**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#2 and #5) of five residents reviewed for edema care out of 30 sample residents. Specifically, the facility failed to: -Ensure physician orders were followed for the application and removal of elastic hose stockings (used to increase circulation, to prevent blood clots and reduce swelling) for Resident #2; and, -Ensure complete documentation of Resident #5's edema was completed accurately per physician order for Resident #5. Findings include: I. Facility policy The Edema Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 6/10/24 at 9:00 a.m. It read in pertinent part Put on elastic hose as ordered, apply while in bed. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included respiratory failure, diabetes, heart failure, chronic ulcer (sore) of left thigh. The 2/29/24 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required substantial assistance with showering and was dependent on staff for transferring, dressing upper and lower body and putting on and taking off footwear. B. Resident interviews Resident #2 was interviewed on 6/5/24 at 12:05 p.m. She said her left foot often swelled due to her diagnosis of diabetes. She said the nursing staff were supposed to put her socks (elastic hose stockings) on in the morning and take off at bedtime. Resident #2 said nursing staff had not yet put them on 6/5/24. Resident #2 was interviewed on 6/6/24 at 9:30 a.m. Resident #2 said nursing staff did not apply elastic hose stockings on 6/5/24 and had not yet applied elastic hose stockings on 6/6/24. Resident #2 was interviewed on 6/6/24 at 1:00 p.m., Resident #2 said nursing staff had not yet applied elastic hose stockings. Resident #2 was interviewed on 6/10/24 at 9:20 a.m. She said her elastic hose stockings had been on since the morning of 6/7/24. Resident #2 said a certified nurse aide (CNA) applied the stockings on 6/6/24 in the afternoon. She said the stockings were removed that night and then reapplied in the morning of 6/7/24. She said the stockings should have been removed at night on 6/7/24 and applied in the morning and removed at night on 6/8/24 and 6/9/24. C. Observations On 6/6/24 at 1:00 p.m. Resident #2's lower extremities were observed with CNA #1 which revealed there were no elastic hose stockings on the resident (see resident interview above). On 6/6/24 at 1:12 p.m. CNA #1 applied elastic hose stockings to Resident #2's lower legs. On 6/10/24 at 9:30 a.m. Resident #2 was observed with registered nurse (RN) #1 and revealed elastic hose stockings in place on Resident #2's lower legs. -According to Resident #2's interview, the elastic hose stockings had been in place since 6/7/24. D. Record review On 4/21/24 at 7:00 a.m., a physician order was initiated for Tubigrips or TED (thrombo-embolic-deterrent) hose (elastic hose stockings) for bilateral lower extremity edema management with directions to be placed in the mornings, removed at bedtime and left in place for no less than 12 hours and no more than 24 hours. A review of the task documentation (5/28/24 to 6/9/24) for application and removal of elastic hose stockings revealed nursing staff documented the application and removal of elastic hose stockings on 6/5/24, 6/6/24, 6/7/24, 6/8/24 and 6/9/24. -However, according to Resident #2's interview on 6/10/24, the elastic hose stockings were applied on the morning of 6/7/24 and had not been removed since they were applied. E. Staff interviews CNA #1 was interviewed on 6/6/24 at 1:03 p.m. CNA #1 said she was not sure if the elastic hose stockings were being used anymore because she had not seen them on Resident #2 in a few days. She said she should check with the nurse to see if they were needed. Licensed practical nurse (LPN) #1 was interviewed on 6/6/24 at 1:10 p.m. LPN #1 said she asked Resident #2 earlier if her stockings were placed and Resident #2 shook her head no. She said she misunderstood Resident #2 and thought the resident did not want them applied. The director of nursing (DON) was interviewed on 6/6/24 at 1:20 p.m. The DON said Resident #2's elastic hose stockings should have been placed and removed per the physician orders. She said staff should not document the stockings were placed and removed if the stockings were not put on. The DON said the elastic hose stockings helped to decrease Resident #2's edema. RN #1 was interviewed on 6/10/24 at 9:35 a.m. RN #1 said nursing staff documented Resident #2's elastic hose stockings were removed 6/7/24, 6/8/24 and 6/9/24. She said the incorrect documentation could have been due to agency staff working during the weekend. -According to Resident #2, the stockings were not removed 6/7/24, 6/8/24 and 6/9/24. The DON was interviewed again on 6/10/24 at 9:40 a.m. The DON said it was important to take off the stockings at night for circulation and comfort. She said she provided staff education to ensure elastic hose stockings were placed as ordered. She said based on the information provided, she planned additional staff education regarding documentation, application and removal of the elastic hose stockings. II. Resident status A. Resident #5 Resident #5, age [AGE], was admitted on [DATE]. According to the June 2023 CPO, the diagnoses included lymphedema (condition causing swelling in the body due to a buildup of fluid) and obesity (excessive fat deposits). The 5/29/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required maximum assistance with transferring and used a wheelchair for mobility. B. Observation During a continuous observation on 6/5/24 beginning at 10:00 a.m. and ending at 2:00 p.m., Resident #5 remained sitting up in her wheelchair engaging in independent and group activities. Resident #5's bilateral (both legs) edema was visible. Resident #5's legs appeared swollen, stretched and shiny. C. Record review The June 2024 CPO revealed a physician's order for staff to encourage Resident #5 to elevate her legs and observing for adverse signs and symptoms of edema, such as; increased swelling redness and complaints of pain or shortness of breath. Minus sign equaled no and positive sign equaled yes, ordered 6/2/24. (-=No +=Yes). -However, staff were not indicating - or + on the medication and treatment administration records (MAR/TAR). Staff were only documenting with a check mark which indicated something was administered. The fluid imbalance care plan, initiated on 9/22/22 and revised on 1/3/23, indicated Resident #5 had a potential for fluid imbalance related to edema with diuretic use. It indicated Resident #5 would remain free from symptoms including good skin turgor (skin's ability to change back to shape quickly after being pulled or pinched). Pertinent interventions included monitoring for worsening edema. D. Staff interviews and facility follow up CNA #2 and CNA #3 were interviewed on 6/6/24 at 1:44 p.m. CNA #2 and CNA #3 both said they were responsible for assisting Resident #5 to elevate her legs every shift and if Resident #5 declined the licensed nurses were notified. CNA #3 said Resident #5 declined to elevate her legs on a regular basis. RN #2 was interviewed on 6/6/24 at 2:00 p.m. RN #2 said Resident #5 was encouraged to elevate her legs every shift but Resident #5 declined on a regular basis. RN #2 said Resident #5 was encouraged to elevate her legs every shift because she had edema. RN #2 said it was important to monitor the swelling and redness to edema sites and report changes to the physician. RN #2 said monitoring for edema changes was documented in the MAR/TAR. RN #2 was unable to locate documentation for monitoring changes. RN #2 said the nursing staff should include supplemental documentation for monitoring Resident #5's edema and were not. The DON was interviewed on 6/6/24 at 3:00 p.m. The DON said she was informed by RN #2 of the supplemental monitoring not being documented correctly in the MAR/TAR for Resident #5 and the order was being rewritten so that all components of the order were visible when nursing was charting.

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure the laundry area was free from multiple environmental and sanitary concerns; and, -Ensure clean and dirty storage were maintained in separate locations. Findings include: I. Facility policy and procedure The Infection Control for Housekeeping Services policy, revised January 2009, was provided by the nursing home administrator (NHA) on 6/11/24 at 9:10 a.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Equipment shall be maintained in a safe, sanitary condition. Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team. II. Laundry observations and interviews On 6/10/24 at 1:30 p.m. the facility's laundry area was observed with the maintenance supervisor (MS). The following was observed: -The exhaust fan in the soiled linen room was not on. The MS turned the switch and then said it was broken. The MS said he was not aware the fan was broken. The MS said he thought it must have not worked for some time because there was a significant amount of dust on the fan blades. -There was a hole in the ceiling approximately 12 inches by 20 inches located above a dryer; -There was a hole in the wall approximately three inches by 12 inches located directly below clean hanging clothes which were to be delivered to residents; and, -There was unfinished sheetrock and holes approximately six inches by eight inches each on either side of the door to the clean laundry area. A rodent trap was located near the door. The MS said he had not had time to repair the holes. III. Storage observations and interviews On 6/10/24 at 1:50 p.m., the Spartan unit soiled utility room was observed with the MS and the NHA. The following was observed: -A hopper toilet (a toilet/sink used to flush contaminants) in the corner of the room contained dark brown fluid with a hole in the ceiling directly above the toilet which dripped fluid. The NHA touched the ceiling and said it was wet and needed immediate repair. -A storage rack contained approximately 15 clean packaged gowns and 10 boxes of unopened gloves which were located next to four dirty linen and trash containers which contained soiled items. -Approximately six large trash bags were on the floor next to the dirty linen and trash containers. The MS said the bags contained clean isolation cart supplies. The NHA said the supplies should be stored in a different clean location. He said the clean supplies would be removed and disinfected. The MS was interviewed on 6/10/24 at 2:30 p.m. The MS said there were multiple areas which needed attention and he had not had time to assess or repair the ceiling in the soiled utility room. The infection preventionist (IP) was interviewed on 6/10/24 at 3:10 p.m. The IP said a soiled utility room should not contain clean items. She said she would not expect gowns and gloves to be stored in the soiled utility room. The IP said the isolation supplies should be stored in a clean area. B. Facility follow-up The Quality Improvement Action Sheet for Soiled Room Storage was provided by the NHA on 6/10/24 at 3:26 p.m. It read in pertinent part: All non-soiled items have been removed from the soiled storage room and either disinfected or discarded. Roof repair from the water leak has been temporarily fixed. Final drywall repair to be completed by 6/11/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to provide services for one (#172) out 31 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #172's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 2/21/2023 at 10:17 a.m. