Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the California Department of Public Health (CDPH).This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.During a review of Resident 1's admission record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including gastroenteritis (an inflammation of the stomach and intestines, causing symptoms like nausea, vomiting, diarrhea, abdominal cramps). During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in December 2018 with multiple diagnosis including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During an interview on 7/11/25 at 11:59 a.m. with Resident 1, Resident 1 stated Resident 2 hit him with a cane on his shin. Resident 1 further stated the incident happened the previous week. During a review of Resident 1's and Resident 2's medical records, there was no documented evidence that indicated the alleged abuse was reported to appropriate agencies prior to 7/11/25. During a follow up interview on 7/17/25 at 11:36 a.m. with Resident 1, Resident 1 stated he immediately notified staff when Resident 2 hit him with a cane on his left shin. Resident 1 further stated he was moved to a different room after the incident. During an interview on 7/17/25 at 11:54 a.m. with Licensed Nurse (LN) 3, LN 3 stated approximately 2 weeks ago, she was notified by Resident 1 that he was hit with a cane on his left shin by Resident 2. LN 3 further stated she immediately notified the Director of Staff Development (DSD) of the alleged abuse so it could be investigated. During an interview on 7/17/25 at 12:05 p.m. with DSD, DSD confirmed LN 3 notified him of alleged abuse between Resident 1 and Resident 2 immediately after the incident. DSD further stated he did not report alleged abuse to the appropriate agencies because he was not sure if alleged abuse happened. DSD acknowledged alleged abuse should have been reported. DSD further stated there was a risk of injury and prolonged abuse when alleged abuse was not reported. During a review of the facility's policy and procedure (P&P) titled Abuse Investigation and Reporting, revised July 2024, the P&P indicated, .All reports of resident abuse.shall be promptly reported to local, state, and federal agencies.and thoroughly investigated by the facility.All alleged violations involving abuse.will be reported.an alleged violation of abuse.will be reported immediately, but no later than: Two (2) hours.or Twenty -four (24) hours.

Based on interview and record review, the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for one of three sampled residents (Resident 35) when two tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for drug diversion (when healthcare staff obtain and use prescription medicines illegally), and inaccurate monitoring of the amount and frequency of medications given to the resident. Findings: Resident 35 was admitted to the facility in 2019. Current principal diagnosis was acute respiratory failure (when the body does not get enough oxygen or there is too much carbon dioxide in the body). During a review of Resident 35's physician orders (PO) dated 3/13/25, the PO indicated, Percocet (oxycodone-acetaminophen, medications used to relieve pain) Oral Tablet 10-325 MG (milligram, unit of measurement, used for medication dosage and/or amount) Give 1 tablet .every 4 hours as needed for .pain. During a review of Resident 35's CONTROLLED DRUG RECORD (CDR), Individual Patient's Narcotic Record (a form that keeps count of the number of narcotics dispensed to a resident), indicated one tablet of Percocet was removed from the medication card (pre-packaged medications dispensed from a pharmacy) on 2/23/25 at 10:06 a.m. and one table of Percocet was removed on 2/27/25 at 6:45 p.m. During a review of Resident 35's MAR dated 2/1/25 - 2/28/25, the MAR did not show documentation of Percocet being administered on 2/23/25 at 10:06 a.m. or on 2/27/25 at 6:45 p.m. There were a total of two Percocet that were signed out from the narcotic medication card but were not documented as given to Resident 35. During a concurrent interview and record review on 3/13/25 at 10:39 a.m. with the Director of Nursing (DON) of Resident 35's records, the DON confirmed the CDR documentation did not match the MAR documentation. The DON confirmed there was no way of knowing if narcotics were given to Resident 35, and it should have been documented in the residents MAR if given. During a review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, dated 2001, the P&P indicated, Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose .

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 34) received a thorough monthly pharmacy medication regimen review (MRR). This failure placed Resident 34 at risk for receiving unnecessary, ineffective, and/or excessive dose of Lorazepam (a psychotropic medication to treat anxiety). Findings: Resident 34 was admitted to the facility with diagnoses including thickening and hardening of the walls of the arteries in the brain and anxiety disorder. Review of the admission MDS (Minimum Data Set, an assessment tool) indicated the resident scored 5/15 in the BIMS (Brief Interview for Mental Status, a cognitive assessment) which suggested he had severe cognitive impairment. Review of Resident 34's medical record indicated the resident had a physician order, dated 5/31/24, for Lorazepam 0.5 MG (milligram) to give 1 tablet by mouth every 6 hours as needed for anxiety for 14 day(s). There was no physician order to renew Lorazepam 0.5mg 14 days after the 5/31/24 order until 10/12/24. Review of the Medication Administration Record (MAR) from May 2024 through October 2024 indicated Resident 34 received Lorazepam 0.5 mg until 10/3/24. During a concurrent interview and records review on 3/12/25 at 9 a.m., with the Director of Nursing (DON), the DON confirmed that as needed Lorazepam 0.5mg was ordered on 5/31/24 for a 14-day period, but it continued to be administered until 10/3/2024 for Resident 34 without a physician order for continuation. The DON also verified there had been no monthly MRR for Resident 34 from May 2024 through December 2024 and acknowledged the irregularities in Lorazepam administration could have been identified by the pharmacist, had the MMR been performed. In a telephone interview on 3/12/2025 at 2:12 p.m., with the Pharmacy Consultant (PC), the PC confirmed the monthly MRR was not provided for Resident 34 from May 2024 through October 2024 and acknowledged MRR should have been provided monthly. The PC stated, It [Lorazepam 0.5 mg] was ordered for 14 days, my understanding is that when it's written that way it should automatically stop [after 14 days]. During a review of the Facility's May 2019 policy and procedure (P&P), Medication Regimen Reviews, indicated, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .the Consultant Pharmacist provides a written report to the attending physicians .the report contains .d. The pharmacist's recommendation. During a review of the facility's P&P titled, Psychotropic Medications Use, dated April 8, 2022, the P&P indicated, .PRN orders for psychotropic drugs are limited to 14 days .Pharmacy will review psychotropic medication usage on admission, monthly, and as needed.

