43 described they did not receive quarterly statements, Resident #73 stated, .Did you ask? .you know you aren't going to get one unless you ask . The Surveyor asked the Social Director, who was leading the meeting, if there was a process for the residents to obtain money from their accounts on the weekend. She stated, .No, they can't get money on the weekend .

Based on interview and record review, the facility failed to ensure residents and/or their representative who received Medicaid benefits were notified when the amount in their trust fund account was within $200 of the Supplemental Security Income (SSI) resource limit to prevent possible loss of Medicaid eligibility for residents who had Medicaid coverage and had trust funds managed by the facility. The failed practice had the potential to affect the 60 residents who had trust accounts managed by the facility according to a list provided by the Business Office Manager (BOM) on 8/31/22 at 9:10 AM. The findings are: 1. The list of residents who had a trust fund account managed by the facility provided by the BOM on 08/31/22 at 9:10 AM consisted of sixty accounts. Two of the listed accounts were within $200 of the resource limit and thirty of the accounts were well over the $2,000 limit. The Surveyor asked the BOM if the resident or their families were notified of their balances. The BOM named multiple staff members that might share in the notification process. The Surveyor asked for a copy of the letter that was sent, none was provided. On 08/31/22 at approximately 1:30 PM, the Owner provided copies of the April 1, 2022 - June 30, 2022, quarterly statements. Four of the quarterly statements had written at the bottom of the page, Please note balance over $2,000. The balances in these 4 accounts were $7,022.11, $7,221.85, $7,480.81, and $11,343.56.

Based on interview and record review, the facility failed to purchase a surety bond, to assure the security of all personal funds in the resident trust funds to prevent potential financial loss. The failed practice had the potential to affect the 60 residents who had a trust fund account managed by the facility according to a list provided by the Business Office Manager (BOM) on 8/31/22 at 9:10 AM. 1. The verification certificate from [Company] Insurance was provided by the BOM on 8/30/22 at approximately 10:00 AM. The document had an original effective date of 12/01/2019 and was issued by, [Company Name], as Surety, in the penal sum of $300,000.00 on behalf of [Facility] as Principal, and in favor of Arkansas Office of Long Term Care, as Obligee, remains in full force and effect subject to all its agreements, conditions and limitations. The document was signed and sealed by [Attorney-In-Fact] on the 13th day of October 2021. 2. On 8/30/22 at approximately 11:00 AM, the Surveyor returned the verification certificate to the BOM and requested a copy of the surety bond currently in effect be provided. 3. On 8/31/22 at approximately 3:00 PM, the BOM returned with the verification certificate. In reference to the date of October 13, 2021, she stated, .that's just when the notary signed it . No other documentation of a current surety bond was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure quarterly assessments were completed in the required timeframe as specified by the Centers for Medicare/Medicaid for 1 (Resident #7) of 1 sampled resident whose assessment was reviewed. The findings are: On 8/31/22, Resident #7's Minimum Data Sets were reviewed with the following results: 1. An Entry MDS dated [DATE] was sent and accepted. 2. A Discharge Return Anticipated MDS with a date of 05/03/2022 was accepted. 3. A Quarterly MDS with a date of 04/28/2022 was accepted. 4. An Entry MDS with a date of 04/21/2022 was accepted. 5. A Discharge Return Anticipated with a date of 04/15/2022 was accepted. 6. On 8/31/22 at 3:15 pm, the Surveyor asked the Business Office Manager, Can you look at [Resident #7's] MDSs and tell me when her last one was? She stated, She had a quarterly done on 4/28/22. The Surveyor asked, So should she have had another one done? She nodded her head and stated, Yes, in July.