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. Kizior, R. J., [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. II. Resident #172 A. Resident status Resident #172, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included iron deficiency anemia related to blood loss, congestive heart failure and atrial fibrillation. The February 2023 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. He required the assistance of two people for bed mobility, transfers, personal hygiene dressing and toileting. B. Observations On 2/16/23 at 9:06 a.m. registered nurse (RN) #2 was observed dispensing a Metoprolol 25 milligrams (mg) tablet for Resident #172. RN #2 did not check the order for the blood pressure parameters or the record for the resident's most recent vital signs. RN #2 then administered the Metoprolol medication to Resident #172. C. Record review The February 2023 CPO documented a physician order of Metoprolol Succinate Extended Release 25 mg once a day for ventricular rate control in atrial fibrillation ordered on 2/9/23. The CPO did not document any vital signs parameters for the Metoprolol medication. The February 2023 medication and treatment administration record (MAR/TAR) documented the resident's vital signs should be checked every shift, initiated on 2/13/23. The first documented vital signs were on 2/13/23. The February 2023 vital signs summary revealed one blood pressure documented on 2/9/23, no blood pressures documented on 2/10/23 or 2/11/23, one blood pressure documented on 2/12/23, one blood pressure documented on 2/13/23, three blood pressures documented on 2/14/23 and one blood pressure documented on 2/15/23. III. Staff interviews RN #2 was interviewed on 2/16/23 at 9:15 a.m. She reviewed the Metoprolol physician's order and said there were no parameters ordered. She confirmed she did not obtain the resident's vital signs prior to administering the Metoprolol medication. She said she was unsure when the resident's vital signs had been last taken. Licensed practical nurse (LPN) #1 was interviewed on 2/16/23 at 10:00 a.m. She said blood pressure medication did not always have documented parameters. She said if the resident was outside of their baseline, she would contact the physician prior to administering the medication. She said the resident's vital signs should be taken and checked prior to administering blood pressure medications to avoid causing severe low blood pressure. The director of nursing (DON) was interviewed on 2/16/23 at 6:50 p.m. She said that blood pressure medication should be given as ordered by the physician. She said if there were parameters ordered for blood pressure medications, the physician should be notified if the resident's blood pressure was outside of parameters. She said if there were no parameters were ordered, the physician should be notified if the resident was outside their baseline. She said resident's vital signs should be taken prior to every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#47) of two residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #47's socialization needs were met by developing a person-centered activity plan. Findings include: I. Facility policy and procedure The Activity Documentation policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 2/17/23 at 2:26 p.m. It revealed, in pertinent part, It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental and psychosocial well-being of the resident. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations. Cognitive impairment: smaller groups without interruption, one-to-one etc. II. Resident #47 status Resident #47, age [AGE] was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, bipolar disorder, psychotic disturbance, mood disturbance and anxiety. The 1/20/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance of one to two people with bed mobility, transfers, personal hygiene, toileting and dressing. It indicated it was important to the resident to have books, newspapers, and magazines to read, be around pets, keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather is good and participate in religious services. A. Resident interview On 2/15/23 at 11:15 a.m. Resident #47 said she had nothing to do. She said she did the same thing every day. She said she was not invited to group activities and did not receive any individualized activities. B. Observations On 2/15/23 at 8:51 a.m. Resident #47 was observed laying in bed, sleeping. -At 9:12 a.m. Resident #47 was observed sitting in bed eating breakfast. The resident did not have a television nor was there music being played. There was no cognitive or social stimulation observed. -At 11:15 a.m. the resident was observed sitting up in bed. There were no meaningful activities provided for the resident. -At 1:28 p.m. Resident #47 was lying in her bed with her lunch tray in front of her. There were no meaningful activities observed. -At 2:26 p.m. the resident was laying in bed, asleep. -At 4:03 p.m. Resident #47 was observed sitting up in bed. There were no meaningful activities observed. C. Record review The 9/27/22 admission activity assessment documented the resident was interested in games, cards, trivia, BINGO, arts and crafts, drawing and painting. It indicated the resident's socialization plan was to encourage her to attend activities of choice and invite her to activities as tolerated. The activity care plan, initiated on 9/27/22, documented the resident was at risk for decreased socialization. It indicated the resident would benefit from small group settings. The interventions included communicating her activity interests to the health care team, introducing her to other residents with similar interests, inviting and encouraging the resident to attend activities with a low stimulation environment when available. The quarterly activity evaluation dated 12/23/22 documented the resident liked to watch people and attended group activities. It indicated the activity staff should continue to offer recreation to the resident. The one-to-one activity participation log documented the resident was provided one-to-one activities two times in November 2022, once in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. The social activity log documented the resident participated in social events three times in November 2022, once in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. According to the independent activity log, the resident watched television 10 times in November 2022, 10 times in December 2022, eight times in January 2023 and twice from 2/1/23 to 2/15/23. According to the entertainment activity log, the resident participated one time in November 2022, one time in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. III. Staff interviews The activity supervisor (AS) was interviewed on 2/16/23 at 6:23 p.m. She said Resident #47 was offered group activities but did not like to participate. She said the resident was a passive participant. The AS said Resident #47 did not watch television. The AS said they had attempted to paint with her but she was not interested. She said the resident was not part of an activity one-to-one program. She said the activity staff offered the resident music, however that was not regularly scheduled. She said she had not offered the resident to attend group activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #55 A. Resident status Resident #55, under the age of 65, was admitted on [DATE] and was readmitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included anxiety disorder due to known physiological conditions, a major depressive disorder with psychotic features and symptoms, mood disorder due to known physiological conditions with depressive features, moderate intellectual disabilities, cognitive communication deficit, and unspecified disorder of psychological development. According to the 12/30/22 minimum data set (MDS), the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required supervision with transfers, dressing, toileting, and personal hygiene. It indicated he did not have any behavioral concerns. B. Observations On 2/15/23 at 8:58 a.m., Resident #55 was observed leaving the dining room after eating breakfast. The resident's pants were soiled with urine. The resident was assisted by an unidentified staff member and returned to the dining area with new, clean pants. -At 9:52 a.m., the resident entered the dining room and filled a mug with water. He sat down on a chair. He sat down for approximately eight minutes, returned to his room, and then came back to the dining area with crayons. Upon returning to the dining room, he began drawing, however, he continued to pace back and forth between his room and the dining room. From 9:00 a.m. until 10:00 a.m., Resident #55 had gone between his room and the dining room seven times. -At 10:39 a.m. the resident paced back to his room and came right back to the dining area and continued drawing. -At 11:17 a.m. Resident #55 went back to his room. -At 11:18 a.m. he walked out of his room and went down the hallway, turned around, and walked right back to the dining room. -At 11:22 a.m. he paced back to his room and came out again in just a minute. He walked down halfway through the hallway and then returned to the dining room. -At 11:28 a.m. the resident paced back to his room and came out at 11:30 a.m., and then sat in the dining room. C. Record review The PASRR (pre-admission screening and resident review) care plan, revised on 5/10/22, documented the resident had both a major mental illness and an intellectual developmental disability. The interventions included providing the resident an evaluation to community integration, a day program, and continuing to monitor any manic episodes. The cognitive impairment care plan, revised on 8/31/22, documented the resident had impaired cognitive function and thought processes due to a diagnosis of dementia. The interventions included administering medications as ordered; communicating with the resident's family regarding the resident's capabilities and needs; engaging the resident in simple, structured activities that avoid overly demanding tasks; giving step by step instructions one at a time to support cognitive function; keeping the resident's routine consistent and providing consistent caregivers; and providing assistance with all decision making. The mood problem care plan, revised 1/10/23, documented the resident had a potential for a mood problem related to his major mental illness. It indicated the resident had a major depressive disorder with behaviors such as being sad and down, sad at his loss of independence, and had potential for verbal aggression. The interventions included administering medications as ordered; monitoring, recording, and reporting to the physician any acute episodes of feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleeping patterns and diminished ability to concentrate; and monitoring increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone and possession of objects that could be used as weapons. The behavior problem care plan, revised 1/10/23, documented the resident had a potential behavioral problem related to his intellectual developmental disability. It indicated the resident had a history of drinking fluids excessively, tried to get multiple mouthwash bottles and then drink them, and excessively drinking water to the point that he threw up on 2/9/22. The interventions included administering medications as ordered, anticipating and meeting the resident's needs, approaching the resident in a calm manner, continuing to monitor how much mouthwash was given, and explaining all procedures to the resident before starting and allowing the resident to adjust to changes. The 12/1/22 psychiatric progress note documented the facility staff had reported Resident #55 had been refusing some care including bed changes at night. It indicated the resident continued to be incontinent at night and typically soaked through his briefs and soiled the linen on the bed. The staff had reported he was not easy to redirect at night when needing to change his linen and had increased agitation and aggression. It indicated the resident said, They wake me up all the time at night and that he just wanted to sleep. The psychiatrist documented the resident had episodes of mania evidenced by perseveration on drinking water and pacing. The recommendations included one change of linen/briefs at night approximately 10:00 p.m. to 11:00 p.m. with evening medications and allow the resident to sleep through the night until awaken at approximately 6:00 a.m. -However, these recommendations were not included in the resident's comprehensive plan of care. The 12/2/23 nursing progress note documented at approximately 5:09 a.m., and certified nurse aide (CNA) entered Resident #55's bedroom to check on him. It indicated the resident was standing by his bed, soiled of urine. Resident #55 swung at the CNA with an open hand and yelled for her to leave the room. The CNA left the room and reported the incident to the nurse. -At 5:26 a.m. the CNA went back into Resident #55's room and changed the resident's soiled sheets while he was in the bathroom. Resident #55 followed the CNA down the hallway shouting I want my stuff back. The resident paced up and down the hallway, in and out of his room. -At 5:42 a.m. the resident continued to pace hallways and his bedroom and to and from the sink, drinking eight cups of water. The nurse called the physician and received an order to send the resident to the emergency department for evaluation and treatment. -At 11:45 a.m. the resident returned from the emergency department with a diagnosis of anxiety with a recommendation to start Lorazepam (anti-anxiety medication) and Seroquel (antipsychotic medication). The psychiatrist called the facility as Resident #55 was arriving back from the hospital and ordered Seroquel 25 milligrams (mg) every night. The 12/27/22 social service summary progress note documented Resident #55 had impaired decision-making and had a diagnosis of intellectual or developmental disability (IDD). He had an order for Seroquel and Lexapro (antipsychotic and anxiety medications) for the behaviors of refusal of care and anxiety management. -A review of the resident's electronic medical record on 12/14/23 did not reveal documentation that the resident had been provided additional psychosocial support to assist in determining the triggers for the resident's behavior. -The comprehensive care plan did not document person-centered, individualized interventions It did not also reflect the