Based on observation, interview and record review, the facility failed to ensure infection prevention and control program were maintained and to provide a sanitary environment when two lounge chairs in the dining/activity room were worn out, threadbare and available for resident use. This failure increased the risk for the transmission of communicable diseases. Findings: During an observation on 3/10/25 at 12:03 p.m., two large wing-back lounge chairs made of imitation leather were badly worn with mesh and foam showing through and available for use in the dining/activity room for use. Resident 51 was seen moving between and sitting in both lounge chairs. During a concurrent observation and interview on 3/10/25 at 12:05 p.m. with the Infection Preventionist (IP), the IP verified observation and stated, The lounge chairs used to be covered in leather. [The material] appears to be man made with the fabric lining and foam showing through. It can't be sanitized properly due to the mesh fabric. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON was asked her expectations and stated, When the furniture is worn, we need to replace because it [because we] can't sanitize it. During an interview on 3/13/25 at 10:03 a.m. with the Maintenance Supervisor (MS), the MS was asked if the worn lounge chairs had been put in the maintenance log and he stated, No one reported the two lounge chairs upholstery was deteriorating . During a further interview on 3/13/25 at 10:56 a.m. with the IP, the IP said, We were aware [of the deterioration of the lounge chairs] . The IP also indicated that multiple residents used the lounge chairs. During a review of the Maintenance Log, dated 1/25, 2/25 and 3/25, no request for repair or replacement of the two worn lounge chairs was found. During a review of the facility policy and procedure (P&P), titled Infection Control, revised 10/24, the P&P indicated The objectives of our infection control policies and practices are to .Prevent .infections in the facility .Maintain a .sanitary .environment for .residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record record review, the facility failed to ensure four of 21 sampled residents (Residents 108, 53, 1, and 10) in a census of 61 privacy when curtains did not reach around personal space and vertical blind slats were missing. These failures resulted Resident 10 felt ashamed and increased the potential for increased feelings of reduced self esteem and embarrassment. Findings: Resident 108 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness and difficulty walking. During a review of Resident 108's Minimum Data Set (MDS, an assessment tool), dated 3/4/25, the MDS indicated Resident 108 had moderate memory impairment. During a review of Resident 108's care plan (CP), titled Potential for alteration r/t [related to] .ADL support for .toileting ., dated 3/6/25, the CP indicated Provide privacy . During a concurrent observation and interview in a shared bedroom on 3/10/25 at 9:02 a.m., as Resident 108's curtains were being checked for coverage of the resident's personal space, Resident 108 began independently disrobing at her bedside. The curtains did not reach around her bed and she was visible from the hallway with her upper body naked and exposed. Resident 108 was asked how it made her feel and she responded, Not good! Resident 53 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 had moderate impairment of her memory. During a review of Resident 53's CP, untitled, dated 1/27/25, the CP indicated MAINTAIN RESIDENT'S PRIVACY . During an observation of Resident 53's personal space on 3/10/25 at 9:03 a.m., the privacy curtains did not reach around the bed for privacy and one slat of vertical blinds was missing across sliding door with the courtyard visible outside. During a concurrent observation and interview on 3/10/25 at 9:04 a.m. with the Social Services Assistant (SSA), the SSA verified the curtain did not reach around residents space and a vertical blind was missing, so that Resident 108 and Resident 53 did not have complete privacy. During an interview on 3/10/25 at 10:58 a.m. with Resident 53, Resident 53 stated, That missing slat bothers me. I've mentioned it several times [to staff]. I don't know why they haven't replaced it .You can see directly into [Resident 108 and Resident 53's] room from across the patio from another room. I've seen it [from another room across the courtyard]. Resident 1 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had moderate impairment of her memory. During a review of Resident 1's CP, titled ALTERATION IN ELIMINATION .ADL support for .toileting ., dated 1/17/25, the CP indicated Provide privacy . During a concurrent observation and interview on 3/10/25 at 9:30 a.m. with Resident 1, a slat was missing from the vertical blinds covering a window. Resident 1 stated, At night I don't like it because I think people are spying on me. I've seen people out there [on the patio] . Resident 10 was admitted to the facility in the fall of 2024 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 10's CP titled ALTERATION IN ELIMINATION .ADL support for .toileting ., dated 11/26/24, the CP indicated Provide privacy . During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident had severe memory impairment. During an observation on 3/10/25 at 9:58 a.m. Resident 10 was observed from the doorway of the bedroom while she was being changed. The privacy curtain was pulled forward on both sides but at the foot of the bed, the resident's perineal [the bottom region of your pelvic cavity] area was visible from the doorway. Resident 20's back, buttocks and perineal area were exposed. During a concurrent observation and interview on 3/10/25 at 10:01 a.m. with Certified Nurse's Assistant (CNA)1, CNA 1 acknowledged Resident 10 's bottom was exposed, yet CNA 1 continued to change Resident 10 without pulling the moveable curtain (available at the foot of a roommate's bed), as other people walked in the hallway past the open doorway of Resident 10's room. CNA 1 indicated the curtain was for use to provide privacy for each of the three residents in the room and verified it could be pulled across the foot of each bed. CNA 1 stated she didn't want to bother [to pull it across] because it got her roommate, upset when you move her stuff around. During an interview on 3/11/25 at 9:09 a.m. with Resident 10, Resident 10 was asked how the exposure made her feel. Resident 10 indicated she felt ashamed when people saw her being changed and wanted privacy. Resident 10 also indicated the staff only used the two side curtains. They did not cover the foot of the bed when they changed her. Resident 10 indicated even her roommates saw her when [staff] did not pull the curtains at the foot of the bed. During an interview on 3/10/25 at 10:22 a.m. with the Administrator (ADM), the ADM stated his expectations for privacy was, Residents should be given privacy when being changed or cared for. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON stated, Curtains should be pulled all the way around for privacy. During a review of the Maintenance Log (ML), dated 1/25, 2/25 and 3/25, no entry was found for repair of the curtains or blinds in the rooms of Residents 108, Resident 53, or Resident 1. During a review of the facility policy and procedure (P&P), dated 2/24, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, feeling of self worth and self esteem .promote and protect resident privacy, including bodily privacy during assistance with personal care .

Based on observation, interview and record review, the facility failed to accurately label medications for a census of 61 when: 1. Resident 54's insulin order was not reflected correctly on the medication label, and 2. The medications lacked resident labels and open dates, and the label was unclear and difficult to read. These failures had the potential for residents to receive the wrong medications, incorrect dosages of medications, and expired medications. Findings: 1. During a concurrent observation and interview on 3/11/25 at 8:55 a.m. during medication administration with Licensed Nurse ( LN 1), LN 1 administered 14 units (unit of measurement) of Humulin N (is an intermediate-acting insulin given to help control blood sugar levels in people with diabetes [a chronic condition that affects the way the body processes blood sugar]) 100Units/ml (milliliter, unit of measurement) to Resident 54. The resident's medication label both on the box, and the vial indicated inject 10 units . LN 1 verified in Resident 54's Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident) included the physician order for Humulin N 14 units every morning and 14 units every night. LN 1 confirmed that Resident 54 had a change to their medication dosage and that it was not correctly reflected on Resident 54's medication label. During an interview on 3/13/25 at 10:46 a.m. with the Director of Nursing (DON), the DON was asked what the expectations were for labeling medications with a change in order. The DON stated, If the order changes, per policy, we need to place a sticker, 'change in direction', that will be put on the medication. The DON stated that the pharmacist should be called for a new, accurate resident label and that the label would be delivered during the scheduled delivery time. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated 2001, the P&P indicated, Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy .Labels for individual resident medications include all necessary information such as .cautionary statements .The nursing staff must inform the pharmacy of any changes in physician orders for a medication . 2. A concurrent observation and interview on 3/11/25 at 2:23 p.m. with LN 1, one of two medication storage carts was inspected. During the observation, one bottle of Biktarvy (a medication to treat human immunodeficiency virus [HIV]) 50 mg/200 mg/25 mg (milligram, unit of measurement), two Breyna Inhalation Aerosol (inhaler, a medication that is delivered in a fine mist and inhaled through the mouth and into the lungs) 160 mcg/4.5 mcg(microgram, unit of measurement), and one unidentifiable inhalation aerosol were found with no resident labels. One Symbicort Inhalation Aerosol 160 mcg/4.5 mcg was found with an resident label that was difficult to read. Two Anoro Ellipta Inhalation Powder (a dry, powdered form of medication that is inhaled into the lungs) 62.5 mcg/25 mcg, and one bottle of Lidocaine Viscous 2% Oral Topical Solution (a medication used to treat pain in the mouth or throat) were found without open dates. LN 1 confirmed that the three inhalation aerosols and the Biktarvy were missing resident labels and Lidocaine and inhalation powder had no open dates, and one label on an inhalation aerosol were difficult to read. During an interview on 3/13/25 at 10:46 a.m. with the DON, the DON was asked what the expectations were regarding illegible labels, open date labeling, and medications with no resident label. The DON stated that you should be able to read the label. The DON confirmed that the label on the inhaler was difficult to read and needed to be replaced. The DON stated that if a medication was not labeled, the pharmacy needed to be contacted and the medication to be verified with the pharmacy. Further stating, The medication should be sent to the pharmacy for confirmation, and to be properly labeled. The DON stated once a medication was opened, an open date needed to be labeled on the medication. The DON confirmed that there were no open dates on the Lidocaine and both inhalation powders, and that she expected them to be discarded. The DON confirmed that the three inhalation aerosols had no resident labels. During a review of the facility's P&P titled, Labeling of Medication Containers, dated 2001, the P&P indicated, Medication labels must be legible at all times .Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. During a review of the facility's P&P titled, Storage of Medications, dated 2001, the P&P indicated, Drug containers that have missing, incomplete, improper or incorrect labels are returned to the pharmacy for proper labeling before storing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the physician ' s order were followed to properly manage one out of two sampled resident's (Resident 1) pain. This failure resulted in inadequate pain management for Resident 1. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 11/10/24 indicated intact cognition. A review of Resident 1 ' s pain monitoring on the electronic medical record (EMAR, an electronic health record that keeps track of when medications are given to the residents) for 11/2024 indicated Resident 1 complained of pain 26 out of 27 days since his admission on [DATE]. Resident 1 ' s EMAR for 11/2024 indicated an order for oxycodone (narcotic, analgesic) 5 milligram (mg, unit of measure) 1 tablet every 6 hours as needed (PRN) for severe pain. A review of Resident 1 ' s pain monitoring on the EMAR for 12/2024 indicated Resident 1 complained of pain 24 out of 26 days from 12/1/24 up to 12/26/24. Resident 1 ' s EMAR for 12/2024 indicated an order for oxycodone 5 mg half (1/2) tablet every 6 hours PRN-start date of 11/29/24 and discontinued date of 12/13/24, for moderate pain. Resident 1 ' s EMAR for 12/2024 also indicated an order for oxycodone 5 mg 1/2 tablet every 4 hours PRN -start date of 12/13/24 for moderate pain. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated staff did not know how to adequately manage his pain. Resident 1 stated he knew he was undermedicated for pain. Resident 1 stated nurses were not following the doctor ' s order for pain management, or they just don ' t bother to read the order. Resident 1 stated due to staff not following the physician order for his pain management, his pain was not adequately controlled. During a concurrent interview and EMAR record review for 11/2024 and 12/2024 on 12/26/24 at 2:46 p.m., the Director of Nursing (DON) stated the facility uses a numeric rating scale (NRS, consist of a series of numbers rating pain intensity, typically from 0 to 10) when identifying pain intensity. The DON stated the facility interprets a pain level (PL) of 1 to 3 to indicate mild pain, a PL of 4 to 6 to indicate moderate pain and PL of 7 to 10 indicate severe pain. The DON stated pain medications were administered based on severity parameters as ordered by the physician. The DON stated it was important to follow the physician ' s orders for pain management so resident could achieve optimal pain relief. The DON stated this was important to improve residents ' quality of life. A concurrent interview and 12/2024 EMAR record review with the DON indicated on 12/26/24 at 2:46 p.m. indicated oxycodone 5 mg ½ tablet by mouth every 6 hours PRN for moderate pain (start date of 11/29/24 and dc date of 12/13/24) was given to the resident on 12/7/24 for a PL 7, 12/11/24 for a PL 8, 12/12/24 for a PL 8, 12/13/24 for a PL 9. The DON verified MD ordered was not followed since Resident 1 was complaining of severe pain and not moderate pain. A review of 12/2024 EMAR with the DON indicated oxycodone 5 mg ½ tablet by mouth every 4 hours PRN for moderate pain, start date of 12/13/24, was administered to Resident 1 on 12/14/24 two times when he complained of PL 7 and 8, on 12/17/24 for a PL 9, on 12/21/24 for a PL 7 and on 12/24/24 for PL 2. The DON verified staff did not the follow the physician ' s order. A review of the numeric rating scale adopted from [NAME], [NAME] et al. 1989 indicated 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. A review of the facility ' s policy and procedure (P&P) titled Pain Assessment and Management, revised 3/2020, the P&P indicated, . the pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident choices related to pain management . A review of the facility ' s P&P titled Administering Medications, revised 4/2019, the P&P indicated, . medications are administered in accordance with prescriber orders . Based on interviews and record reviews, the facility failed to ensure the physician's order were followed to properly manage one out of two sampled resident's (Resident 1) pain. This failure resulted in inadequate pain management for Resident 1. Findings: A review of Resident 1's face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1's diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/10/24 indicated intact cognition. A review of Resident 1's pain monitoring on the electronic medical record (EMAR, an electronic health record that keeps track of when medications are given to the residents) for 11/2024 indicated Resident 1 complained of pain 26 out of 27 days since his admission on [DATE]. Resident 1's EMAR for 11/2024 indicated an order for oxycodone (narcotic, analgesic) 5 milligram (mg, unit of measure) 1 tablet every 6 hours as needed (PRN) for severe pain. A review of Resident 1's pain monitoring on the EMAR for 12/2024 indicated Resident 1 complained of pain 24 out of 26 days from 12/1/24 up to 12/26/24. Resident 1's EMAR for 12/2024 indicated an order for oxycodone 5 mg half (1/2) tablet every 6 hours PRN-start date of 11/29/24 and discontinued date of 12/13/24, for moderate pain. Resident 1's EMAR for 12/2024 also indicated an order for oxycodone 5 mg 1/2 tablet every 4 hours PRN -start date of 12/13/24 for moderate pain. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated staff did not know how to adequately manage his pain. Resident 1 stated he knew he was undermedicated for pain. Resident 1 stated nurses were not following the doctor's order for pain management, or they just don't bother to read the order. Resident 1 stated due to staff not following the physician order for his pain management, his pain was not adequately controlled. During a concurrent interview and EMAR record review for 11/2024 and 12/2024 on 12/26/24 at 2:46 p.m., the Director of Nursing (DON) stated the facility uses a numeric rating scale (NRS, consist of a series of numbers rating pain intensity, typically from 0 to 10) when identifying pain intensity. The DON stated the facility interprets a pain level (PL) of 1 to 3 to indicate mild pain, a PL of 4 to 6 to indicate moderate pain and PL of 7 to 10 indicate severe pain. The DON stated pain medications were administered based on severity parameters as ordered by the physician. The DON stated it was important to follow the physician's orders for pain management so resident could achieve optimal pain relief. The DON stated this was important to improve residents' quality of life. A concurrent interview and 12/2024 EMAR record review with the DON indicated on 12/26/24 at 2:46 p.m. indicated oxycodone 5 mg ½ tablet by mouth every 6 hours PRN for moderate pain (start date of 11/29/24 and dc date of 12/13/24) was given to the resident on 12/7/24 for a PL 7, 12/11/24 for a PL 8, 12/12/24 for a PL 8, 12/13/24 for a PL 9. The DON verified MD ordered was not followed since Resident 1 was complaining of severe pain and not moderate pain. A review of 12/2024 EMAR with the DON indicated oxycodone 5 mg ½ tablet by mouth every 4 hours PRN for moderate pain, start date of 12/13/24, was administered to Resident 1 on 12/14/24 two times when he complained of PL 7 and 8, on 12/17/24 for a PL 9, on 12/21/24 for a PL 7 and on 12/24/24 for PL 2. The DON verified staff did not the follow the physician's order. A review of the numeric rating scale adopted from [NAME], [NAME] et al. 1989 indicated 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. A review of the facility's policy and procedure (P&P) titled Pain Assessment and Management , revised 3/2020, the P&P indicated, . the pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident choices related to pain management . A review of the facility's P&P titled Administering Medications , revised 4/2019, the P&P indicated, . medications are administered in accordance with prescriber orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure there was an updated discharge plan for one out of two sampled residents (Resident 1) when: 1.There were no regular re-evaluation of Resident 1 to identify changes that require the modification his discharge plan. The discharge plan was not updated, as needed, to reflect these changes. 2.Resident 1 was not involved in the development of the discharge plan and was not informed of the final discharge plan. 3.There was no documentation that Resident 1 has been asked about his plans in returning to the community after he completed skilled services on 12/15/24. These failures to fully prepare Resident 1 be discharged for discharge from the facility could result to safety issues, prevent Resident 1 to be an active partner to effectively transition him to post-discharge care to prevent potential readmissions. Findings: A review of Resident 1's face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1's diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). A review of Resident 1's Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long-term care nursing facilities) assessment dated [DATE] indicated he had intact cognition. Resident 1's MDS also indicated he needed maximal assistance (staff provides more than half of the effort) when it comes to transfers. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he wished to be discharged from the facility as soon as possible. Resident 1 stated staff did not talk to him about his discharge plan and his preference to go home with his cousin. Resident 1 stated no one from the facility talked to him about being discharged from the facility and what the current plan was. Resident 1 stated for now all he knew was he can't be discharged from the facility. Resident 1 stated the facility nurses, and the social services knew he wished to be discharged from the facility. During a concurrent interview and Social Services Initial assessment dated [DATE] record review on 12/26/24 at 4:37 p.m., the Director of Nursing (DON) stated she was aware Resident 1 wished to be discharged from the facility. The DON verified Resident 1's previous discharged plan was to go home; however, it was now changed since Resident 1 had no one to care for him and has limited funding. The DON stated Resident 1 was custodial (non-medical care provided by non-licensed staff and does not require the constant attention of trained medical professional) as of 12/15/24. The DON stated she was aware of Resident 1's desire to be discharged from the facility. The DON was unsure on whether anyone from her team had spoken to Resident 1 about Resident 1's plan to be discharged to his cousin's care. The DON was unable to provide documentation about a new DC plan in place for Resident 1. During a concurrent interview and Social Service Director (SSD) note dated 11/8/24 record review on 12/26/24 4:43 p.m., the Minimum Data Set Coordinator (MDSC) verified there were no plans yet on when to discharge Resident 1 from the facility and there was no note to indicate a new plan to discharge Resident 1 from the facility had been initiated at this time. The MDSC stated it was Resident 1's right to be discharged from the facility if he so wished and it was the facility's responsibility to ensure safe discharge from the facility. A review of the facility's policy and procedure (P&P) titled Transfer or Discharge- Resident Initiated dated 10/2022, the P&P indicated, Resident Initiated Transfer or Discharge means the resident, or the responsible party had provided written or verbal notice of intent to leave the facility .documentation: written or verbal notice of intent to leave the facility, a discharge plan, documented discussion with the resident, or if appropriate, with his/her representative containing details of discharge planning and arrangements . Based on interviews and record reviews, the facility failed to ensure there was an updated discharge plan for one out of two sampled residents (Resident 1) when: 1.There were no regular re-evaluation of Resident 1 to identify changes that require the modification his discharge plan. The discharge plan was not updated, as needed, to reflect these changes. 