Based on observation, interview, and record review, the facility failed to review and revise the care plan to include Hospice Services for 1 (Resident #31) of 3 (Residents #16, #31 and #35) sampled residents who received Hospice Services, oxygen therapy, and tube feedings for 1 (Resident #61) of 13 (Residents #3, #10, #11 #22, #30, #32, #41 #42, #43, #46, #54, #61, and #74) sampled resident who had orders for oxygen therapy, and 7 (Residents #7, #9, #35, #37, #46, #61 and #65) sampled residents who had orders for tube feedings to promote continuity of care. The findings are 1. Resident #31 had diagnoses of Alzheimer's Dementia, Malnutrition, and Neoplasm. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/31/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received Hospice Services. a. The Care Plan with a revised date of 06/28/22 did not address Hospice Services. b. On 08/31/22 at 3:52 PM, the Surveyor asked the Director of Nursing (DON), Is [Resident #31] receiving Hospice Services? The DON stated, Yes she is. The Surveyor asked the DON, Does [Resident #31's] care plan address that she is receiving Hospice Services? The DON looked in the electronic record and stated, I do not see it in the care plan. The Surveyor asked the DON, Should [Resident #31's] care plan address that she is receiving Hospice Services? The DON stated, Yes Ma'am it should. The Surveyor asked the DON, Why is it important that the care plan addresses that the resident is receiving Hospice Services? The DON stated, So that anyone who needs to know about her care will have the information that they need. 2. Resident #61 had diagnoses of Stroke, End Stage Renal Disease, Type 2 diabetes mellitus with diabetic chronic kidney disease, Moderate Protein-Calorie Malnutrition and Encounter for Attention to Gastrostomy. The Quarterly MDS with an ARD of 7/18/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and was totally dependent on one person for bed mobility, transfers, dressing, toileting, personal hygiene, required supervision with eating, had lost weight and received dialysis. a. The Care Plan with a revision date of 07/18/22 did not address oxygen therapy or tube feedings. b. The August 2022 Physicians Orders documented, .Nepro at 50cc/hr [cubic centimeters per hour] with 20cc/hr H2O [Water] flush X [times] 23 HR . Order Date 08/15/22 . prn [as needed] o2 [Oxygen] @ [at] 2L [Liters] r/t [related to] sob [shortness of breath] . Order Date 08/25/22 . b. On 08/29/22 at 1:49 PM, Resident #61 was lying in bed with eyes closed with oxygen at 2.5-3 liters per nasal cannula and Nepro 1.5 at 50 ml (milliliters)/hour with a water flush at 20ml/hour per feeding tube. c. On 08/31/22 at 9:05 AM, Resident #61 was lying in bed with oxygen in use at 2.5-3 liters per nasal cannula. d. On 08/31/22 at 3:33 PM, the Surveyor asked the Director of Nursing (DON), Does [Resident # 61] have orders for oxygen therapy? The DON looked in the electronic record and stated, Yes she does. The Surveyor asked the DON, Does [Resident # 61's] care plan address that she is receiving oxygen therapy? The DON looked in the electronic record and stated, I do not see it in the care plan. The Surveyor asked the DON, Should [Resident # 61's] care plan address that she is receiving oxygen therapy? The DON stated, Yes Ma'am. The Surveyor asked the DON, Why is it important that the care plan addresses that the resident is receiving oxygen therapy? The DON stated, It needs to be known so that anyone who is involved in her care will have that information. e. On 08/31/22 at 3:45 PM, the Surveyor asked the DON, Does [Resident # 61] have orders for tube feedings? The DON looked in the electronic record and stated, Yes Ma'am. The Surveyor asked the DON, Does [Resident # 61's] care plan address that she is receiving tube feedings? The DON looked in the electronic record and stated, No Ma'am. I do not see it in the care plan. The Surveyor asked the DON, Should [Resident #61's] care plan address that she is receiving tube feedings. The DON stated, Yes Ma'am it should. The Surveyor asked the DON, Why is it important that the care plan addresses that the resident is receiving tube feedings. The DON stated, It is important so that anyone taking care of her will have the updated information so that they can provide care to her. f. The facility policy titled, Care Plans, Comprehensive Person-Centered provided by the Business Office Manager (BOM) on 9/1/22 at 1:00 PM documented, .Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation: .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being .

2. Resident #14 had diagnoses of Dementia, Chronic Obstructive Pulmonary Disease, and Anorexia. The Significant Change in Condition MDS with an ARD of 8/8/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS), was totally dependent on one person for personal hygiene. a. The Care Plan with a start date of 8/08/22 documented, . Problem: .ADL deficit unable to perform adl's requires (setup, limited, extensive, total) assistance per 1-2 staff, Self-Care Deficit, General weakness, and pain .Goal: [Resident #14] will be kept well-groomed and clean daily, .Approach: .Bath per schedule 3 x weekly if tolerated . Nail care with baths and prn . b. On 08/30/22 at 9:03 AM, Resident #14 was lying in bed. The resident's fingernails were long, extending approximately 1/8 to 1/4 inch past the end of the nail bed with a black substance under the fingernails. c. On 08/31/22 at 9:10 AM, Resident #14 was lying in the bed. The Surveyor asked the resident if she could look at her fingernails and the resident raised her right hand. The fingernails extended approximately 1/8 to 1/4 inch past the end of the nail bed with a black substance under the nails. The Surveyor asked the resident, Do you let the staff cut and clean your nails? The resident stated, Yes. d. On 08/31/22 at 9:15 AM, the Surveyor asked Registered Nurse (RN) #1, How much assistance does [Resident # 14] need with Activities of Daily Living? RN #1 stated, She is total assistance with ADL's. The Surveyor asked RN #1, How much assistance does [Resident # 14] need with nail care? RN #1 stated, Staff