above interventions recommended by the resident's psychiatrist as the night staff continued to awaken the resident to offer incontinent care resulting in aggressive behaviors and refusal of care, as was documented in the nursing notes and within the staff interviews. The nursing progress note dated 12/12/22 documented at 1:10 a.m. that the nursing staff continued to offer incontinent care to the resident at night resulting in the resident yelling with an angry tone saying get out. The CNA tasks documented in December 2022 (between 12/2/22 to 12/31/22) the facility staff attempted to provide incontinence care to the resident on seven occasions during the night. D. Staff interviews Certified nursing aide (CNA) #2 was interviewed on 2/16/23 at 4:45 p.m. She said Resident #55 had behaviors and frequently refused care. CNA #2 said if the resident refused care, she would wait 10 minutes, come back and try again. She said Resident #55 would become agitated and angry when he was constantly being asked to change his clothing or bedding. The activity supervisor (AS) was interviewed on 2/16/23 at 6:05 p.m. She said Resident #55 has a diagnosis of intellectual or developmental disability. She said the resident used to participate in a lot of activities but did not anymore. The AD said the resident would become repetitive sometimes. She said leaving the resident alone and giving him a personal one-on-one task sometimes helped him calm down when he was anxious. The social services director (SSD) was interviewed on 2/16/23 at 5:45 p.m. She said Resident #55 had an intellectually disabled with obsessive-compulsive disorder. The SSD said she had identified some of the resident's triggers such as when the staff offered to change the resident multiple times. She said the resident would get really upset when the staff would ask him to change and then continued to ask him when he refused. She said part of the resident's manic episodes was pacing between his room and the common areas and drinking excessive amounts of water. She said when the resident was triggered, he would pace, become verbally aggressive, and drink water excessively. She said on 12/1/22, Resident #55 had probably been triggered because the CNA had entered his room after he yelled for her to leave and then changed his bedding without his permission. The SSD said she was responsible for developing the behavioral care plans. She said she was unsure of any person-centered interventions that assisted the resident when he became upset or was having a manic episode. The SSD said the resident had been seen regularly by a psychiatrist. She said she did not have time to read the psychiatrist's notes. She said she was unaware if the psychiatrist had developed any interventions to assist the resident in being triggered. She confirmed the resident's plan of care did not indicate any person-centered interventions to address the resident's behavior. The director of nursing (DON) was interviewed on 2/16/23 at 6:49 p.m. The DON said Resident #55 exhibited behaviors such as excessive drinking of water, agitation, pacing back and forth in the hallway, and refusal of care. She said sometimes the resident would get upset because the staff wanted to assist him with incontinence care. The DON said the facility struggled with the resident's incontinence care because of his refusals. She said part of the trigger for the resident's behavior was changing his bed sheets. She said the resident was frequently incontinent in bed and would get very upset when staff would change his bedding. She said the resident wanted a certain kind of sheet and a certain blanket. She said she believed that was what triggered the resident in early December 2022. She said she was aware of the recommendations made by the psychiatrist. She said she was not sure if those recommendations were documented in the resident's medical record or had been relayed to the facility staff. She said the comprehensive care plan should have person-centered approaches documented to assist the resident when he had exhibited behaviors. She said social services were responsible for developing behavioral care plans, but that the interdisciplinary team was able to update the interventions as needed. Based on interviews and record review, the facility failed to ensure two (#64 and #55) of two out of 31 sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #64 was provided psychosocial support after he had voiced difficulty in adjusting to his new level of care and admission to the facility; and, -Ensure Resident #55 was provided person-centered interventions to address the resident's behavior and provided continued psychosocial support. Findings include: I. Facility policy and procedure The Behavioral Health policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 2/17/23 at 2:26 p.m. It revealed in pertinent part, The interdisciplinary team (IDT) will ensure that residents who display or is diagnosed with mental disorder or psychosocial adjustment difficulty receives the appropriate treatment and services to attain the highest practicable mental or psychosocial well-being and will have an individualized plan of care that addresses the needs of the resident, based on the comprehensive MDS assessment of the resident. The plan of care will include non-pharmacological interventions and individualized, person-centered care approaches as well as trauma-informed approaches in accordance with resident's customary routines, with input from the resident and/or resident representative. The physician, in collaboration with the IDT team, will determine the appropriate psychiatric or psychological treatment or rehabilitative services needed. Treatment will be provided as ordered by the physician. II. Resident #64 A. Resident status Resident #64, age [AGE], was admitted to the facility on [DATE]. According to the February 2023 computerized physician orders (CPO) the diagnoses included post viral fatigue syndrome, dysarthria, anarthria, dysphonia (difficulty with speech), Parkinson's disease, repeated falls, and adult failure to thrive. The 1/18/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive intact with a brief interview for mental status score of 12 out of 15. He required extensive assistance with a two-person physical assist for transfers, dressing, toileting and bed mobility. It indicated the resident had mild depression with a PHQ-9 (patient health questionnaire) score of seven out of 27 indicating mild depression. B. Resident observations and interview On 2/13/23 at 5:17 p.m. Resident #64 was in his room sitting in a wheelchair eating from his dinner tray. He was watching his television while eating his dinner. He said was unhappy at the facility and there was nothing to do. He said he did not get visitors very often and he was tired of watching television. On 2/14/23 at 11:42 a.m. the resident was sitting in his wheelchair in his room. He said he was unhappy, bored and was unable to do anything because of an infection in his stool. He said the only thing he was able to do was watch television. Resident #64 was interviewed on 2/16/23 11:02 a.m. He said his goal was to move back to his apartment. He said he felt like he could not leave his room due to his medical condition. He said that he had nothing to do and no staff came by to do things with him or offer anything. He said he liked sports, especially baseball. He said he would really enjoy it if someone would come into his room and talk baseball with him. He said the only time he had any social interaction was when the staff entered the room to provide care. C. Record review The potential for adjustment issues care plan, initiated 1/16/23, revealed Resident #64 had a potential for adjustment issues due to his admission to the skilled nursing facility (SNF). The interventions included encouraging conversations with staff and other residents, providing the resident the opportunity to communicate his feelings regarding his admission, providing the resident the opportunity to communicate his feelings regarding attending group activities, and providing the resident situations in which he will have control over his environment and care delivery. The 1/16/23 social services summary documented the resident did not have any behavior or mood concerns. The activity care plan, initiated 1/20/23, revealed the resident had little or no activity involvement. It indicated the resident was unsure if he would participate in recreation while he was at the facility, as the resident wanted to focus on getting better. The interventions included establishing and recording the resident's prior level of activity involvement and interests by talking with resident, caregivers and family upon admission and as necessary. The 1/22/23 nursing note revealed the resident was very frustrated and said this is no way to live. The nurse said he had no plans to hurt himself and he would be monitored. The 1/23/23 behavior progress note revealed the resident was very frustrated with life and asked if the nurse could take him out and just let him freeze. He said it was hard since his life changed so much, recently. The 2/2/23 activity assessment identified his needs as he is eager to get back to his place and he wants to get better. It did not indicate what interventions would be put in place to address the resident's socialization needs. The activity participation log documented from 1/14/23 to 2/14/23 revealed that the resident was not provided any one-to-one activities. -A review of the resident's medical record did not reveal documentation of psychosocial support provided to the resident after he had voiced that he was having a difficult time since his admission to the facility and accepting his new level of care. -The facility failed to develop person-centered approaches to provide the resident with additional support and meet the resident's psychosocial needs. IV. Staff interviews The social services director (SSD) was interviewed on 2/16/23 at 5:47 p.m. She said she had spoken with Resident #64 after his behavior on 1/23/23. She said he had refused counseling. She said she had not offered the resident any other psychosocial support. She said she did not document this interaction in the resident's medical record. She said socialization helped Resident #64. She said the resident's brother and friends visited often. She said she had not documented any person-centered approaches to assist the resident with his difficulty in accepting his level of care or admission to the facility. She said the interdisciplinary team (IDT) had not discussed possible interventions for the resident. The director of nursing (DON) was interviewed on 2/16/23 at 6:52 p.m. The DON said during the care conference on 1/20/23, the resident had agreed to counseling. She said she was unsure if it was documented in the resident's medical record or if it had been arranged by social services. She confirmed the resident's plan of care did not document any psychosocial person-centered interventions to assist the resident in adjusting to his level of care or admission to the facility. The activity supervisor (AS) was interviewed on 2/16/23 at 6:23 p.m. She said she was not made aware of the resident's difficulty in adjusting to his admission to the facility. She said she was unaware the resident had made statements of wanting to freeze outside. She said, when she completed the resident's admission assessment, he was focused on physical therapy and wanting to get better to go home. She said she had not placed the resident on a one-to-one activity program. She said she was unaware the resident enjoyed baseball. She confirmed the resident would benefit from socialization from facility staff. She confirmed the resident should receive socialization from the facility staff, other than just when the staff entered his room to provide care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for two (#41 and #45) of five residents reviewed out of 31 sample residents. Specifically, the facility failed to ensure a response to pharmacist recommendations from monthly medication regimen reviews for: -Resident #41 regarding the physician's recommendation to discuss the risk and benefits of the drug interaction of Tramadol, Trazodone, Bupropion, and Ativan (psychotropic and pain medications); and, -Resident #45 regarding the physician's recommendation to refer medication questions to the hospice provider. Findings include: I. Facility policy and procedure The Medication Regimen Review and Reporting policy and procedure, dated September 2018, was provided by the director of nursing (DON) on 2/17/23. It read in pertinent part: The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medication each resident receives is clinically indicated. Resident-specific medication regimen review recommendations and findings are documented and acted upon by the nursing care center and/or physician. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. II. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, bipolar disorder, end-stage renal disease, cognitive communication deficit, and chronic kidney disease. The 12/30/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of twelve out of 15. She required supervision and set-up help only with her activities of daily living (ADLs). B. Record review A review of the resident's medication administration record (MAR) and treatment administration record (TAR) revealed the resident had orders to receive the following medication: -Tramadol HCI tablet 50 milligrams, one tablet by mouth every six hours as needed for moderate pain. Ordered 12/7/22. -Trazodone HCI tablet 50 milligrams, give 0.5 tablets by mouth at bedtime for depression. Ordered 12/7/22. -Bupropion HCI tablet 75 milligrams, give 1 tablet by mouth two times a day for depression. Ordered 12/7/22. The 4/25/22 pharmacist medication regimen review reported a concern for Resident # 41 medication regimen. The recommendation indicated a concern with the use of Tramadol, Trazodone, and Bupropion which has two interactions with Tramadol. According to the report, these interactions increase the risk for death or ineffectiveness. The 6/21/22 pharmacist medication regimen review alerted the physician on the above concerns as Resident #41 had had three falls in three weeks. The report requested not to recommend Tramadol use in geriatrics due to unpredictable metabolism which increases the risk for death or ineffectiveness, serious drug interactions, and worrisome side effects. This was the second request, as the first time occurred on 4/25/22. The attending physician recommended on 6/28/22 the facility discuss the risk and benefits of these medications with the resident. III. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease and anxiety disorder. The 1/20/22 minimum data set (MDS) assessment revealed the facility was unable to conduct a brief interview for mental status (BIMS) as the resident was rarely/never understood. He required two-person physical assistance with his activities of daily living (ADLs). B. Record review A review of the resident's medication administration record (MAR), treatment administration record (TAR), and pharmacy recommendation note revealed the resident was receiving the following medications: -Cyclobenzaprine 5 milligrams, two times a day for muscle spasms. Discontinued 1/13/22 (see below). -Trazodone HCI 50 milligrams tablet, give 0.5 milligrams by mouth at bedtime for insomnia. Order date 7/14/22. -Celexa 15 milligrams tablets by mouth daily for depression. Order date 7/14/22. -Zyprexa 10 milligrams, by mouth every day for dementia.Order date 7/14/22. The 11/18/22 pharmacist medication regimen review for Resident #45 requested to not recommend Cyclobenzaprine for the elderly due to it causing sedation and requested for it to be evaluated and consider discontinuation. The attending physician's response on 12/19/22 indicated all medication requests and questions were to be referred to the hospice provider. -The facility had no records of any follow-up with the hospice provider. The Cyclobenzaprine was not discontinued until 1/13/22 by the hospice provider, which was more than a month later. IV. Staff interview The director of nursing (DON) was interviewed on 2/16/22 at 6:48 p.m. The DON said the facility had poor communication with the hospice care provider. She said scheduling appointments with the hospice care provider was difficult and the facility should have discussed the recommendations for Resident #45 with the hospice provider in a timely manner. The DON said she could not find any documentation of the facility discussing the pharmacy recommendations and the physician's request to discuss the recommendations with Resident #41.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide therapeutic and mechanically altered diets consistent with dietary orders for two (#51 and #66) of two out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #51 was served puree textured vegetables, which was ordered by the physician; and, -Ensure Resident #66 was served large portions, which was ordered by the physician. Findings include I. Facility policy and procedure The Food and Nutrition Services policy and procedure, last revised October 2021, was provided by the director of nursing (DON) on 2/17/23. It read, in pertinent part It is the policy of the facility that therapeutic diet shall be prescribed as necessary for each resident. A tray identification system is established to ensure that each resident receives his/her diet as ordered. Dietary staff will follow menu extensions while preparing and serving meals. II. Tray line observations Diner tray line service was observed on 2/15/23. The meal was ham and beans, mixed greens, broccoli, pureed vegetables, canned pineapple, and cornbread. A bistro menu was available for residents who did not want the main meal and consisted of tomato soup, cheese quesadilla, a hot dog, and a grilled cheese sandwich. Serving began at 4:40 p.m. The kitchen manager (KM) served all the meals, including the bistro menu requests. One dietary aide and the dietary manager (DM) stayed at the other end and assisted with the tray line and served the food to the residents. At 5:15 p.m. a tray for Resident #51 was prepared by the KM. She served the resident a regular textured diet, even though the tray card indicated the resident should be served pureed texture vegetables. The tray was passed on to the DM, she inspected the tray and placed the wrong order on the cart ready to leave the kitchen to be served to the resident. She did not observe that the vegetable was served in the incorrect texture. Upon prompting, the DM brought the tray back to the kitchen. The DM confirmed the tray was not accurate and contained regular-texture broccoli. She asked the KM to redo the tray, confirmed the correct texture of the vegetables, and placed it on the cart to be served. At 5:22 p.m. a meal tray with a large portion diet ordered indicated on the tray card for Resident #61 was dished up by the KM and passed on to the DM. The plate did not contain double portions, which was indicated on the tray card. The DM placed the tray on the cart to be served. Upon prompting, the DM confirmed the order was not accurate and gave it back to the kitchen for additional food items to be dished onto the plate. III. Resident #51 A. Resident status Resident #51, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnosis included unspecified dementia and dysphagia (swallowing difficulty). The 12/25/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance of one person for dressing and toileting and supervision for bed mobility, transfers, and eating. B. Record review The December 2022 CPO documented a dysphagia mechanical soft diet with puree vegetables. IV. Resident #61 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the January 2023 CPO, diagnosis included malnutrition. The 1/13/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required supervision with bed mobility, transfers, dressing, toileting, and eating. B. Record review The January 2023 CPO documented a regular diet and texture with large portions for his meals. The resident care plan, dated 1/13/23 and revised on 2/13/23, indicated the resident was at risk of malnutrition and unexpected weight loss. The interventions included large portions for meals. V. Staff interviews The dietary manager (DM) was interviewed on 2/15/23 at 5:40 p.m. The DM said Resident # 51 was assessed by a speech-language pathologist therapist who recommended puree vegetables for the resident. The DM said Resident #51 was ordered, by the physician, to be served pureed vegetables. She said Resident #66 was admitted with a high risk of malnutrition and had experienced weight loss. She said it was ordered by the physician that the resident be served large portions for meals. The director of nursing (DON) was interviewed on 2/16/23 at 6:49 p.m. The DON said diets were prescribed by the physician. She said all diets should be followed and served according to physician orders. She said she would ensure that periodic audits would be completed to eliminate any future occurrences.

Based on record review and interviews, the facility failed to ensure that five out of five certified nursing assistants (CNA) were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct yearly staff competencies for certified nursing assistants. Findings include: I. Record review The annual competency checklist was requested on 2/16/23 for certified nursing assistants (CNA) #4, #5, #6, #7 and#8. An annual competency checklist for 2022 was unable to be provided by the facility. II. Staff interviews The director of nursing (DON) was interviewed on 2/16/23 at 7:00 p.m. She said the facility had not completed competencies for the CNAs since she had become the DON (May 2022). She said there had been a recent change in nursing management, however she was unable to find documentation that competencies had been completed for 2022 for all CNAs that were employed by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in three out of three units. Specifically, the facility failed to: -Ensure orientation for outside agency personnel regarding COVID-19 isolation precautions and donning/doffing of appropriate personal protective equipment; -Ensure an effective water management plan was in place; and, -Ensure residents' rooms were cleaned in a sanitary manner. Findings include: I. COVID-19 isolation precautions A. Facility policy and procedure The COVID-19 donning and doffing competency policy and procedure, initiated March 2020, and provided by the nursing home administrator (NHA) on 2/15/23 at 3:00 p.m. It revealed in pertinent part, Donning step 1-gown fully cover torso from neck to knees, arms to end of wrists, and wrap around the back, fasten in back of neck and waist; step 2-mask or respirator secure ties or elastic band at middle of head and neck, fit flexible band to nose bridge, fit snug to face and below chin, fit check respirator; step 3- goggles or face shield place over face and eyes and adjust to fit; step 4 -gloves extend to cover wrist of isolation gown. Standard precautions wipe down equipment between residents. Isolation precaution residents have designated equipment. B. Observations On 2/15/23 at 2:30 p.m. certified nursing assistant (CNA) #3 was observed entering a COVID-19 positive isolation room without donning personal protective equipment (PPE) and with a portable blood pressure/temperature/oxygen saturation monitor. COVID isolation precautions signs were observed on the door and a PPE cart was next to the door. After taking the resident's vital signs, CNA #3 left the room and observed the PPE cart next to the door. CNA #3 wiped the temperature probe and machine with sanitizing wipes and washed his hands at the sink. He did not remove or change his mask. CNA #3 then took the same portable blood pressure monitor and entered the resident room next to the COVID-19 isolation room. C. Staff interviews CNA #3 was interviewed on 2/15/23 at 2:30 p.m. He said that he was not aware the resident in the isolation room was COVID-19 positive. He confirmed he entered the COVID-19 positive room without donning PPE. He confirmed after he exited the COVID-19 positive room, he entered another resident's room to continue taking vital signs. He said it was his first day at the facility. The director of nursing (DON) was interviewed on 2/15/23 at 3:15 p.m. She said the facility did not provide orientation to outside agency personnel. She said she the previous shift should have informed CNA #3 which residents were under isolation precautions. The infection preventionist (IP) was interviewed on 2/15/23 at 3:30 p.m. She said the facility's current process did not include orienting outside agency personnel at the beginning of their shift on isolation precautions, use of PPE or the sanitization of equipment. She said that information should have been covered by their agency. She said the outside agency personnel should follow the information regarding isolation precautions and use of dedicated equipment posted on the residents' doors and CNAs would give a change of shift report on residents that were on isolation precautions. The nursing home administrator (NHA) was interviewed on 2/15/23 at 5:15 p.m. He said a binder was now created to orient outside agency personnel on isolation precautions and the use of PPE prior to the beginning of their shift.II. Failure to ensure the water management plan was effective A. Record review The Water Management plan was provided by the nursing home administrator on 2/14/23. It did not include documentation to indicate the control measures, how often the control measures were being conducted and the monitoring system for the control measures. It did not indicate a risk assessment had been completed. It did not indicate how the facility was ensuring the water management program was working and effective. B. Staff interviews The nursing home administrator and the maintenance director (MD) were interviewed on 2/16/23 at 5:12 p.m. The maintenance director said she