2.Resident 1 was not involved in the development of the discharge plan and was not informed of the final discharge plan. 3.There was no documentation that Resident 1 has been asked about his plans in returning to the community after he completed skilled services on 12/15/24. These failures to fully prepare Resident 1 be discharged for discharge from the facility could result to safety issues, prevent Resident 1 to be an active partner to effectively transition him to post-discharge care to prevent potential readmissions. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). A review of Resident 1 ' s Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long-term care nursing facilities) assessment dated [DATE] indicated he had intact cognition. Resident 1 ' s MDS also indicated he needed maximal assistance (staff provides more than half of the effort) when it comes to transfers. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he wished to be discharged from the facility as soon as possible. Resident 1 stated staff did not talk to him about his discharge plan and his preference to go home with his cousin. Resident 1 stated no one from the facility talked to him about being discharged from the facility and what the current plan was. Resident 1 stated for now all he knew was he can ' t be discharged from the facility. Resident 1 stated the facility nurses, and the social services knew he wished to be discharged from the facility. During a concurrent interview and Social Services Initial assessment dated [DATE] record review on 12/26/24 at 4:37 p.m., the Director of Nursing (DON) stated she was aware Resident 1 wished to be discharged from the facility. The DON verified Resident 1 ' s previous discharged plan was to go home; however, it was now changed since Resident 1 had no one to care for him and has limited funding. The DON stated Resident 1 was custodial (non-medical care provided by non-licensed staff and does not require the constant attention of trained medical professional) as of 12/15/24. The DON stated she was aware of Resident 1 ' s desire to be discharged from the facility. The DON was unsure on whether anyone from her team had spoken to Resident 1 about Resident 1 ' s plan to be discharged to his cousin ' s care. The DON was unable to provide documentation about a new DC plan in place for Resident 1. During a concurrent interview and Social Service Director (SSD) note dated 11/8/24 record review on 12/26/24 4:43 p.m., the Minimum Data Set Coordinator (MDSC) verified there were no plans yet on when to discharge Resident 1 from the facility and there was no note to indicate a new plan to discharge Resident 1 from the facility had been initiated at this time. The MDSC stated it was Resident 1 ' s right to be discharged from the facility if he so wished and it was the facility ' s responsibility to ensure safe discharge from the facility. A review of the facility ' s policy and procedure (P&P) titled Transfer or Discharge- Resident Initiated dated 10/2022, the P&P indicated, Resident Initiated Transfer or Discharge means the resident, or the responsible party had provided written or verbal notice of intent to leave the facility .documentation: written or verbal notice of intent to leave the facility, a discharge plan, documented discussion with the resident, or if appropriate, with his/her representative containing details of discharge planning and arrangements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was safe during transfer when four certified nursing students were allowed to assist a staff member to transfer Resident 1 from his bed to the shower chair. This failure resulted to Resident 1 to fall on 11/15/24. Findings: A review of Resident 1's face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1's diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1's Brief Interview for Mental Status (BIMS, a screening tool used to assess a person's cognitive functioning) dated 11/10/24 score was 15 indicating intact cognition. A review of Resident 1's Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment dated [DATE] indicated he had intact cognition and he needed maximal assistance (when a helper/staff member provides more than half of the effort to help a resident complete an activity) when it comes to transfers. A review of the Interdisciplinary Team (IDT, a group of health care professionals from different disciplines who work together to provide care for patients) note dated 11/18/24 indicated during transfer from bed to the shower chair Resident 1 fell while being transferred by the certified nursing assistant (CNA) with the assistance of 4 students. During an interview on 12/26/24 at 12:36 p.m., Licensed Staff (LS) B stated Resident 1 required an assistance of 2 staff during transfers. LS B stated students were not allowed to assist staff with transfers because they were only at the facility to observe. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he fell while a staff member and 4 students attempted to transfer him from bed to the shower chair. Resident 1 stated the students did not know what they were doing. Resident 1 stated there was no coordination and he felt the students yanking him from different directions. Resident 1 stated he knew students should not be assisting with his transfers. Resident 1 stated he fell because instead of 2 staff assisting him during transfers, there was only 1 staff who assisted him and 4 students. Resident 1 stated this compromised his safety. Resident 1 stated the facility did not follow the protocol. During a concurrent interview and IDT note dated 11/18/24 record review on 12/26/24 at 1:16 p.m., the Director of Nursing (DON) verified the IDT note indicated Resident 1 fell during transfer to shower chair while being assisted by a staff and 4 students. The DON stated Resident 1 required the assistance of 2 staff during transfers. When asked if students were allowed to assist CNAs to transfer residents, the DON stated no . A review of the facility's policy and procedure (P&P) titled Falls and Fall Risks, Managing revised 3/2018, the P&P indicated, . staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling . Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was safe during transfer when four certified nursing students were allowed to assist a staff member to transfer Resident 1 from his bed to the shower chair. This failure resulted to Resident 1 to fall on 11/15/24. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1 ' s Brief Interview for Mental Status (BIMS, a screening tool used to assess a person's cognitive functioning) dated 11/10/24 score was 15 indicating intact cognition. A review of Resident 1 ' s Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment dated [DATE] indicated he had intact cognition and he needed maximal assistance (when a helper/staff member provides more than half of the effort to help a resident complete an activity) when it comes to transfers. A review of the Interdisciplinary Team (IDT, a group of health care professionals from different disciplines who work together to provide care for patients) note dated 11/18/24 indicated during transfer from bed to the shower chair Resident 1 fell while being transferred by the certified nursing assistant (CNA) with the assistance of 4 students. During an interview on 12/26/24 at 12:36 p.m., Licensed Staff (LS) B stated Resident 1 required an assistance of 2 staff during transfers. LS B stated students were not allowed to assist staff with transfers because they were only at the facility to observe. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he fell while a staff member and 4 students attempted to transfer him from bed to the shower chair. Resident 1 stated the students did not know what they were doing. Resident 1 stated there was no coordination and he felt the students yanking him from different directions. Resident 1 stated he knew students should not be assisting with his transfers. Resident 1 stated he fell because instead of 2 staff assisting him during transfers, there was only 1 staff who assisted him and 4 students. Resident 1 stated this compromised his safety. Resident 1 stated the facility did not follow the protocol. During a concurrent interview and IDT note dated 11/18/24 record review on 12/26/24 at 1:16 p.m., the Director of Nursing (DON) verified the IDT note indicated Resident 1 fell during transfer to shower chair while being assisted by a staff and 4 students. The DON stated Resident 1 required the assistance of 2 staff during transfers. When asked if students were allowed to assist CNAs to transfer residents, the DON stated no. A review of the facility ' s policy and procedure (P&P) titled Falls and Fall Risks, Managing revised 3/2018, the P&P indicated, . staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During an observation on 6/6/23 at 8:25 AM, Resident 45 was receiving personal care by CNA 1 and CNA 2. Following the care, the two CNA's left the room. Resident 45's bed was elevated in the highest position, several feet off the floor. During a concurrent observation and interview on 6/6/23 at 8:28 AM, with CNA 1, CNA 1 stated sometimes the residents will accidentally use the button and raise the bed by themselves, and stated Resident 45 could have raised it herself and then referred me to speak with CNA 2. CNA 1 lowered Resident 45's bed back to the lowest position when prompted. During an interview on 6/7/23 at 8:40 AM, CNA 2 stated when she CNA 1 left the room following providing care on 6/6/23, they must have forgotten and did not return Resident 45's bed to the lowest position as they should have. During a review of Resident 45's Care Plan, dated 5/15/23, the Care Plan indicated Resident 45 had a fall risk assessment of 12, with 10 or above being high risk. The Care Plan indicated the environment would be kept free of hazards by facility staff. Based on observation, interview, and record review, the facility failed to provide a safe environment for 3 of 17 sampled residents (Residents 25, 34, and 45). a. For Resident 25, two unlabeled cups, containing medication pills, were left unattended on the bedside table. b. For Resident 34, a white oblong pill was left on a plastic spoon unattended on the table. c. For Resident 45, Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) failed to lower the bed to its lowest position after they completed personal care to Resident 45. These failures had the potential to cause serious bodily injuries, and unauthorized access to narcotics (to treat moderate and severe pain) and medications to Residents in the facility. Findings: a. Review of the admission Record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, current episode mixed, severe, without psychotic features (changes in a person's mood, energy, and ability to function) and Type 2 Diabetes Mellitus with unspecified complications (a problem in the way the body regulates and uses sugar as fuel). Review of Resident 25's active physician order summary as of 6/5/23, indicated the following medications: 1. Order dated 3/24/23, metformin (for type 2 Diabetes Mellitus) extended release (the medication is released slowly over time) twenty-four hour 500 milligram (mg) give 4 tablets by mouth one time a day. 2. Order dated 3/24/23, Allupurinol (for protein in the urine) 300 milligram (mg) give one tablet by mouth one time a day. 3. Order dated 3/24/23, ezetimibe (for elevated cholesterol levels) tablet 10 milligram (mg) give one tablet by mouth one time a day. 4. Order dated 3/24/23, cyanocobalamin (for vitamin B12 deficiency) tablet 1000 microgram (mcg) by mouth one time a day for supplement. 