have to do her nails. The Surveyor asked RN #1, Can you describe [Resident # 14's] nails to me? RN #1 asked Resident #14 if she could look at her nails and the resident showed the nurse her hands. RN#1 stated, The nails on the right hand need to be trimmed and one finger on the right hand needs to be cleaned. The nails on the left hand need to be trimmed and two nails on that hand need to be cleaned. The Surveyor asked RN #1, Who is responsible for nail care? RN #1 stated, All the nursing staff are responsible for nail care. Anyone can do it. The Director of Nursing, the Assistant Director of Nursing, the charge nurses and the aides are all responsible for nail care. The Surveyor asked RN #1, How often should nail care be done?' RN#1 stated, At least weekly, but if you see that they need to be done you should do them then. The Surveyor asked RN #1, Why is it important that a residents nails are kept clean and groomed? RN #1 stated, It is important to prevent infection. The main priority is safety. Resident's that have dementia may scratch themselves, but they might scratch other residents as well causing injury and risk for infection due to bacteria. The Surveyor asked RN #1, Does [Resident #14] refuse nail care? RN #1 stated, Maybe sometimes she might, but I think if you ask her, just like I did to look at her nails, she will let you do it. e. On 08/31/22 at 9:25 AM, the Surveyor asked CNA #1, Do you provide care to [Resident # 14]? CNA #1 stated, Yes I take care of [Resident #14]? The Surveyor asked CNA #1, How much assistance does [Resident #14] need with Activities of Daily Living? CNA #1 stated, She is total assistance with ADL's. The Surveyor asked CNA #1, Who is responsible for doing the residents nail care? CNA #1 stated, The CNAs are responsible. The Surveyor asked CNA #1, How often should nail care be done? CNA #1 stated, It should be done every shift. The Surveyor asked CNA #1, Why is it important that nails are kept clean and groomed? CNA #1 stated, It is important, so the resident does not cut themselves and it helps prevent the risk of infection. f. On 08/31/22 at 3:58 PM, the Surveyor asked the DON, Who is responsible for doing nail care? The DON stated, The nursing staff are responsible. The Surveyor asked the DON, How often should nail care be done? The DON stated, They are supposed to do that on their bath day. Some residents get baths Tuesday, Thursday and Saturday and some Monday, Wednesday, and Friday. All except the diabetics and [Resident #14] is not a diabetic. The Surveyor asked the DON, Does [Resident #14] refuse nail care? The DON stated, She did refuse to let staff cut her nails today, but she let them clean them. The Surveyor asked the DON, Why is it important that the residents nails are kept clean and groomed? The DON stated, To prevent infection. She could cut herself with her nails. g. The facility policy titled, Care of Fingernail/Toenails On provided by the BOM on 9/1/22 at 1:00 PM documented, .Purpose: The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infection . General Guidelines: 1. Nail care includes daily cleaning and regular trimming . Based on observation, interview, and record review, the facility failed to ensure oral care was provided for 1 (Resident #7) of 15 (Residents #7, 9, 14, 16, 28, 29, 30, 31, 37, 40, 41, 46, 54, 61 and 69) sampled residents who were dependent on staff for oral care and fingernails were cleaned and trimmed for 1 (Resident #14) of 18 (Residents #7, 9, 14, 16, 20, 22, 28, 29, 30, 31, 37, 38, 40, 41, 45, 46, 54, 55, 61, 69, 71, 72, 77 and 179) sampled residents who were dependent on staff for nail care to promote good personal hygiene and grooming. The findings are: 1. Resident #7 had diagnoses of Cerebrovascular Disease, Cerebral Infarction, Multiple Sclerosis, and Disturbances of Salivary Secretion. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/22 documented was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and was totally dependent of one person for personal hygiene. a. The Care Plan dated 4/28/22 documented, .Problem: Potential for aspiration related to swallowing impairment and risk for dehydration due to gastrostomy tube . [Resident] will be absent of s/s [signs/symptoms] of aspiration, dehydration will tolerate feeding thru [through] this quarter . Approach: Observe for s/s of malnutrition/dehydration: dry cracked lips . ADL [activities of daily living] deficit unable to perform adl's require total care per 1-2 staff . Oral care daily and prn [as needed] . b. The Activities of Daily Living sheets provided by the Business Office Manager (BOM) on 08/31/22 at 10:28 AM did not contain any documentation under Personal Hygiene from 8/24/22 to 8/29/22. c. On 08/29/22 at 3:04 PM, Resident #7 was lying supine in bed with her eyes closed. Her lips were dry with dried skin on both the upper and lower lips. d. On 08/30/22 at 10:20 AM, Resident #7's lips were still dry with dried skin. Her mouth was open slightly and there was yellow build up between all her teeth and at the gum line on every tooth. e. On 08/30/22 at 10:47 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Can you explain to me what her mouth looks like? She stated, Well the CNA [Certified Nursing Assistant) is about to do her mouth care. The Surveyor asked, Yes, but would you say this buildup has been there awhile? She stated, Are you talking about the dried skin on her lips? The Surveyor stated, Yes, and she doesn't eat by mouth, and she has buildup in between her teeth. She stated, Honestly? She nodded her head and stated, Yes, it's been like that awhile. f. On 8/31/22 at 10:29AM, the Surveyor asked the Director of Nursing (DON), How often should residents that are dependent for oral care, receive oral care? She stated, At least twice a day. g. The facility policy titled, [Facility] Oral Care Policy, provided by the BOM on 9/1/22 at 8:02 AM documented, .PURPOSE 1. To cleanse the mouth, teeth, and dentures .3. To moisten the mucous membrane . General Guidelines for Assessment may include . Mouth Dryness . Procedure Note: Offer Oral Hygiene before breakfast, after each meal, and at bedtime .