was unable to locate the risk assessment within the facility's water management plan. She said the control measures included testing, however was unable to provide documentation that showed the control measures, how often the control measures were being conducted and a monitoring system. She said she was unable to determine if the water management plan was working or effective because the control measures had not been documented as completed and the facility did not have a monitoring system in place. III. Failed to ensure resident rooms were cleaned in a sanitary manner A. Facility policy and procedure The Proper Glove Usage policy and procedure, undated, was provided by the nursing home administrator (NHA) on 2/17/23. It revealed, in pertinent part, When cleaning a resident room, it is best practice to change gloves and rags in between cleaning the restroom and both sides of the patient room. When you clean the restroom, use one rag and one set of gloves, then discard the rag in dirty rags and remove gloves. Sanitize hands, put on new gloves, and grab a new rag to clean side B of the room. Once side B is complete, discard the rag and gloves, sanitize hands and then repeat for side A of the room. B. Observations On 2/15/23 at 2:20 p.m. housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER]. With gloved hands, he grabbed a rag, soaked in disinfectant, from the housekeeping cart and entered the bathroom. He wiped the inside of the bowl first and with the same rag wiped the toilet handle, the bottom of the toilet, on the ground around the toilet and then the toilet seat. He used the toilet brush to scrub the inside of the toilet and then exited the bathroom. He returned to the housekeeping cart in the hallway, placed the rag in a dirty bin and put the toilet brush away. With the same gloved hands, he grabbed the broom and entered the room. He swept the bathroom and the debris into the dust pan. He emptied the dust pan, put the broom away, grabbed a mop pad (with the same gloved hands) and the mop handle and re-entered the room. He placed the dripped wet mop head on the floor of the bathroom and mopped the bathroom. He mopped into the window side of the room with the same mop head. He then picked up the mop, discarded the mop head into the dirty bin and put the mop away. He doffed his gloves and obtained alcohol based hand rub (ABHR) from the wall unit. He rubbed the ABHR on his hands for three seconds and grabbed a new pair of gloves. His hands were visibly wet with white residue from the ABHR in between his fingers. He had difficulty donning the gloves due to his visibly wet hands. He was only able to don the gloves to cover halfway up the palms of his hand with an inch of glove not utilized at the fingertips. He grabbed a rag, soaked in disinfectant and entered the room. He wiped down the sink and counter and then moved to the window side of the room. After cleaning the window side of the room, he moved to the other side of the room and began cleaning off surfaces with the same rag and same gloved hands. After disposing of trash from the room, he grabbed a mop pad, the mop handle and entered the room. He mopped the window side of the room and then the hallway side of the room. HSKP #1 put the mop back on the cart and moved to resident room [ROOM NUMBER]. He obtained ABHR from the wall unit, rubbed it in his hands for four seconds and then attempted to don gloves. His hands were visibly wet with white residue from the ABHR on his knuckles and in between his fingers. He was only able to put the gloves halfway up his palm. He grabbed a red rag, soaked in disinfectant, toilet bowl cleaner and a toilet bowl brush and entered the resident bathroom. The bathroom was a shared bathroom between two resident rooms. Using the red rag, HSKP #1 wiped the window sill, the toilet seat, inside the toilet bowl, the bottom of the toilet and the toilet handle. He then moved to the commode and wiped the top of the commode seat and then the commode handles. He then used the toilet brush to scrub the inside of the toilet bowl, grabbed the trash from the trash can and moved the commode back over the toilet, with the same gloved hands. He put the rag in the dirty bin and then doffed his gloves, obtained ABHR and rubbed it in for five seconds and attempted to don a new pair of gloves. He had visibly wet hands with white residue from the ABHR and was unable to get the gloves all the way past his palm. C. Staff interviews The maintenance director was interviewed on 2/16/23 at 5:12 p.m. He said ABHR should be used prior to cleaning the room and in between glove changes. He said the ABHR should be rubbed in for approximately 20 seconds or until it is completely dry. He said once it was dry, then gloves should be donned. He confirmed the ABHR was not effective if not used according to the manufacturer's instructions. He said new gloves should be donned after cleaning the bathroom and each side of the room. He said, in a shared room, each side of the room should be cleaned separately and the housekeeper should not share the rag between both sides of the room. He said the toilet should be cleaned from the top down starting with the tank, handle and then the seat. He said the seat should be cleaned last and once it was cleaned the rag should not be used to clean any other surfaces. He said he provided education with return demonstrations to all the housekeeping staff regarding glove usage and hand hygiene that day following the observation of HSKP #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Basically the facility failed to ensure residents were freedom from corporal punishment and involuntary seclusion not required to treat the resident's medical symptoms for two (#223 and #52) of two out of 42 sample residents. Specifically, the facility failed to ensure that Residents (#223 and #52) were free from involuntary seclusion to treat Resident #223's medical symptoms/elopement behaviors. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/3/21 to 11/9/21, resulting in the deficiency being cited as past non-compliance with a correction date of 8/23/21. This is when all staff were trained on the definition of abuse, involuntary seclusion; abuse reporting requirements; alternative methods of redirecting and monitoring a resident presenting with eloplent behaviors; and ending the working relationship with the assailant/agency certified nurse aide (CNA). I. Facility policy The Resident Rights: Abuse Prevention and Prohibition Against policy and procedure, last revised 1/20/21, was provided by the nursing home administrator (NHA) on 11/3/21 at 12:33 p.m. The policy read in pertinent part: The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect . The Facility will engage in training and orienting its new and existing nursing staff on topics, which relate to the delivery of care in the post-acute setting. Topics of such training will include, but not be limited to: . -Prohibiting and preventing all forms of abuse, neglect -Recognizing signs of abuse, neglect . -Reporting abuse, neglect ., and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; -Dementia management/ Care of Cognitively Impaired -Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following: .Wandering or elopement-type behaviors; Resistance to care . The Facility will provide oversight and supervision of staff in connection with the above, to confirm that its policies prohibiting abuse, neglect ., are being implemented. To assist the facility's staff members in recognizing incidents of possible abuse ., the following definitions are provided: -Involuntary seclusion is separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's representative. The Behavioral Health policy and procedure last revised April 2019, was provided by the NHA on 11/8/21 at approximately 10:00 a.m. The policy read in patient part: The Inter-Disciplinary Team (IDT) will ensure that residents who display or is diagnosed with mental disorder or psychosocial adjustment difficulty ., receives the appropriate treatment and services to attain the highest practicable mental or psychosocial well-being and will have an individualized plan of care that addresses the needs of the resident . The plan of care will include non-pharmacological interventions and individualized, person-centered care approaches as well as trauma-informed approaches in accordance with resident's customary routines The facility will provide appropriate training to staff, to ensure skills and competencies that include but not be limited to the following: -Caring for residents with mental and psychosocial disorders -Implementing non-pharmacological interventions. The Safe-guarding Vulnerable Adults policy, undated, was provided as a part of the facility reported investigative packet, by the NHA on 11/4/21 at 1:30 p.m. The policy read in pertinent part: Individual agencies are responsible for ensuring that their employees are competent and confident in carrying out their responsibilities for safeguarding and promoting vulnerable adult's welfare. This policy and procedures are based on the following principles: - All incidents of alleged poor practice, misconduct and abuse will be taken seriously and responded to swiftly and appropriately. II. Facility reported incident-involuntary seclusion-8/15/21 at approximately 11:30 p.m. The resident had made several attempts to elope the facility throughout the week of 8/15/21. On 8/15 21 the resident was documented to have exited the door at least three times throughout the day. The resident was not on continuous monitoring, only frequent checks. Staff were alerted of the resident's elopement attempts by the sounding wanderguard. Staff were to respond to wander guard alerts immediately. The facility investigative report dated 8/16/2021 at 10:59 p.m. The investigative report documented: On 8/15/21 at 11:30 p.m. The staff nurse heard a loud noise down the hall, went to investigate and found that a resident's room door had been tied shut with a plastic bag. The residents were trying to get out but neither resident residing in that room were able to get out of the room. The nurse immediately removed the restraint (a plastic bag tied in a manner so the door could not be removed without the bag being removed). A. Investigation Upon initial investigating the nurse discovered that an agency CNA tied Residents #223 and #52's door shut with a plastic bag on the door handle to the hallway grab bar so Resident #223 could not continue to elope from the facility. Resident #52 was also confined to the room. The facility estimated that the residents had been confined to the room for approximately five to 10 minutes; however, the investigative report did not reference viewing of the facility surveillance camera located to view the facility hallways to confirm staff reports of events. On 8/16/21 the day following the incident the assistant director of nursing (ADON) assessed each resident for injuries and side effects of the in room confinement the ADON documented there were no physical injuries to either residents, both residents reported no distress, both residents appeared to be at baseline for mood and behavior. -There was no documentation of an assessment from the nurse who discovered the residents confined to their room; it is unknown of the initial effects on the resident due to lack of commutation. RN #3 wrote a witness statement; the header was dated 8/15/21. In the statement the RN reported hearing a loud noise about 11:30 p.m. Upon investigating the noise, she discovered Resident #223 and #52's door was tied shut with a plastic bag. She immediately cut the bag from the door and educated staff on alternative approaches. On 8/16/21 Resident #223 was interviewed about the incident. Resident #223 was unable to give details of the event and did not have any responses that made sense and reported the resident did not appear upset or distressed during the interview. The assessor attributed Resident #223's response to being diagnosed with advanced dementia. On 8/16/21 Resident #52 confirmed the door to his room was tied closed and neither he or Resident #223 were able to get out. On 8/16/21 CNA #6 was interviewed. CNA #6 admitted to tying the residents door closed with a plastic bag because he was trying to keep Resident #223 safe. The CNA acknowledged it was a poor decision. CNA #7 who was on shift and was reported to have knowledge of the incident of Resident #223 and #52's involuntary confinement was not interviewed about her version of events and not specifically asked for a response of what she observed about the incident. B. Investigative conclusions The report documented there was a deviation from agency policy and procedure when an agency hired CNA utilized an inappropriate intervention to prevent wandering. The facility substantiated that an agency staff member tied the residents ' room door shut. C. Facility actions/response -An investigation was reported and an investigation was started the day following the incident of involuntary seclusion when