5. Order dated 3/24/23, fenofibrate (to lower high cholesterol levels) 160 milligram (mg) by mouth one time a day. 6. Order dated 3/24/23, lamotrigine (for shaking and bipolar disorder) 25 milligram (mg) give one tablet by mouth one time a day. 7. Order dated 3/24/23, Losartan potassium (for high blood pressure) 100 milligram (mg) give one tablet by mouth one time a day. 8. Order dated 3/24/23, venlafaxine (for anxiety) extended release twenty-four hour 75 milligram (mg) give one tablet by mouth one time a day. During an observation of Resident 25's room on 6/5/23 at 9:35 AM, two unlabeled medication cups containing eight medication pills, were left unattended on Resident 25's bedside table. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/5/23 at 9:38 AM, LVN 1 confirmed she left the two cups of medication pills on Resident 25's bedside table, unattended for thirty minutes. LVN 1 also stated she did not wait for Resident 25 to consume metformin 500 mg, Allupurinol 300 mg, ezetimibe 10 mg, cyanocobalamin 1000 mcg, fenobibrate 160 mg, lamotrigine 25 mg, Losartan potassium 100 mg, and venlafaxine 75 mg. During an interview with the Director of Nursing (DON) on 6/5/23 at 9:45 AM, the DON confirmed Resident 25 did not have a nursing care plan for self-administration of medications. The facility's policy and procedure, titled, Administering Medications, revised April 2019, indicated, Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions and honoring resident choices and preferences, consistent with his or her care plan. Resident may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they have the decision-making capacity to do so safely . b. Review of the admission Record indicated, Resident 34 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome. During a concurrent observation and interview with Resident 34 on 6/5/23 8:40 AM, a white oblong pill sitting on a plastic spoon was on a table next to Resident 34's bed. When asked about the pill, Resident 34 stated, That's my Percocet! (opiate/narcotic pain medication) and immediately picked up the pill, put it in his mouth, and swallowed it. Resident 34 stated the night shift nurse, Licensed Vocational Nurse 5 (LVN 5) brought him the Percocet a few hours prior. Resident 34 reported, Sometimes they watch me swallow the pills but sometimes they don't, and I can keep it for later. During a concurrent interview and record review with (LVN 2) on 6/5/23 at 9:44 AM, Resident 34's Medication Administration Record was reviewed. LVN 5 documented he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM. Resident 34's Percocet supply was observed with LVN 2. LVN 2 confirmed Percocet were white oblong pills. During an interview with on 6/8/23 at 7:30 AM, LVN 5 stated Resident 34 was knowledgeable about his medications and could identify which pill was Percocet. LN 5 confirmed he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM, but denied he left the medication at the bedside. LVN 5 further denied noticing an unsecured white pill sitting on Resident 34's table during his shift. During an interview with the Director of Nursing (DON) on 6/8/23 at 8:15 AM, the DON stated it was unacceptable for nursing staff to leave medications unsecured at the resident's bedside, especially controlled medication. The DON stated it was very concerning that Resident 34 reported nursing staff did not always observe him consume his Percocet, because staff needed to know the exact time the medication was consumed. The DON stated, If the resident is saving them for later, there is opportunity for overdose. During a review of Resident 34's Minimum Data Set (resident assessment tool), dated 3/29/23, Resident 34's Brief Mental Status score was 15, which indicated Resident 34 was cognitively intact. During a review of Resident 34's physician's order, dated 4/21/22, indicated Resident 34 could receive one Percocet 10 mg (milligrams)/350 mg Tylenol tablet every four hours as needed. Review of the facility's policy titled, Controlled Medication Storage, dated 2007, indicated, . Only authorized licensed nursing and pharmacy personnel have access to controlled medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for the care and maintenance of a PICC (Peripherally Inserted Central Catheter) (a long catheter that is inserted through the skin into a large vein just above the heart used for administering antibiotics or fluid) for one of 17 sampled residents (Resident 28). As a result of this failure, Resident 28 was at risk for infection and complications from his PICC. Findings: Review of the admission Record indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included sepsis (blood infection) and pressure ulcers, and Resident 28 required intravenous (IV) antibiotics (medication given through a vein to treat infection). During a concurrent observation and interview with Resident 28 on 6/6/23 at 8 AM, Resident 28 stated he had a PICC for IV antibiotics, which were discontinued approximately two weeks prior. Resident 28 reported the hub (essential part of the catheter where a syringe or medication tubing would connect) of the PICC broke off two days after the antibiotics were discontinued, and a nurse coiled the tubing and placed a dressing over the tubing. Resident 28 stated, No one has done anything with it since, and I am waiting to have it removed. Resident 28 stated he was concerned he was at risk for infection due to the broken PICC. A catheter was observed in Resident 28's right upper chest. There was no hub at the end of the catheter tubing; instead, the catheter end was exposed. The entire length of the exposed catheter tubing was coiled, and a clear tape dressing was placed on top. The dressing was not dated to indicate when it was changed. During an interview with Registered Nurse 3 (RN 3), who was the charge nurse, on 6/6/23 at 1:42 PM, RN 3 stated she was unaware of any issues with Resident 28's PICC. She stated Resident 28 was waiting for a physician's appointment to have the PICC removed. RN 3 stated the PICC dressing should have been changed weekly and flushed per order. RN 3 stated she had just observed Resident 28's PICC and confirmed the hub was broken off and the dressing was not dated. She stated, I'm not sure how long it's been like that, but the resident says it's been a long time. RN 3 stated she was unaware if the physician was notified the PICC was broken. During a concurrent interview and review of Resident 28's record with the Director of Nursing (DON) on 6/8/23 at 8:15 AM: The physician's order, dated 3/18/23, indicated Resident 28 had a PICC in his right upper chest. The order directed staff to change the PICC dressing and hub every Sunday and monitor the insertion site for signs and symptoms of infection. The Minimum Data Set, dated [DATE], indicated Resident 28's Brief Mental Status score was 15 (which indicated Resident 28 was cognitively intact). The physician's order, dated 5/24/23, indicated Resident 28's antibiotics were discontinued. Nursing Notes on 5/7/23 and 5/14/23, indicated nursing staff changed Resident 28's PICC dressing. There was no documentation which indicated the PICC had been assessed or the PICC dressing was changed, on 5/21/23, 5/28/23, or 6/4/23. The DON stated she was unaware of any issues with Resident 28's PICC until it was identified during the survey. The DON confirmed there was no documentation of assessments or dressing changes for Resident 28's PICC after 5/14/23, no documentation which indicated the PICC hub was broken, and no documentation the physician was notified. The DON stated the broken PICC placed Resident 28 at risk for bleeding and infection, and staff should have notified her and the physician when the line broke and documented the notification. Review of the facility's policy titled, Central and Midline Dressing Changes, undated, indicated, The following information should be recorded in the resident's medical record: Date and time the dressing was changed . any complications, interventions that were done . Report any signs and symptoms of complications to the provider, supervisor, and oncoming shift .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were in stock and available to administer, for one unsampled resident (Resident 250). As a result of this failure, Resident 250 was at risk for potential complications of not receiving medications timely. Findings: Review of the admission Record indicated Resident 250 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection and colonic polyps (abnormal growths in the lining of the colon). During an observation of medication pass with Licensed Vocational Nurse 2 (LVN 2) on 6/7/23 at 8:05 AM, LVN 2 prepared Resident 250's morning medications. LVN 2 confirmed she was administering five medications to Resident 250 during the medication pass. Review of Resident 250's medication orders on 6/7/23 at 12 PM, indicated Resident 250 should have received six medications during the medication pass. LVN 2 did not administer Colace 250 mg (milligram) gel capsule (an over-the-counter stool softener) during the medication pass observation. During an interview with LVN 2 on 6/7/23 at 12:10 PM, LVN 2 stated Resident 250's Colace was not available to administer, and she sent a message to pharmacy to refill the medication. LVN 2 confirmed the medication was due at 9 am, and Resident 250 had not received Colace at the time of the interview. LVN 2 stated she did not notify the physician the medication was not available and was late. During an observation of the central supply closet with the Infection Preventionist (IP 1) and the Administrator on 6/7/23 at 2 PM, the over-the-counter medication supply was noted. There were no Colace 250 mg gel capsules in the supply. During an interview on 6/8/23 at 1:34 PM LVN 1 stated there should be at least a seven-day supply of medication for every resident. LVN 1 stated, every Friday the med nurse should check the cart for low supply and make sure medications are ordered if supply is low. LVN 1 stated, over-the-counter medications were stored in the central supply closet and, if a medication was not available in the supply closet, staff should notify the Director of Nursing so she could purchase the medication. LVN 1 stated this process was not documented, and no inventory was kept of over-the-counter medications in the medication carts. During a review of Resident 250's physician's orders, dated 5/31/23 at 4:43 PM, the order indicated Resident 250 should receive Colace 250 mg capsule once daily. During a review of the facility's medication administration schedule, dated 2/6/23, daily medications should be administered at 9 AM. The facility did not provide a policy related to the inventory and supply of over-the-counter medications during the survey.