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications and Oxygen in Use signage was in place to promote oxygen safety for 1 (Resident #61) of 13 (Resident #3, #10, #11, #14, #22, #30, #32, #41 #42, #43, #46, #54 and #61) sampled residents who had physician orders for oxygen therapy. This failed practice had the potential to affect 27 residents who had physician orders for oxygen therapy as documented on a list provided by the Business Office Manager (BOM) on 09/01/22 at 1:00 PM. The findings are: 1. Resident #61 had diagnoses of End Stage Renal Disease, Coronary Artery Disease, and Atherosclerotic Vascular Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. The Physician's Order dated 8/25/22 documented, .prn [as needed] o2 [Oxygen] @ [at] 2L [Liters] r/t [related to] sob [shortness of breath] . b. On 08/29/22 at 1:49 PM, Resident #61 was lying in bed with eyes closed. Oxygen was in use at 2.5-3 liters per nasal cannula. There was no Oxygen in Use sign on the resident's door. c. On 08/31/22 at 9:05 AM, Resident #61 was lying in bed with oxygen in use at 2.5-3 liters per nasal cannula. There was no Oxygen in Use sign on the resident's door. d. On 08/31/22 at 9:06 AM, the Surveyor asked Registered Nurse (RN) #1, Can you tell me what [Resident #61's] oxygen flow rate is set at? RN #1 looked at Resident #61's oxygen flow rate and stated, It is just a little under three. RN #1 adjusted the resident's oxygen flow rate to 2 liters. The Surveyor asked RN #1, Who is responsible for making sure the oxygen is set at the correct rate? RN #1 stated, I am, the charge nurse. The Surveyor asked RN #1, How often should the oxygen flow rate be checked? RN#1 stated, It needs to be checked when you come on at the beginning of your shift. The Surveyor asked RN #1, What is [Resident # 61's] oxygen flow rate supposed to be set at? RN #1 looked in the electronic record and stated, It is ordered at 2 liters as needed for shortness of breath. The Surveyor asked RN #1, Is there a sign on the [Resident # 61's] door stating, Oxygen in Use? RN #1 looked at the resident's door and stated, No there is not. The Surveyor asked RN #1, Should there be a sign on the door stating, Oxygen in Use? RN #1 stated, Yes. The Surveyor asked RN #1, Should doctor's orders for oxygen flow rate be followed? RN #1 stated, Yes. e. On 08/31/22 at 3:27 PM, the Surveyor asked the Director of Nursing (DON), Who is responsible for ensuring that the oxygen flow rate is correct? The DON stated, The charge nurse is responsible. The Surveyor asked the DON, How often should the oxygen flow rate be checked? The DON stated, At least once during their shift. They [Nurses] are in there several times giving medications, and they can check then. The Surveyor asked the DON, Should there be a sign on the resident's door stating, Oxygen in Use? The DON stated, Yes Ma'am there should. The Surveyor asked the DON, Should doctors order for oxygen flow rate be followed? The DON stated, Yes they should be followed. f. The facility policy titled, Oxygen Policy, provided by the BOM on 9/1/22 at 1:00 PM documented, . Purpose: The purpose of the procedure is to provide guidelines for safe oxygen administrator . Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Equipment and Supplies . 4. No Smoking/Oxygen in Use signs . 7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on record review and interview, the facility failed to ensure an antidepressant dose reduction was attempted, in the absence of a physician's documented evaluation of the potential risks versus benefits of continuing the medication and any contraindications for attempting a dose reduction, in order to determine the lowest effective dose and reduce the potential for adverse medication effects for 1 (Resident #31) of 17 (Residents #4, #10, #14, #22, #28, #29, #30, #31, #32, #37, #42, #45, #52, #55 #71, #72 and #77) sampled residents who had a physician's order for an Antidepressant Medication. This failed practice had the potential to affect 39 residents who had physician's orders for an Antidepressant Medication according to a list provided by the Business Office Manager (BOM) on 09/01/22 at 1:00PM. The findings are: 1. Resident #31 had a diagnosis of Alzheimer's Dementia, Acute Kidney Failure and Depression. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/31/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on the Brief Interview for Mental Status (BIMS) and received an antidepressant medication 7 days of the 7 day look back period. a. The Physicians Order dated 12/9/20 documented, .Venlafaxine HCL [Hydrochloride] 75mg [milligram] 1/2 tablet every morning and 1/2 tablet after lunch for Depression . b. The Care Plan with an edited date of 6/6/22 documented, .Problem: .Category: Psychosocial Well-Being [Resident #31] has a hx [History] of depression . Approach: .Medications/labs per MD [Medical Doctor] orders. Notify MD of any changes/concerns . c. The Note to Attending Physician/Prescriber signed by the Consultant Pharmacist, with a printed date of 6/20/22, provided by the Director of Nursing (DON) on 9/1/22 at 9:15 AM documented, .This resident is currently receiving Remeron (Mirtazapine) 15 mg at bedtime and Venlafaxine 37.5 mg twice daily. The combination of these medications may increase the risk of serotonin syndrome. CNS [Central Nervous System] depression, and psychomotor impairment. CMS [Centers for Medicare and Medicaid Services] guidelines state there should be 2 reductions of an antidepressant in the first year of the therapy and then at least yearly thereafter. Please consider one or more of the following: .Taper to Venlafaxine 37.5mg daily . Signature: [Advanced Practice Nurse's signature] Date: 7/18/22 . d. On 09/01/22 at 10:17 AM, the Surveyor asked the Director of Nursing (DON), Was the pharmacy recommendation that was signed by the Advanced Practice Nurse on 7/18/22 to reduce [Resident # 31's] Venlafaxine to 37.5mg daily carried out? The DON looked in the electronic record and stated, No it was not carried out, the order still reads 37.5mg twice daily. The Surveyor asked the DON, Do you know why it was not carried out? The DON stated, No I do not know why. The ADON [Assistant Director of Nursing] who is not here anymore is the person who signed it off. So, I am not sure why it was not carried out, but I will take care of it now. e. The facility policy titled, Medication Therapy (Undated) provided by the Business Office Manager (BOM) on 9/2/22 at 3:05 PM documented, . Policy Statement: 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . Policy Interpretation and Implementation: .4. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. 5. The Physician will identify situations where medications should be tapered, discontinued, or changed to another medication. for example: a. When a mediation is being given in excessive doses, for excessive period of time, without adequate monitoring, or in the absence of a valid clinical rational .