Resident #52 reported the incident to the ADON. -CNA #6 was suspended pending the facility's investigation and did not return to work in the facility following the conclusion of the investigation. -A one-hour in-service education was provided to 47 facility staff members between 8/16/21 and 8/17/21. Curriculum included education on behavioral objectives, containment to room and involuntary seclusion and the Safeguarding Vulnerable Adults policy (see pertinent information listed above). -On 8/16/21, RN #3 participated in the in-services. -On 8/16/21, CNA #7 had signed the in-service training record to show proof that they were attended the immediate inservice; however, CNA #7 was given disciplinary coaching based on failure to report a situation that went against facility policy. The CNA was educated on facility policy and the expectation that she needed to communicate matters she was unsure of or felt were not correct to the RN on duty. If did not handle the situation an immediate phone call to the director of nursing was warranted. The 8/16/21-8/17/21 training documented showed in addition to the policy review and education provided the training curriculum documented the following information: Interventions for active exit seekers diagnosed with dementia: -redirect by offering snacks or fluids; -Offer activities (i.e. puzzles, television, music , etc.) -Offer a walk around the courtyard. Residents may go for a walk outside if accompanied by a staff member for their safety; -Provide frequent check on the resident Abuse and neglect: Our residents have the right to quality care and quality of life. This includes freedom from neglect, abuse, . Residents at no time are to be confined to their room against their will. This includes doors being tied to where the resident cannot open it. This type of abuse is considered mental anguish, punishment and denervation and will not be tolerated. Disciplinary action will be initiated and will result in immediate termination for employment if justified. The facility implemented a quality assurance and improvement plan with a start date of 8/16/21. The plan documented a goal to prevent recurrence of the incident (involuntary seclusion). It was determined the root cause of the incident was lack of redirection techniques and staff education for keeping residents from eloping and keeping residents safe. The plan was presented to the quality assurance and performance improvement committee for review and ongoing monitoring. Corrective measures included: -Assess residents for mental and physical harm; -Interview other residents to identify others with potential concerns; -Inform the staffing agency of the CNA's performance; -Verify agency staffing are compliant with abuse training; -Educate staff on redirection techniques; -Educate staff on recognizing abuse; -Add additional redirection interventions to Resident #223's care plan (see resident record review document above); -Audit new staff abuse training weekly. While some measures had a completion date of 8/23/21, many interventions remain ongoing. III. Residents named in the facility reported incident A. Resident #223 1. Resident status Resident #223 age of 66, was admitted on [DATE] and discharged on 9/10/21. According to the September 2021 computerized physician orders (CPO), diagnosis included schizophrenia, vascular dementia and insomnia. The 7/30/21 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident was usually able to make himself understood. The resident comprehended most conversation; the resident had impairment in ability to consistently understand others and/or missed some part or intent of message in verbal communication. The resident had fluctuations in ability to focus attention, could be easily distractible or had difficulty keeping track of what was being said. The resident experienced disorganized or incoherent thinking displayed as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. The resident experienced hallucinations, wandering almost daily. The resident did not reject care assistance or the evaluation of care. The resident required supervision (oversight, encouragement or cueing) during transfers and walking on and off the unit. The resident was able to walk 150 feet once standing, and was able to navigate uneven surfaces independently. 2. Interviews and observation Interviews and observations of Resident #223 were not possible because the resident moved out of the facility. 3. Record review Physician orders: Monitor placement and functioning of wander guards every shift to ensure the device is in place and function correctly; initiated 6/27/21. Resident #223's comprehensive care plan documented the resident's care needs to address wandering and elopement seeking behaviors. The care focus initiated 8/23/21 read in pertinent part: Resident #223 presented an elopement risk related to a history of wandering behaviors; being disoriented to place; and impaired safety awareness. Interventions included: Distract resident from wandering by offering snacks, television, help to turn radio on to a program he likes (spirituality is very important to the resident). Set him up with his Bible, so he can read it. Take him for a walk. Help the Resident #223 complete tasks that are needed. Offer favorites such as diet coke and a small candy bar. Redirect from areas within the facility where he may get stuck. Progress note document the following information about Resident #223's behavior expressions and response to care. Social services note dated 5/26/21 at 3:08 p.m., read in part: Resident #223 is alert and oriented to self, family and where his room is. He has been difficult to 'read' . Resident is able to answer some questions appropriately, and struggles with others. He seems to have hallucinations secondary to schizophrenia . He is very spiritual, use to play the guitar, likes listening to Christian music . Family states he is quiet, reacts well to affection; can get frustrated when too restricted. Behavior note dated 7/7/21 at 1:26 p.m., read in part: Resident is confused this afternoon and keeps stating that he just wants to go where they are. Wondering into residents rooms; trying to find a way outside. We continue to redirect and will continue to monitor. Daily skilled note dated 8/11/21 at 2:43 p.m., read in pertinent part: Cognitive symptoms described as alert, oriented to self only, wanders facility frequently . Resident up per usual routine, ate in dining room for breakfast and lunch. Walking and wandering throughout the facility per usual, needs reminders on room location and dining times. Accepts redirection easily. Pleasant and cooperative with staff. Nursing note dated 8/12/21 at 2:09 p.m., read in part: Resident has been exit seeking today. Responds to redirection. Frequent checks in place for resident safety. Staff aware. Daily skilled note dated 8/14/21 at 3:27 p.m., read in pertinent part: .Resident up per usual routine, wandering throughout facility. At approximately 1:00 p.m., resident attempted to open the outside door by the therapy room. Was actively searching for a way out of the facility and stated, 'I just want to go out for a little while'; redirected by staff. A CNA provided one to one activity out in the courtyard and activity aide. Enlisted resident's help in passing out bingo prizes No further wandering noted. Nursing note dated 8/15/21 at 11:00 a.m., Resident eloped two times and was found by a dumpster on the north side of the building. Also was found heading east after eloping out of the front door. Ativan was given with effect after residents eloped. Fifteen minutes checks were initiated and the resident's physician was notified. Earlier on evening shift, resident was in bed lying with his eyes closed. Daily skilled note dated 8/15/21 at 5:50 p.m., read in pertinent part: Resident up per usual routine, wandering throughout facility. Rested in bed during the afternoon hours. Pleasant and cooperative with staff. No other concerns at this time. Nursing note dated 8/16/21 at 4:48 p.m., read in part: Clarification to previous note. Resident attempted to elope two times; he was found on facility property within minutes of exiting the building. -There was no documentation of the incident and an assessment of the residents. B. Resident #52 1. Resident status Resident #52 under the age of 65, was admitted on [DATE]. According to the November 2021 CPO, diagnosis included lack of expected normal physiological development in childhood, major depressive disorder with psychotic symptoms, and cognitive communication deficit. The 11/1/21 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The resident did not exhibit psychosis, had no behaviors and did not reject care assistance or evaluation of care. The resident did not wander. The resident was able to walk independently without an assistive device but required supervision (oversight, encouragement or cueing) during transfers and walking on and off the unit. 2. Interviews and observation Resident #52 was interviewed 11/4/21 at 11:02 a.m. Resident #52 said he remembered a time when he could not get out of his room but was unable to give details and said it was a long time ago. Resident #52 had no current concern with access to the community (facility) or staff. 3. Record review The resident's medical record documentation dated 8/1/21 to 11/5/21 was reviewed and there was documentation of resident elopement attempts or of the facility reported incident. IV. Staff interviews RN #4 was interviewed on 4/19/21 at 9:38 a.m. RN #4 did not know any details of this incident but heard about it. After that incident, all staff were provided an in-service on appropriate measures to manage a resident's wandering behaviors like offering redirection with preferred activity. If redirection attempts were unsuccessful, the facility would place the resident on 15 minute checks. CNA #2 was interviewed on 11/4/21 at 10:30 p.m. CNA #2 said it was never acceptable to lock a resident in their room. If a resident was wandering and eloping the facility staff should offer redirection. If that does not work staff should notify the nurse on duty and they would offer other interventions including increased checks of the resident. The NHA was interviewed on 11/19/21 at 12:10 p.m. The NHA said upon discovery of this incident the staff was suspended and an investigation began immediately. All staff participated in retraining. Confining a resident in their room under any circumstances was unacceptable. In addition, to reeducating staff on abuse identification and reporting; staff were educated on techniques to manage residents with elopement behaviors. The ADON was interviewed on 11/9/21 at 1:30 p.m. The ADON said she encountered Resident #52 upon arrival at the facility on 8/16/21. Resident #52 said he had been locked in his room last night. He was not able to explain who it happened to or who locked him in. The ADON reported this immediately to the NHA and was instructed to assess Resident #52 and Resident #223. Neither resident was able to give details of the incident. Neither resident showed signs of symptoms of physical injury or increased symptoms of psychosocial harm. RN #3 was interviewed on 11/11/21 at 432 p.m. RN #3 returned a call for an interview and said she heard a noise like someone was trying to get the door open. She went to investigate and found Resident #223 and #52's door was tied shut with a plastic bag; the bag was tied from the handle of the doorknob to the handrail just outside the door. The RN had to get scissors to cut the bag off the door. RN #3 said it was hard to tell if the residents were upset or confused, immediately following being let out of the room because both residents were always confused and had difficulty expressing their feelings. RN#3 said she talked with the staff on duty and educated them on more appropriate methods of preventing a resident from eloping. CNA #6 was permitted to finish the shift and the incident was reported in the morning to oncoming staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure for one (#221) of four residents, and/or their responsible person and the ombudsman were provided a written discharge notice to include the reasons for the move in a language and manner they would understand; ensuring the written notice was provided out of 37 sample residents. Specifically, the facility failed to provide Resident's #221, an appropriate notice of discharge that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -The location to which the resident is transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request; -The name, address (mailing and email) and telephone number of the Office of the State; and, -For nursing facility residents with intellectual or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. Findings include: I. Facility policy and procedure The Admissions, Transfer and Discharge policy, revised November 2016, was provided by the nursing home administrator (NHA) on 11/10/21/at 3:20 p.m. It read in pertinent part: When the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The resident's physician shall document if the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the Facility. Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; and (F) All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. II. Resident #221 A. Resident status Resident #221, age [AGE], was admitted on [DATE] and discharged on 7/20/21. According to the July 2021 computerized physician orders (CPO), diagnoses included bipolar disorder, dissociative identity disorder, and history of stroke. The 6/22/21 admission minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment failed to document whether or not the resident participated in the assessment process. There was no indication regarding the resident's overall expectations on discharging to the community or another facility or if the resident wanted to remain in this facility. There was no indication of there being a discharge plan. The 7/20/21 discharge MDS documented that the resident was discharged to an acute hospital and there was no discharge plan. B. Record review 1. Physician's orders According to the July 2021 CPO orders included: -Admit to skilled services, started 6/22/21; and, -I the Physician Certify that there is medical necessity for residents to remain at a skilled setting, started 6/22/21. 2. Physician's note Physician's note dated 7/1/21 read in part: for her per facility standing orders. Facility reports Resident #221 has started having behaviors, stating she couldn't swallow her medications although she ate breakfast without any difficulty, no choking or coughing noted . Resident was encouraged to get out of bed for lunch and resident didn't want to. Resident was encouraged to get out of bed as she is at the facility for rehab to get stronger . Above noted. These behaviors are typical of Resident #221, unfortunately. This is why she was given a thirty-day notice from the previous assisted living facility; previous living establishment where the Resident #221 was living until she required hospitalization. 2. Care plan The comprehensive care plan initiated on 6/23/21, documented a care plan intervention for discharge that read Wishes to return/be discharged to home. Resident lived at and assisted living prior to admission to the facility. Interventions included: -Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits and needs for maximum independence. -Make arrangements with required community resources to support independence post-discharge. -The care plan was not revised after additional information was received from the resident physicians documenting that the resident was discharged from her previous living situation, making the above care plan focus for discharge not possible or resident centered. 3. Progress notes Behavior note dated 7/8/21 at 2:13 p.m., read: Received call from the resident physician regarding resident increase in agitation/anxiety, and the facility's request for a provider visit to evaluate and treat, maybe a mood stabilizer at a small dose. Dr. (doctor) suggested that we call the resident's daughter to see if she can come into the facility to talk with her mother about behaviors being inappropriate for this setting and if not controlled we would be unable to meet her needs. The physician informed this writer that the resident had been given a 30 day notice at her last facility related to her behaviors, informed this writer that the resident has a diagnosis of multiple personality disorder and that she refuses medications. Call placed to the resident's daughter to explain the situation. Daughter states she was never told that her mother had that diagnosis. States that she and her brother have been asking for years for someone to diagnose their mother. Daughter said she would call the physician and that she and her brother were planning on coming in today to look at rooms for their mother to move to but would now rather wait to see if their mother is going to need another placement in another facility. Behavior note dated 7/8/21 at 2:55 p.m., read: Message left with receptionist at physician's office for resident's case worker, regarding placement for psychiatric care. 4. Discharge notes The resident progress notes dated 6/22/21 to 7/20/21 were reviewed. The progress note failed to document any information to show the resident was admitted for only a temporary respite stay or that there were plans in place to discharge the resident permanently when the resident was sent to the hospital for a planned surgical procedure at the hospital. -The resident medical record failed to document a discharge summary or provide a written discharge notice. There was no documentation to show the resident was provided with a discharge notice in an understandable language to explain who and what services were in place to assist the resident with next steps after discharge or why the resident would not be returning to the facility. 4. Transfer to hospital 7/20/21 Nursing note dated 7/20/21 at 12:03 p.m., read: Late Entry: This nurse spoke with both the hospital and the resident's physician's office in regards to assuring that resident arrived for planned surgery and also to inform of residents behavior's and her stay at facility being respite and that she is not a planned return to our facility as respite stay is over. Both parties verbalized an understanding and stated they would let the teams know. III. Interviews The assistant director of nursing (ADON) was interviewed on 11/8/21 at 1:30 p.m. The ADON said the director of nursing (DON) made the decisions of who to admit to the facility. The DON admitting Resident #221 was no longer working in the facility. The ADON was told by the previous DON that Resident #221 was only in the facility while the resident waited for an upcoming surgical procedure. When the resident went to the hospital, the ADON made sure to call the receiving hospital and give a verbal report to the receiving hospital and inform the hospital that the resident would not be readmitting to the facility. The ADON did not prepare or supply a written discharge summary or discharge notice for the resident. The social services director (SSD) was interviewed on 11/9/21 at 2:12 p.m. The SSD sad Resident #221 was having behaviors and was scaring the other residents, and acknowledged the resident needed a more appropriate placement. The SSD acknowledged there was no record of a discharge summary or discharge notice in the resident's chart. The NHA was interviewed on 11/9/21 at 2:14 p.m. The NHA acknowledged the facility did not provide the resident a discharge notice and the reason for not providing the resident a discharge notice was because the resident was only accepted into the facility under special circumstances on a respite stay while she gained strength for an upcoming planned surgical procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#4) of five residents reviewed for medication management, treatment and services in accordance with professional standards, out of 37 sample residents. Specifically, the facility failed to follow parameters to administer a as needed dose of an antihypertensive medications to Resident #4, as a prescribed treatment as ordered. Findings include: I. Facility policy and procedure The Physician's Orders policy, revised May 2019, was provided by the nursing home administrator (NHA) on 11/10/21 at 3:20 p.m. It read in pertinent part: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. A request was made to the facility for a policy and procedure regarding following physician's order related to administering medications, no related policy was provided during or after survey. II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted [DATE]. According to the November 2021computerized physician orders (CPO), diagnoses included hypertension, history of stroke and dementia. The 10/22/21 minimum data set (MDS) assessment revealed the resident had moderately impaired cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. B. Resident interview Resident #4 was interviewed on 11/3/21 at 9:45 a.m. Resident #4 had no concerns about medications. C. Record review The CPO documented the following orders: -Clonidine HCL 0.1 milligram (mg) tablets; give one (1) tablet, by mouth, two times a day for hypertension. Hold for systolic blood pressure (SBP) less than 105; start date 4/1/21. -Clonidine HCl 0.1 mg tablets; give one (1) tablet, by mouth, every 24 hours as needed for hypertension. Give for SBP greater than 190; start date 4/5/21. Review of the resident medical record and medical administration records (MAR) from 6/1/21 to 11/4/21 revealed the following orders and medication administration information regarding failure to administer the as needed dose of Clonidine for SBP greater than 190. -On 6/25/21, the resident SBP was 210; the MAR revealed the as needed dose of Clonidine was not administered. -On 7/5/21, the resident SBP was 193; the MAR revealed the as needed dose of Clonidine was not administered. -On 7/17/21, the resident SBP was 194; the MAR revealed the as needed dose of Clonidine was not administered. -On 7/29/21, the resident SBP was 203; the MAR revealed the as needed dose of Clonidine was not administered. -On 8/5/21, the resident SBP was 204; the MAR revealed the as needed dose of Clonidine was not administered. -On 8/21/21, the resident SBP was 192; the MAR revealed the as needed dose of Clonidine was not administered. -On 9/22/21, the resident SBP was 201; the MAR revealed the as needed dose of Clonidine was not administered. -On 10/12/21, the resident SBP was 197; the MAR revealed the as needed dose of Clonidine was not administered. -On 10/27/21, the resident SBP was 198; the MAR revealed the as needed dose of Clonidine was not administered. Pharmacy recommendation dated 8/26/21 read in pertinent part: Note to attending physician/ prescriber: Resident has orders for metoprolol ER 100 mg, by mouth, daily, hold for SBP greater than 105 or pulse less than 60. He is also on hydralazine 100 mg twice a day, Clonidine 0.1 mg twice a day (and has as needed), Lisinopril 20 mg, by mouth, daily. -His BPs are often high (some this month were 204/101, 190/92, 187/95). His metoprolol has been held seven out of 25 times so far due to his pulse being less than 60. -Please evaluate current hold parameters on metoprolol and hypertension regimen to see if adjustments could be made to better control his blood pressure. -Also generally do not recommend long term use of as needed blood pressure medications as they often result in medication errors (errors of omission). -The physician made changes to the hold parameters for metoprolol; no other changes were made. The care plan, initiated 4/17/21 and last revised 10/21/21 failed to document a care focus for hypertension. III. Staff interviews The assistant director of nursing (ADON) was interviewed on 11/8/21 at 1:05 p.m. The ADON said the resident's Clonidine medication should have been given as ordered when the resident SBP was greater than 190. The absence of a nurse's electronic signature indicated the medication was not given. It would be a medication error if the SBP was taken and the as needed Clonidine dose was not administered. The resident physician should have been notified if the resident SBP was over 190 and the medication was not administered as ordered. Registered nurse (RN) #5 was interviewed on 11/8/21 at 1:15 p.m. RN#5 was aware of Resident #4's as needed Clonidine order for the medication to be administered for SBP greater the 190. RN#5 said she would not have administered the as needed medication because when she measured the resident blood pressure it was at the time of the standing blood pressure medication and that standing routine medication administration would have lower the resident blood pressure to a level where the resident did not need the as need order. RN#5 acknowledged the resident physician should be notified that the as needed medication was not being administered when the resident's SBP was greater than 190 and said she would contact the physician right away. The pharmacist consultant (PC) was interviewed on 11/9/21 at 2:36 p.m. The PC said failure to administer the as needed dose of Clonidine for someone whose blood pressure was running high as was Resident #4's blood pressure could have significant health effects and he may have experienced dizziness and headaches. Resident #4 had chronically high blood pressures and they had been adjusting the resident's medications since admission to stabilize his blood pressure so that the as needed medication would not have been necessary. The PC was not an advocate of as needed blood pressure medications as it could lead to missed medications and medication errors if a nurse was unfamiliar with the medication regime. This past August 2021, the pharmacy recommended the as needed Clonidine not be used long term and for the physician to discontinue the as needed order; and provide parameters for the administering nurse to call the physician when the SBP was greater than given result for