Based on observation, interview and record review, the facility failed to provide food at an appetizing temperature for 3 of 17 sampled residents (Resident 9, Resident 28, Resident 100) and one unsampled resident (Resident 10). This failure resulted in residents' dissatisfaction with their meals and the potential to decrease the amount of food consumed by residents, therefore reducing nutritional support aiding in recovery from illness or injury. Findings: During an interview with Resident 100 on 6/5/23 at 8:30 AM, Resident 100 stated, food is cold .and they don't do anything about it. During an interview with Resident 9 on 6/8/23 at 7:33 AM, Resident 9 stated his food is always cold by the time he got to eat. During an observation with Food Service Manager 1 (FSM 1) on 6/8/23 at 7:35 AM, FSM 1 validated the temperature of Resident 9's breakfast following delivery to Resident 9's room. The waffle was 82 degrees, and the hot cereal was 93 degrees. During an observation on 6/8/23 at 7:45 AM, Resident 10's eggs were verified by FSM 1 to be 97.6 degrees on the food rack prior to delivery to Resident 10. During an observation on 6/8/23 at 7:50 AM, FSM 1 verified Resident 28's waffle was 100.6 degrees, and the eggs were 100.1 degrees once the tray arrived in his room. During an interview on 6/8/2023 at 7:51 AM, FSM 1 stated the food should arrive at the residents' room at 120 degrees or higher. During an interview with Resident 100 on 6/8/23 at approximately 8:30 AM, Resident 100 stated, I do not know how they transport it here, but it is always cold. During an observation on 6/8/23 at 11:55 AM, FSM 1 verified the temperature of the cheeseburger for Resident 28, it was 112.5 while on the tray rack prior to distribution to Resident 28. At 11:57 AM, the cheeseburger for Resident 100, on the tray rack, was verified by FSM 1 to be 104 degrees. During an interview with resident 100 on 6/8/23 at 11:58 AM, Resident 100 stated his cheeseburger was not cold, just adequate. During a review of the facility's policy and procedure titled, Food Temperature, dated 10/17, indicated, .hot foods should be 140 degrees or above while on tray line .

Based on observation, interview and record review, the facility failed to keep the kitchen and equipment clean, free from residual food build up and grime. This failure resulted in unsanitary work areas where pathogens could potentially affect the residents with food-borne illness. Findings: During an observation on 6/8/23 at 7:05 AM, in the facility kitchen, many surfaces and equipment had the discoloration of food build-up and grime in various locations. Photographs were taken to capture the soilage. Areas noted were: An electrical socket located behind the toaster, the facial surface of the blender, the toaster, the steamer door, inside and out, the scale, a bracket fixated on the doorframe of the door to the parking lot, the dishwasher, signage, the can opener's base and the door frame to the food service office. During a concurrent interview and observation on 6/8/23 at 9:00 AM with Food Service Manager 1 (FSM 1), in the kitchen, the FSM 1 verified the presence of the discoloration from food build-up and grime at the various locations observed. The FSM 1 stated his staff should do a more thorough job, and the grime and residual food was not washed well with the daily wipes currently being done. During a review of the kitchen's Daily Cleaning Schedule, dated June 2023, the Daily Cleaning Schedule indicated the staff signed off on daily cleaning with multiple tasks. Evidence of soilage present indicated cleaning tasks were not completed effectively.

Based on interview and record review, the facility failed to provide evidence of annual tuberculin skin test (a test to determine the presence of infection with tuberculosis and bacterial infection of the lungs) results for Infection Preventionist 1(IP 1). This failure had the potential to spread undetected Tuberculosis (TB) infection (spread through the air from one person to another when a person with TB coughs and speaks) to a universe of 55 Residents in the facility. Findings: During a review of IP 1's personal file, indicated, Quantiferon-TB Gold Plus test (tests for TB infection) results were done on 3/20/22. During an interview with the Director of Staff Development (DSD) on 6/8/23 at 9:45 AM, the DSD confirmed the IP 1 did not have an updated purified protein derivative (PPD-to help diagnose tuberculosis infection) skin test for TB. During an interview with Director of Nursing (DON) on 6/8/23 at 10:39 AM, the DON stated the IP 1's tuberculin skin test should have been updated and done annually. The facility's policy and procedure, titled, Employee Tuberculosis Screening, updated September 2019, indicated, The individual State mandates annual testing by law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow professional standards of practice when a Licensed Nurse did not ensure pain medication for 1 of 3 residents (Resident 1), was administered completely before leaving the resident's room. This failure had the potential to result in the patient not taking the medication correctly, unrelieved pain, danger of other residents taking the medication, patient dissatisfaction, and loss of patient trust and confidence in the nursing staff of the facility. Findings: A review of Resident 1's admission record, indicated she was admitted to the facility on [DATE] for dizziness and giddiness, localized swelling, mass, and lump on both her lower extremities, generalized muscle weakness, pressure ulcer (wound caused by pressure on an area of the skin) of the sacral region (base of the spine) and adult failure to thrive among other conditions. A review of Resident 1's Minimal Data Set (MDS -providing information of each resident's functional capabilities and helps nursing home staff identify health problems) dated 4/5/23, indicated Resident 1 was receiving pain medication as needed (as the situation demands). During an interview on 4/12/23, at 3:32 p.m., Resident 1 stated, on the Monday following Easter Sunday (4/10/23), she waited for Licensed Nurse P (LN P) to see her. When the LN P came, LN P left Resident 1's pain medication in a cup and left without seeing Resident 1 take the medication. Resident 1 stated LN P was supposed to make sure she took the medication. During interview on 4/20/23, at 1:49 p.m., LN P stated she was informed Resident 1 was waiting for LN P for an hour. LN P stated she immediately prepared Resident 1's pain medication and went to the resident's room to administer the medication. At the resident's room, LN P stated she gave the medication to the resident but could not recall if the pain medication was in a small dispensing cup or she handed the medication into the resident's hand. LN P stated when she saw the resident move forward, she assumed Resident 1 was thanking her and left the room. LN P acknowledged she did not see the resident take her medication before she turned and headed back to the nurse's station. During a subsequent interview on 4/24/23 at 3:40 p.m., LN P stated she had not asked the pain level of Resident 1 before and after she gave the pain medication. LN P stated Resident 1's pain level was monitored every shift and before and after administration of pain medication. During a review of Resident 1's Controlled drug record documenting the date and time Percocet, a brand name for a narcotic (medication that dulls the senses and relieves pain) containing 5 milligrams (mg - unit of measure) of oxycodone, and 325 mg acetaminophen (pain reliever), indicated 1 tablet of Percocet was given to Resident 1 on 4/10/23 at 3:00 p.m. A review of the policy titled, Administering medications revised 4/2019, indicated medications are administered in a safe manner, and as prescribed. Resident may self-administer their own medications only if the attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. During an interview on 4/15/23, at 11:26 a.m., the Director of Nursing (DON) stated the facility performs assessments of residents who prefer to self-administer their own medication. A physician's order is obtained when a resident is assessed safe to self-administer his/her own medication. The DON stated a Licensed Nurse reminds the resident of the schedule and supervises the self-administration of the medication. The DON stated that the licensed nurse must be physically present and witness the resident take and swallow the medication before documenting the medication administration. The DON confirmed Resident 1 did not have an order to self-administer her own medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interviews, and policy review, it was determined the facility failed to label clothing in a manner promoting dignity for one of 23 sampled residents (Resident (R) 29). This failure had the potential for other residents' clothing to be labeled in a manner not promoting dignity. Findings include: Review of R29's Electronic Medical Record (EMR) admission Record revealed an admission date of 11/09/2018 with medical diagnoses that included unspecified dementia with behavioral disturbance. Review of the EMR quarterly Minimum Data Set (MDS), dated [DATE], revealed R29 had a Brief Interview for Mental Status (BIMS) score of three out of a possible 15, indicating severe cognitive impairment. Review of this MDS indicated that R29 requires the assistance of one staff to dress. Observation on 09/11/19 at 12:15 PM revealed R29 walking in the hallway wearing khaki pants that had her name written on the outside of the pants in approximately 1-2-inch lettering. During an interview on 09/11/19 at 12:20 PM, the nurse consultant confirmed R29's name was written across the seat of her pants. The nurse consultant stated the residents' names should be written on the inside of the clothing for dignity concerns. Review of the facility policy titled, Personal Care Items and Clothing, with a revision date of July 2015, revealed: Residents have personal care items and clothing available. The policy fails to address the labeling of residents' clothing. During