Based on observation of the 8:00 a.m. medication pass on 8/30/22, record review, and interview, the facility failed to ensure orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 5 (Residents #60, 21, 52, 37 and 7) observed during the medication pass. This failed practice had the potential to affect all 74 Residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Acting Administrator on 8/30/20. The medication error rate was 34.78% based on observation of 40 medications administered. The findings are: 1. Resident #60 had diagnosis of Type 2 Diabetes, Dysphagia, and Constipation. a. The August 2022 Physician Orders documented, .Cymbalta 20mg [milligram] delayed release 1 tablet once a day .; Amlodipine 5mg 1 tablet once a day .; Keppra solution 100mg/cc [milligrams per cubic centimeter] 5cc oral twice a day at 8:00 am and 4:00 pm .; ASA EC [Aspirin Enteric Coated] 81mg 1 tablet once a day .; Docusate Sodium 100mg by mouth twice a day at 8:00 am and 4:00 pm .; Ferrous Sulfate 220mg amount 10cc oral twice a day at 8:00 am and 4:00 pm .; Miralax 17G [Grams] dissolved in 8oz [ounces] of water by mouth once a day at 8:00 am . b. Resident #60 did not receive the Docusate Sodium, Ferrous Sulfate and Miralax during the 8:00 am medication pass 2. Resident #21 had diagnosis of Asthma, Heart Failure, and Type 2 Diabetes. a. The August 2022 Physician Orders documented, .Symbicort HFA aerosol inhaler 160-4.5 mcg [micrograms]/actuation 1 puff inhalation twice a day at 8:00 am and 5:00 pm . b. Resident #21 received 2 puffs instead of 1 puff of the Symbicort inhaler during the 8:00 am medication pass. 3. Resident #52 had diagnosis of Cardiomegaly, Abnormal weight loss, and Essential Hypertension. a. The August 2022 Physician Orders documented, .Potassium 20meq [milliequivalent] extended release 1 tablet once a day .; Cymbalta 30mg delayed release 1 tablet once a day .; Namenda 10mg 1 tablet twice a day .; Lasix 20mg 1 tablet once a day .; Metoprolol Tartrate 25mg 1/2 tablet twice a day .; Multivitamin 1 tablet by mouth every day at 8:00 am .; Miralax 17G dissolved in 8oz of water by mouth once a day at 8:00 am .; ASA [Aspirin] 325mg delayed release 1 tablet by mouth every day at 8:00 am .; Colace 100mg 1 capsule by mouth twice a day at 8:00 am and 4:00 pm . b. Resident #52 did not receive the Multivitamin, Miralax, ASA and Colace during the 8:00 am medication pass. 4. Resident #37 had diagnosis of Essential Hypertension, Pressure Ulcer to Sacral Area Stage 3 and Unspecified Cerebral Vascular Disease. a. The August 2022 Physician Orders documented, .Atorvastatin 20mg 1 tablet once a day .; Metformin 500mg 1 tablet twice a day .; Prilosec 40mg 1 tablet once a day .; Folic Acid 1 mg 1 tablet once a day .; Aspirin 81mg 1 tablet once a day .; B1 100mg 1 tablet once a day .; Colace 100mg 1 tablet once a day .; Tylenol 500mg 2 tablets every 6 hours as needed for pain .; Vitamin D3 50mcg 1 tab by mouth every day at 8:00 am .; Ferrous sulfate 220mg 10cc via peg [percutaneous] tube every day at 8:00 am .; MVI [Multivitamin] 1 tablet by mouth every day at 8:00 am .; Miralax 17G dissolved in water via peg tube every day at 8:00 am . b. Resident #37 did not receive the Vitamin D3, Ferrous Sulfate, Multivitamin and Miralax during the 8:00 am medication pass. 5. Resident #7 had diagnosis of Tachycardia, Essential Hypertension, and Ventricular Fibrillation. a. The August 2022 Physician Orders documented, .Robinul 1mg 1 tablet three times a day; Metoprolol tartrate 50mg 1 tablet twice a day .; Lisinopril 20 mg 1 tablet once a day .; Isosorbide 20mg 1 tablet three times a day .; Amlodipine 10mg 1 tablet once a day .; Amiodarone 200mg 2 tablets once a day .; Prostat 30cc once a day .; Potassium 10% solution 20meq 15cc once a day .; Geritol 10cc once a day .; Calcium Carbonate chewable 500mg 1 by mouth every day at 8:00 am .; ASA 1 tablet by mouth every day at 8:00 am . b. Resident #7 did not receive the Calcium Carbonate and ASA during the 8:00 am medication pass. 6. On 8/30/22 at 3:30 pm, the Surveyor asked LPN#1, Why didn't you give all of the over the counter medications that were ordered for these residents? She stated, My computer was messing up. I didn't have good internet service, so I didn't realize I had missed the meds [medications]. The Surveyor asked, When you sat down to chart and realized you had missed them, why didn't you give them? She stated, I guess I thought I gave them. The Surveyor asked, Should you chart that medications were given, when in fact they weren't? She stated, No. 7. On 8/30/22 at 3:40 pm, the Surveyor asked the Director of Nursing (DON), Should all medications ordered by the Physician that is scheduled, be given? She stated. Yes, it should. The Surveyor asked, Should medications be charted that were not given? She stated, No.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled, stored, and disposed of in accordance with manufacturer's instructions and accepted standards of pharmacy practice to prevent potential administration of expired medications to residents. The findings are: 1. On 08/31/22 at 12:54 PM, the 400 Hall medication cart was checked with Licensed Practical Nurse (LPN) #3 with the following findings: a. One opened vial of Novolin R insulin with the label torn off and no opened date was in the top drawer. The Humulin R Insulin manufacturer's insert documented, .STORAGE . In-use vials must be used within 31 days or be discarded, even if they still contain Humulin R U-100 . b. One vial of Levemir insulin with no opened date was in the top drawer. The Levemir Insulin manufacturer's insert documented, . Refrigerated LEVEMIR vials should be discarded 42 days after initial use. Unrefrigerated LEVEMIR vials should be discarded 42 days after they are first kept out of the refrigerator . c. One vial of Lantus insulin with no open date was in the top drawer. d. The Surveyor asked LPN #3, Should this be labeled with an opened date? She stated, It should be labeled when opened. The Surveyor asked, Why is it important to label with an opened date? She stated, Because we don't want to use it if it's expired. The Surveyor asked, Why is it important not to use expired insulin? She stated, Because it doesn't work as well. 2. On 8/31/22 at 1:05 PM, the medication room was checked with Registered Nurse (RN) #1 with the following findings: a. One opened vial Tubersol dated 7/20/22. The Tubersol manufacturer's insert documented, .STORAGE .A vial of TUBERSOL which has been entered and in use for 30 days should be discarded . 3. On 8/31/22 at 1:15 PM, the 200 Hall medication cart was checked with RN #1 with the following findings: a. In the top drawer there was a bottle of Systane eye drops with no opened date. b. One bottle of Combigan eye drop with no opened date. c. One bottle of Latanoprost ophthalmic solution with no opened date. The Xalatan (Latanoprost) manufacturer's insert documented, .Storage: Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks . d. The Surveyor asked RN #1, Why is it important to label eye drops with opened dates? She stated, Because most of them expire after 30 days. The Surveyor asked, Why is that important? She stated, They wouldn't be as effective. 3. The Narcotic book was checked with RN #1, #136 of Tramadol 50 mg (milligrams) with #60, a partial card of Tramadol 50 mg with #46 and an expired card of Tramadol 50mg with different RX number with #29. She stated, I forgot to sign that out. The Surveyor asked, Why are these expired ones in here? She stated, The DON [Director of Nursing] hasn't picked them up yet. The Surveyor asked, Why are they on the same page as the new ones? She stated, I don't know. 4. On 8/31/22 at 1:19 PM, the Surveyor asked the DON, Should nurses be labeling multiuse vials and eye drops when they open them? She stated, Yes, they should be putting the opened date on there, because they are usually only good for 28 days. The Surveyor asked, Why is it important for the opened date to be on there? She stated, So we'll know that it's not expired. The Surveyor asked, Why is it important to know when it expires? She stated, Because it won't have the same effectiveness when used. It may have a drop in effectiveness. 5. The facility policy titled, Storage of Medications, provided by the Business Office Manager (BOM) on 9/1/22 at 8:02 AM documented, .3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . 6. A facility policy titled, Administering Medications, provided by the BOM on 9/1/22 at 8:02 AM documented, .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu for serving pureed diets to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who received a pureed diet according to a list provided by Director of Nursing on 08/31/22 at 12:44 PM. The findings are: 1. The Lunch Menu for 8/29/22 provided by the Dietary Manager on 8/29/22 at approximately 11:30 AM documented the residents on a pureed diet were to receive pureed chili mac, pureed green beans, pureed cornbread, and pureed peanut butter cookie. 2. On 8/29/22 at 12:10 PM, the meal tray consisted of pureed chili mac, pureed green beans, pureed bread, and ice cream. The Surveyor asked Dietary Employee #2 to identify the dessert served to the residents who required a pureed diet. Dietary Employee #3 stated, .They are getting ice cream . 3. The Lunch Menu for 08/30/22 provided by the Dietary Manager on 8/29/22 at approximately 11:30 AM documented the residents on pureed diets were to receive pureed [NAME] pork chop, pureed black eyed peas, pureed southwest slaw, pureed bread, and pureed apple cobbler. 4. On 8/30/22 at 12:00 PM, the dining room tray line had pureed pork chop, pureed black eyed peas, and pureed steamed cabbage. The Surveyor asked Dietary Employee #1 the location of the pureed bread. She stated, .I ran out . The serving line in the kitchen had pureed pork, pureed black eyed peas, and pureed steamed cabbage. The Surveyor asked Dietary Employee #3 the location of the pureed bread. The [NAME] stated, .I don't guess she ever made any of that . They were supposed to get light bread . 5. On 8/31/22 at 2:50 PM, the Surveyor asked the Dietary Manager to discuss the importance of following the menu. She stated, .So they will have a variety and get what they need .