an interview on 09/12/19 at 9:40 AM, the nurse consultant verified that the facility policy does not address the labeling of residents' clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and interviews, it was determined the facility failed to ensure privacy of clinical information for one of 23 sampled residents (Resident (R) 41). This failure had the potential for other residents' clinical information to not be kept private. Findings include: Review of R41's paper-based admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included a colostomy (a surgical procedure diverting the colon to an opening in the abdomen where fecal material is collected in a bag). Review of the Minimum Data Set (MDS) admission MDS with an Assessment Reference Date (ARD) of 09/10/18 revealed the resident required extensive assistance for activities of daily living, including the care of the colostomy. On 09/09/19 at 12:50 PM, a sign was observed over R41's bed that listed the supplies needed to provide care to the colostomy site. During an observation on 09/09/19 at 4:30 PM, the Director of Nursing (DON) verified that the sign over the bed revealed that R41 had a colostomy. The DON verified that this information was visible to other residents, visitors, and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy, it was determined the facility failed to ensure an injury of unknown origin was investigated for one of 23 sampled residents (Resident (R) 25). This failure had the potential for other injuries of unknown origin to not be investigated. Findings include: Review of R25's paper-based medical admission Record indicated the resident was admitted on [DATE] with diagnoses that included dementia. Review of the paper-based medical record revealed an SBAR (a nurse's note) dated 07/14/19 documenting a noted skin discoloration to the left superior orbital rim (upper lid crease). Review of the paper-based Minimum Data Set (MDS) annual assessment, dated 07/19/19, revealed the Brief Interview for Mental Status (BIMS) scored a three of 15, which indicated severe cognitive impairment. R25 was unable to express an accurate account of what occurred at the time the discoloration was identified. During an interview on 09/09/19 at 9:50 AM, the resident was confused and was unable to answer questions about the discoloration to the eye identified on 07/14/19. An interview with the Director of Nursing (DON) on 09/11/19 at 1:20 PM revealed there was no investigation completed when the resident was discovered with the discoloration of his eyelid. Review of the facility's abuse policy, revised September 2017, revealed injuries of unknown source were injuries that were not observed by anyone and the injury was located in an area not generally vulnerable to injury. The abuse policy stated that injuries of unknown origin are to be investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to ensure two of 23 sampled residents (Residents (R) 37 and R26) were positioned so they would be able to eat meals independently. This failure has the potential for other residents to not be positioned for independent dining. Findings include: 1. Review of the paper-based medical record admission Record revealed R37 was re-admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and muscle weakness. Review of the paper Minimum Data Set (MDS) quarterly assessment, with an Assessment Reference Date (ARD) of 08/07/19, revealed the Brief Interview for Mental Status (BIMS) score was 11 of 15, which indicated a moderate amount of cognitive impairment. The assessment revealed the resident required supervision and setup help for meals. Review of the care plan, initiated 09/28/18, revealed the resident had a performance deficit with activities of daily living (ADL) related to muscle weakness, flaccid hemiplegia (loss of muscle movement), and cerebrovascular disease. The interventions included the resident was able to feed himself after setup for meals. On 09/09/19 at 1:15 PM, R37 was observed in his room trying to eat his lunch that was on a tray on the over bed table. The table was not positioned in front of the resident who was in his wheelchair. His left arm was flaccid on his lap. The resident stated he was having difficulty eating his lunch. The surveyor requested the Certified Nurse Aide (CNA)31 position the resident's lunch tray so he would be able to eat his meal. CNA31 verified in an interview on 09/09/19 at 1:15 PM the resident was having difficulty eating lunch because of the position of the tray. On 09/10/19 at 12:55 PM, R37 was observed in the wheelchair in his room attempting to eat lunch. The over bed table with his lunch tray was not positioned so the resident would be able to eat his lunch easily. The resident's left arm was flaccid on his lap and he was only able to use his right hand. CNA5 was requested to position the resident's lunch tray so he could reach and eat his lunch. CNA5 verified in an interview on 09/10/19 at 12:55 PM the lunch tray was not positioned to promote independent dining. 2. Review of the paper-based medical record admission Record revealed R26 was admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of the liver. Review of the paper MDS quarterly assessment, with an ARD of 07/23/19, revealed a BIMS score of 12 of 15, which indicated no cognitive impairment. The assessment revealed the resident required supervision and setup help for meals. Review of the self-care deficit care plan, initiated 11/16/18, revealed R26 had a deficit related to cirrhosis of the liver and movement disorder and required assistance with bed mobility. On 09/09/19 at 1:12 PM, R26 was observed in his bed. Two CNAs were observed putting the head of his bed up and setting up his tray. The resident was observed attempting to eat lunch. He was not positioned high enough in the bed to enable him to eat independently. R26 stated it was difficult for him to eat. The CNAs were requested to reposition the resident so he would be able to eat independently. The CNAs repositioned the resident in bed and he was able to eat his lunch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to provide assistance with meals to two of 23 sampled residents (Resident (R) 13 and R51). This failure had the potential for other residents to not receive assistance with dining. Findings include: 1. Review of the paper medical record admission Record revealed R13 was admitted to the facility on [DATE] with diagnoses that dysphagia (difficulty swallowing). Further review of the paper medical record Nutrition Evaluation Form, dated 11/02/18, revealed R13 had chewing and swallowing difficulties related to dysphagia. The care plan, updated 02/11/19, revealed R13 required extensive assistance of one staff person for eating. Review of the paper Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 06/26/19 indicated that R13 required extensive assistance for bed mobility and eating. During an interview on 09/09/19 at 12:30 PM, Certified Nurse Aide (CNA) 11 stated that R13 required extensive supervision during meals due to her behavior of trying to get up from the chair. CNA11 stated that R13 usually ate her meals in her room but was brought to the dining room on weekends for more assistance with meals. 2. Review of the paper medical record admission Record revealed R51 was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. Further review of the paper medical record nutrition care plan, updated 07/03/19, revealed the resident was on required extra time to eat and needed assistance that included cueing. Observation on 09/09/19 at 1:00 PM, revealed R51 was sitting up in the wheelchair in her room with her lunch still in front of her since it was delivered at 12:30 PM. CNA28 was sitting next to the head of the bed of R2. He stated he was doing one on one with R2 who was sleeping in bed. R51 was seated next to CNA28 in the wheelchair eating the pureed lunch that was delivered at 12:30 PM. She was eating the pureed meal with her fingers. CNA28 stated R51 took a long time to eat. R51 was asked if she needed help eating and she said yes. CNA28 sat and fed the resident while the surveyor was in the room. Further observation on 09/09/19 at 1:15 PM, revealed R51's lunch tray had been removed. The Licensed Vocational Nurse (LVN) 57 checked the resident's tray which was returned to the cart and verified there was 75% of the resident's lunch that still remained on the dish. Observation on 09/10/19 at 12:05 PM, revealed R51 being assisted during her meal in the dining room. R51 took a long time to eat but ate most of the meal with the help of the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, it was determined the facility failed to provide one of one resident reviewed for risk of elopement (Resident (R) 2), 1:1 supervision in the sample of 23 residents. This failure had the potential of residents to not receive supervision for the risk of elopement. Findings include: Review the paper-based admission Record revealed R2 was admitted on [DATE] with diagnoses that included dementia and anxiety. Review of the risk of injury related to wandering care plan, dated 09/04/19, revealed R2 required 1:1 supervision. Review of a nursing staffing assignment sign-in sheet dated 09/09/19 and 09/10/19 revealed staff was continuously assigned to the resident from 7:30 AM to 7:30 PM. The staff was assigned to check the resident every hour on night shift. Review of the paper Minimum Data Set (MDS) annual assessment, with an Assessment Refence Date (ARD) of 08/21/19, revealed a Brief Interview of Mental Status (BIMS) score of three out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had wandering behavior four to six days of the assessment period. On 09/09/19 at 1:00 PM, R2 was observed lying in bed with Certified Nurse Aide (CNA)28 sitting next to her bed. CNA28 stated he was doing one to one supervision because the resident had a history of eloping. On 09/10/19 at 1:00 PM, R2 was observed walking through the halls of the facility without any staff with her. She was observed walking into the nurses' station. On 09/11/19 at 10:50 