Based on observation, interview, and record review, the facility failed to ensure dietary staff washed their hands between clean and dirty tasks; expired food items were promptly removed and/or discarded by the expiration or use by dates; equipment was clean prior to use to prevent food borne illness; food items stored in the refrigerator/freezer were covered or sealed to retain freshness, taste, and nutrient levels and transport carts were cleaned and well maintained. These failed practices had the potential to affect 71 residents who receive their meals from one of one kitchen according to a list provided by the Owner on 8/31/22 at 1:46 PM. The findings are: 1. On 08/29/22 at 10:08 AM, a bag of bread containing approximately 8 slices was on the shelf above the work surface. The bag was unsealed and opened to contaminants. 2. On 08/29/22 at 10:15 AM, the following items were on the top shelf in the walk-in refrigerator: a. A clear plastic container of cheese sauce. The date on top of the container was 8/24/22. b. A half full pan of macaroni and cheese, was not dated. The pan was covered with clear plastic wrap that did not adhere to the rim of the pan, leaving the food open to air and contaminants. c. The following items were on the middle shelf of the walk-in refrigerator: 1) A pan of leftover roast beef, covered with clear plastic wrap that did not adhere to the top of the pan, leaving the food item open to air and contaminants. 2) A pan of sliced tomatoes, covered with clear plastic wrap that did not adhere to the top of the pan, leaving the food item open to air and contaminants. 3) A pan of chicken spaghetti, covered with clear plastic wrap that did not adhere to the top of the pan, leaving the food item open to air and contaminants. 4) A pan hamburger patties, covered with clear plastic wrap that did not adhere to the top of the pan leaving the food item open to air and contaminants. d. A case of scrambled eggs was on the bottom shelf and was dated 7/7. The Dietary Manager stated, .That is the date we received them. I have told them that they need to put the date that they are taken out of the freezer . No other date was on the box. e. A bag containing 8 large tortillas with a date of 8/8. f. A tub of ricotta cheese was on the top not dated. The Dietary Manager opened the lid, grimaced, and exclaimed, .This needs to be thrown out . 3. There was a bread rack with a bag that was opened and had two Hoagie rolls dated 8/4/22 and an opened bag with 3 Hoagie Rolls was not sealed. 4. On 8/29/22 at 10:26 AM, the following were noted in the walk-in freezer: a. The rubber seal to the walk-in freezer was protruding from around the door. When the freezer door was opened, the floor contained multiple food particles/crumbs in a variety of shades of brown and tan and patches of ice on the floor. The Surveyor asked the Dietary Manager bout the source of the ice. She stated, .Oh, that happens when the door is opened a lot . b. A bag of 8 bread sticks to the right of the entrance was not sealed and left the food item open to air and contaminants. 5. On 8/29/22 at 10:30 AM, the Surveyor and the Dietary made the following observations in the dry storage area: a. There was a large plastic tub of utensils with the top of the tub opened. With unwashed hands, the Dietary Manager raised the lid, rearranged the utensils, and contaminated several items so that the lid would close. b. There was a large tub on the middle shelf. Inside of the tub were 2 bags of spaghetti in the original packaging that had been opened and placed in zip lock bags. The zip lock bags were not sealed. 6. On 8/29/22 at 10:45 AM, two carts with 3 shelves were against the wall in the Dining Room. The carts contained clean water pitchers that were available for the residents. There were two wrinkled and discolored napkins on the bottom shelf. The Dietary Manager stated that there is a resident who enjoys tossing his trash onto the cart. The carts had multiple scuffs and was covered with black marks and dirt. The Surveyor asked the Dietary Manager how often the carts were cleaned. She stated, .Probably not often enough . It's probably been a month . How often should they be cleaned? . 7. On 8/29/22 at 12:00 PM, Dietary Employee #2 was resting an insulated tray base against his pant leg. He obtained items necessary to work the tray station including utensils and condiments. He rearranged the tray racks for easy accessibility. Without washing his hands, he loaded the trays and placed a lid on each individual bowl of green salad. 8. On 08/30/22 at 10:47 AM, Dietary Employee #1 obtained 2 quarter steam table pans from the warmer, holding one pan against her person for transport. 