AM, R2 was observed sleeping in bed without any staff present. At the time of the observation, the Director of Nursing (DON) verified there was no staff with R2. During an interview on 09/11/19 at 10:50 AM, the DON verified that staff were to provide one to one supervision from 7:30 AM to 7:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to assess one of 23 sampled residents (Resident (R) 57) for bladder incontinence. This failure had the potential for residents not to be assessed for bladder incontinence and to not receive care to improve bladder function. Findings include: Review of the paper-based admission Record revealed R57 was admitted on [DATE] with diagnoses that included an infection following a surgical procedure and a urinary tract infection (UTI). Review of the paper 48-Hour Baseline Plan of Care Form, dated 08/15/19, revealed R57 required extensive assistance for toileting. The plan revealed the resident was incontinent (loss of bladder control). Review of the paper-based medical record Bladder Evaluation, dated 08/15/19, revealed R57 had Urge Incontinence (sudden loss of bladder control). The evaluation was not complete and did not include the treatment options to address the incontinence. Review of the paper-based Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/19, revealed a Brief Interview for Mental Status (BIMS) score of ten out of a possible 15, indicating moderate cognitive impairment. The resident was totally dependent of two or more people for bed mobility, toilet use, personal hygiene and bathing. The assessment revealed the resident was frequently incontinent of urine. Review of the care plan, dated 08/15/19, regarding incontinence of bladder included an intervention to check and change the adult brief every two hours and as needed for incontinence. This care plan did not include interventions to attempt improvement in bladder function. During an interview on 09/12/19 at 2:00 PM, the Director of Nursing (DON) verified the incontinence evaluation was incomplete and did not determine interventions appropriate to ensure an attempt to maintain and improve bladder function. The DON stated the expectation was to complete the bladder evaluation and implement the appropriate plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, interviews, and review of the facility's policy, it was determined the facility failed to ensure contact isolation precautions were implemented and failed to prescribe an effective antibiotic for a urinary tract infection for one of eight residents reviewed for isolation (Resident (R) 57) in 23 sampled residents. This failure of staff not following contact precautions had the potential for spread of infections to other vulnerable residents. Findings include: Review of the paper-based admission Record revealed R57 was admitted to the facility on [DATE] with diagnoses that included an infection following a surgical procedure and a urinary tract infection (UTI). Review of the paper 48-Hour Baseline Plan of Care Form, dated 08/15/19, revealed the resident was to be on contact precautions for the right hip wound and the UTI. Contact isolation precautions are used for infections that are spread by touching. Healthcare workers should wear a gown and gloves while providing care. Further review of the baseline care plan revealed R57 required extensive assistance for toileting and was incontinent of bladder. The Care Directive Form, dated 08/15/19, revealed the resident was on contact precautions for a UTI and wound infection. Review of the paper-based Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/19, indicated R57 was totally dependent of two or more people for bed mobility, toilet use, personal hygiene, and bathing. This MDS indicated R57 was frequently incontinent of urine. On 09/09/19 at 9:55 AM, R57 was observed in bed. Certified Nurse Aide (CNA)31 was with the resident and stated she just completed morning care. CNA31 had on no protective equipment other than gloves. CNA31 stated she was unaware the resident was on contact precaution for the UTI. CNA31 confirmed she changed the incontinent brief using gloves only. During an interview on 09/09/19 at 4:15 PM, the Director of Staff Development (DSD) and the Director of Nursing (DON) verified the urine culture, dated 08/09/19, was positive for Vancomycin Resistant Enterococcus (VRE-an infectious bacterium resistant to antibiotics). The laboratory results also indicated the right hip surgical wound drainage was positive for a Multidrug Resistant Organism (MDRO-infectious bacteria resistant to antibiotics). The DSD and DON verified the resident was not on contact isolation precautions despite having drug resistant infections that can be spread by exposure to body fluids such as urine and wound drainage. During an interview on 09/11/19 at 2:30 PM, the DSD stated that the antibiotic R57 was receiving effective against the MDRO but not the VRE in the urine. The DSD stated new orders were received from the physician to get another urine culture to determine if R57 still had a UTI and to continue the contact isolation until the results were returned. Review of the facility policy Transmission-Based Precautions (Isolation), dated May 2015, revealed transmission-based precautions were used whenever measures more stringent than standard precautions were needed to prevent or control the spread of infection.

Based on observations and interviews, it was determined the facility failed to ensure there was adequate space in the dining room for two of 23 sampled residents (Resident (R) 7 and R57). This failure had the potential for residents who preferred to eat in the dining room, but space could not accommodate them. Findings include: Continuous observations made on 09/09/19 from 11:55 AM to 12:05 PM revealed six residents in the main dining room. During an interview on 09/09/19 at 12:30 PM, CNA11 stated that not all residents were taken to the main dining room due to the size of the room. She verified there were six residents eating in the main dining room. During an interview on 09/09/19 at 1:15 PM, R57 stated he eats all his meals in bed because there isn't enough space in the dining room. During an interview on 09/12/19 at 5:40 PM, R7 revealed he normally ate in his room, he sometimes ate in the dining area but felt the space was limited. Observation on 09/10/19 at 12:00 PM, revealed 11 residents in the main dining room eating lunch. There was seating available for three more residents. Observation on 09/11/19 at 12:10 PM, revealed ten residents in the main dining room. There were five tables in the main dining room. At 12:15 PM, while in the main dining room, an interview with the Administrator confirmed there would only be enough room for about three more people to eat in the main dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, it was determined the facility failed to ensure a clean and homelike environment for 14 rooms out of 26 sampled resident rooms. This failure had the potential for other resident rooms to not be maintained in a clean and homelike manner. Findings include: The following observations were made during an environmental tour with the maintenance supervisor on 09/12/19 that began at 2:45 PM and concluded at 3:25 PM. During this tour the maintenance supervisor confirmed these observations in an interview. 1. Observations of room [ROOM NUMBER] revealed the base of the bathroom door was scratched and scraped. Dirt build up was around the perimeter of the bathroom floor. 2. Observations of room [ROOM NUMBER] revealed the walls in the room and bathroom were scratched and patched. The floors in the bathroom and room were dirty and stained. 3. Observations of room [ROOM NUMBER] revealed the sliding glass doors in the room had a dirty, smeared window and a screen with a build-up of dirt. The bathroom door was scraped and chipped. The floor and walls in the room were dented, scraped, and stained. 4. Observations of room [ROOM NUMBER] revealed the sliding glass door was smeared with dirt and the screen had a build-up dust and had small holes in it. The floor and walls in the room were scratched, scraped and stained. 5. Observations of room [ROOM NUMBER] revealed the wall under the television was marked and scarred. The floors were dirty and stained. 6. Observations of room [ROOM NUMBER] revealed the base of the wall under the window was scarred and marked up. The wall in the center of the room under the television was scarred and marked. 7. Observations of room [ROOM NUMBER] revealed the sliding glass doors in the room had smeared dirt on the window and a build-up of dirt on the screen. The bathroom door was scraped and chipped. The floor and walls in the room were dented, scraped, and stained. 8. Observations of room [ROOM NUMBER] revealed that the bottom right edge of the door was scarred and chipped. The walls had areas of an unknown dried substance that was brown in color. 9. Observations in room [ROOM NUMBER] revealed the room floor and bathroom floor were dirty and stained. The room and bathroom walls were scratched, scraped, dirty, and patched. 10. Observations of room [ROOM NUMBER] revealed the over bed table was soiled with a large amount of an unknown dried brown substance. The floors in the room and bathroom were dirty, scratched, and stained. The door frames were scratched, peeling, and splintered in the bathroom and room. There was a hole on the outside surface of the bathroom door. 11. Observations of room [ROOM NUMBER] revealed the floors and walls were dirty, scratched, stained, and scraped. A piece of the floor molding was coming off. The sliding doors had dirty smeared glass and a build-up of dirt on the screen. 12. Observations of room [ROOM NUMBER] revealed the floors and walls in the room and bathroom were dirty, scratched, and stained. The baseboard was loose. The door frames were scratched, peeling, and splintered in the bathroom and room. The floor mat next to the resident who lived in C bed was dirty and torn. The overbed table near the C bed was dirty and had pieces of the table broken off.