9. On 8/30/22 at 10:48 AM, Dietary Employee #1 lifted the lid of a large plastic bin that contained powdered thickener. Without washing her hands, she reached in and obtained a Styrofoam cup that had been left in the bin. After use, she returned the cup to rest on top of the remaining thickener in the bin. After pureeing the steamed cabbage and without washing her hands, Dietary Employee #1 lifted the pans with her thumbs resting inside the lip of the pan. She got a container of plastic wrap, covered the top of the pans, and placed the pans in the warmer. A Robo Coup bowl was removed from the base. The blade was removed and placed in the bottom of a two compartment sink along with the lid. The bowl was rinsed out with water, no soap. The blade was rinsed and returned to the bowl. The lid was rinsed off with water and shaken. Items were not dried prior to being returned to the base of the machine. Dietary Employee #1 blended one container of pork chops for the residents on mechanical soft diets. The chopped meat was returned to the steam pan. Plastic wrap was used to cover pan. She did not wash her hands. She added additional pork to the bowl of the Robo Coup. She used water to add moisture to mixture. She covered the pan with plastic wrap and placed it in a water bath on the range. She did not wash her hands. She laid the Robo Coup blade and lid in the bottom of the two-compartment sink. She rinsed the blade and placed it on the counter. She rinsed the lid, placed it on the counter, and placed it in the bowl of the Robo Coup. The blade, lid, or bowl were not dried prior to being placed on the machine base. Black eyed peas were placed into the bowl. After initial blending, Dietary Employee #1 lifted the lid of the large plastic tub containing the powdered thickener, without washing her hands she retrieved the styrofoam cup placed thickener into the pea slurry and then returned to the cup to the tub. Without washing her hands, she covered the peas with clear plastic wrap and placed the pan into the water bath on top of the range. Dietary Employee #1 stated, .I'm through . 10. On 9/1/22 at approximately 2:45 PM, the Surveyor asked the Dietary Manager to describe the correct way to store food. She stated, .It should be placed in an air-tight container and dated . The Surveyor asked the Dietary Manager if hands should be washed between clean and dirty tasks. She stated, .Yes .

Based on interview, the facility failed to ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for the residents who resided in 1 of 1 facility. The failed practice had potential to affect 74 residents who resided in the facility according to the Census Report provided by the Administrator on 8/29/22 at 10:15 AM. The findings are: On 8/29/22 at 4:30 PM, in response to the Entrance Conference Worksheet the Administrator verbalized that the facility did not have a policy concerning food being brought into the facility. The Surveyor asked for confirmation and the Administrator repeated, .I am not aware of us having a policy addressing food being brought into the facility from an outside source .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the residents, their representatives, and families 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 a new onset of respiratory symptoms occurring within 72 hours of each other. The failed practice had the ability to affect the 74 residents who reside in the facility according to the Room/Bed list provided by the Administrator on 08/29/22 at 10:09 AM. The findings are: 1. On 08/29/22 at 4:18 PM, the Business Office Manager (BOM) provided a list of the last five COVID positive employees and the last 5 COVID positive residents. 2. On 08/30/22 at approximately 8:30 AM, the Surveyor asked the Business Office Manager who was responsible for notifying the residents, their representatives, and families of a change in the COVID status of the building. She stated, .The Social Director is responsible for calling the families . The Surveyor asked where the calls are documented. She stated, .In the resident's chart . in the progress notes. 3. On 8/30/22 at 3:00 PM, on examination of the lists related to COVID positivity, there were 2 residents and 2 employees who tested positive on 08/22/22. A review of multiple resident medical records revealed no corresponding notations made by the Social Director informing the residents or their families/representatives of the change in COVID status of the building. On 07/28/22 there were 3 residents who tested positive for COVID. A review of the medical record documented no corresponding notation completed by the Social Director or other staff member. 4. On 8/31/2022 at 7:45 AM, the owner of the facility provided the following written confirmation, The facility notifies families and responsibly parties about Covid positives and Covid updates via phone call by social worker and this is documented in Progress Notes of Matrix. 5. On 08/31/22 at 8:30 AM, the Surveyor asked the Social Director where the notifications concerning COVID are documented when made. She stated, .In the Progress Note section of the resident's chart . The Surveyor asked the Social Director if the notifications were made concerning the two employees that tested positive on 8/22/22. She stated, .[Name of previous Administrator] told me she would make those calls because I was sick, my sugar was really high. The Surveyor asked the Social Director if she was the individual responsible for making the notifications for the employee who tested positive on 8/1/22. She stated, .I didn't know anything about that . The Surveyor asked if she was the individual responsible for notifications concerning the two employees who tested positive on 7/25/22. She stated, .I wasn't aware of those either . The Surveyor asked how she was typically notified of a positive test within the building. She stated, .Word of mouth . [Name] would usually tell me . but now they have run her off . we started having stand up again last week but that was the day I was driving the van .