clinical guidance; the physician did not agree and to order remained. The administering nurse should have given the Clonidine as order; when the SBP was greater than 190. IV. Facility follow-up Physician visit note provided by the NHA on 11/10/21 at 4:39 p.m. Physician visit note dated 11/9/21 at 3:21 p.m., read in pertinent part: Patient seen for ongoing hypertension, I have changed his regimen today to Hydralazine 100mg at 6:00 a.m., noon and 10:00 p.m., metoprolol extended release 100 mg daily. History of present illness: essential (primary) hypertension. Diastolic blood pressure gets elevated into the 100's at times. Resident denies any headaches, chest pain or dizziness. Heart rate runs generally 60-90 . Medications reviewed . Assessment and plan: Essential (primary) hypertension: Regimen as above, discontinue clonidine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to notify the physician timely for three (#4, #369 and #60) of three residents reviewed out of 42 sample residents. Specifically, the facility failed to notify the physician to notify of a resident change of condition for: -Resident #4 when blood pressure was out of parameters and the as needed medication was not administered as ordered; -Resident #369 when resident temperatures were elevated over 99.0 F, for three days; and, -Resident #60 with timely notification for lab results. Findings include: I. Facility policy The physician notification policy, revised August 2007, was received from the director of nursing (DON) on 11/9/21 at 1:10 p.m. It read in pertinent part: The policy of this facility is to promptly notify the resident's attending physician of changes in the resident's condition or status. The nurse supervisor will notify the resident's attending physician when there is a need to alter the resident's treatment. Except in medical emergencies, the notifications will be made within 24 hours of a change that occurred in a resident's condition or status. II. Residents A. Resident #4 1. Resident status Resident #4, age [AGE], was admitted [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included hypertension, history of stroke and dementia. The 10/22/21 minimum data set (MDS) assessment revealed the resident had moderately impaired cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. 2. Record review The CPO documented the following orders: - Clonidine HCL 0.1 milligram (mg) tablets; give one (1) tablet, by mouth, two times a day for hypertension. Hold for systolic blood pressure (SBP) less than 105; start date 4/1/21. -Clonidine HCl 0.1 mg tablets; give one (1) tablet, by mouth, every 24 hours as needed for hypertension. Give for SBP greater than 190; start date 4/5/21. Review of the resident's medical record and medical administration records (MAR) from 6/1/21 to 11/4/21 revealed the Resident #4's SBP was greater than 190 on nine occasions; the as needed dose of clonidine was not administered and the physician was not notified of the SBP result or the missed medication. Cross-referenced to F684 failure to follow physician's orders to administer as needed dose of blood pressure medications when the resident blood pressure met prescribed parameters 3. Staff interviews The assistant director of nursing (ADON) was interviewed on 11/8/21 at 1:05 p.m. The ADON said the resident's should have been notified if the resident SBP was over 190 and the medication was not administered as ordered. B. Resident #369 1. Resident status Resident #369, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included fracture of left femur (thigh), fracture of left ulna (arm), hip joint replacement, status post fall. The 11/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had not received any or the recommended vaccinations for SARS-CoV-2 COVID-19. 2. Record review Review of the resident medical record vital signs report from admission on [DATE] through 11/9/21 revealed the resident had an elevated temperature higher they the resident normal baseline temperature. Temperature vital signs records documented the resident had a temperature of 99.6 degrees F on 11/2/21, 99.5 degrees F on 11/3/21, and 99.5 degrees F on 11/4/21. Progress Notes failed to show documentation that the resident physician was notified of the resident elevated temperatures. There was no physician notification for three days (11/2/21, 11/3/21, and 11/4/21) of temperatures over 99.0 degrees F until brought to the facility's attention. Cross-referenced to F880 failure to monitor and quarantine an unvaccinated resident with potential COVID-19 symptoms. 3. Staff interviews LPN #2 was interviewed on 11/4/21 at 3:32 p.m. LPN #2 said if vital signs are out of range she would recheck. She said she would call the physician if there was a repeated temperature over 99.0 degrees F. RN #2 was interviewed on 11/4/21 at 3:39 p.m. RN #2 said she would call the physician if a resident had a repeat temperature over 99 degrees F. The clinical consultant (CC) was interviewed on 11/8/21 at 1:29 p.m. The CC acknowledged the CDC guidance, which would indicate that Resident #369 should have been placed in isolation as a precaution following more than two days of temperatures greater than99 degrees F. The CC said the resident's physician would be notified of the resident pattern of elevated temperatures for further guidance. C. Resident #60 A. Resident status Resident # 60 age [AGE] was admitted on [DATE]. The October 2021 computerized physicians orders (CPO) included a diagnosis of quadriplegia, altered mental status, and stage four pressure ulcers. The 10/13/21 minimum data set (MDS) indicated the resident was cognitively impaired for brief interview with a mental status score of 12 out of 15. He required an extensive two person mechanical lift for transfers. The resident was totally dependent for transferring, eating, bathing,toileting and personal hygiene. B. Record review The laboratory report indicated that a culture was obtained from the resident's wound on 9/10/21. The lab received the culture on 9/13/21, and sent the result of the lab test to the facility on 9/17/21. The results of the culture test revealed a Heavy Growth of Staphylococcus aureus isolated.There was no record that the lab results had been sent to Resident #60's physician. The medication administration record (MAR) dated 9/30/21 indicated a prescription for Vancomycin HCl Solution 1250 MG (miligram)/250ML (milliliter), Use 1250 mg intravenously one time only for wound infection dated 9/30/21. This dose ended on 10/1/21. -The antibiotic order was not ordered timely due to the physician not being notified of the lab result. The second prescription dated 9/30/21 was for Vancomycin 750 mg every 8 hours intravenously. This dose ended on 10/4/21. A nursing note dated 9/30/21 indicated the writer called the pharmacy for the dosing of Vancomycin for Resident #60 which was ordered on 9/28/21. The writer indicated that the physician notified the resident's family on 9/28/21 about the change in medication orders. C. Interview The director of nursing (DON) was interviewed on 11/9/21 at 11:29 a.m.She said there was no record that a lab culture result was sent to Resident # 60's physician. She said she spoke to the resident's physician today and he said he did not receive notification of the lab results until 9/28/21. He did not specify who notified him of those results. At that point he sent prescriptions to the facility and the pharmacy for Resident #60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to consistently provide activities of daily living (ADL) support for four (#11, #21, #27, #56) of five dependent residents reviewed for ADLs out of 37 sample residents. Specifically, the facility failed to provide or offer showers according to the bathing schedule for Residents #11, #21, #27, #56. Findings include: I. Facility policy and procedure The Nursing Clinical Bath, Shower policy and procedure, revised January 2020, was provided by the nursing home administrator (NHA) on 11/9/21 at 10:37 a.m. It read in pertinent part, It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Residents have the choice between bed bath, shower, or bath. When residents admit please review the preference sheet with the resident. Complete a shower preference form. Residents may choose the days of the week they choose to bath or shower. Residents may choose their time that they can bathe or shower .Residents may change their preferences at any time during the stay. Nursing will upload preferences into the plan of care (POC) task. If a resident does not have a preference, the facility will utilize their default schedule. Facility is transitioned to electronic on bathing documentation. Facility is no longer using bathing sheets. II. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included acute pancreatitis, cellulitis lower limbs, and morbid obesity. The 8/5/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required limited assistance with dressing, and bed mobility with one person physical assistance. Supervision with one person physical assistance for transfers, toilet use, and personal hygiene. Bathing activity itself did not occur over the entire seven day MDS period so no functional status was listed. Preference was listed as very important to him to choose between a tub bath, shower, bed bath, or sponge bath. No rejection of care or other behavioral symptoms. B. Resident observations and interviews On 11/3/21 at 2:22 p.m. Resident #11 was seated on the edge of bed without pants on but wearing a shirt. His hair was oily and uncombed. He had a strong odor of urine and sweat. Resident #11 said he was bathed about one time per week. He said he preferred showers/baths two times per week. He said he does not ambulate but had help to transfer to his wheelchair. He said he can brush his own teeth with set up help. On 11/4/21 at 8:49 a.m. observed Resident #11 in bed sleeping. He had a strong odor of urine and sweat. On 11/4/21 at 2:45 p.m. Resident #11 was seated in bed without pants on but wearing a shirt, his hair was oily and uncombed. On 11/8/21 at 2:46 p.m. Resident #11 was seated in bed without pants on but wearing a shirt and a sheet over his legs. He had a strong odor of urine and sweat. C. Record review Care plan The care plan for ADL's, initiated 10/24/21, revealed ADL self care performance deficit. Interventions for bathing include requiring one person assistance with bathing two to three times a week per his preference in the evenings and as necessary. Care documentation The EMR task documentation completed by CNA's revealed Resident #11 prefers showers two to three times per week in the evenings. July 2021: Revealed zero bathing was provided from admission on [DATE] to 7/31/21. There were no refusals documented. August 2021: Revealed zero bathing was provided in the month of August from 8/1/21 to 8/31/21. There were no refusals documented. September 2021: Revealed three sponge baths were completed on 9/12/21, 9/22/21, 9/30/21 with total dependence; resident refusal on 9/24/21. October 2021: Revealed zero bathing was provided in the month of October from 10/1/21 to 10/31/21. There were no refusals documented. November 2021: Revealed one sponge bath was completed on 11/7/21 with total dependence (between 11/1/21 and 11/7/21). There were no refusals documented. Resident #11 had received a total of four baths, of any type, since admission on [DATE]. Resident #11 should have received a minimum of 29 showers. He received four out of 29 scheduled showers since July 2021. Progress notes A review of progress notes failed to reveal the resident refused or was offered an opportunity to bathe/shower at another time, on another shift or on subsequent days until he was bathed. Preference sheet completed upon admission 7/29/21 revealed in pertinent part, Resident #11 would prefer a shower, in a chair, two to three days per week, depending on what is easier. Prefers to shower in the evenings before he goes to bed. III. Resident #27 A. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the November computerized physician orders (CPO), the diagnoses included non-pressure chronic ulcer of left thigh, restless legs syndrome, and cellulitis of both lower limbs. The 8/30/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with two person physical assistance for bed mobility, toilet use, and transfers. Dressing, and personal hygiene required extensive assistance with one person physical assistance. Eating required setup and supervision. Bathing activity itself did not occur over the entire seven day MDS period so no functional status was listed. Preference was listed as not very important to her to choose between a tub bath, shower, bed bath, or sponge bath. No rejection of care or other behavioral symptoms. B. Resident observations and interviews On 11/3/21 at 10:17 a.m. Resident #27 was in bed. Her hair was greasy and uncombed. She said the caregivers do not brush her hair or her teeth. She said the caregivers do not brush her teeth because she did not have any and they also did not clean her gums. Her fingernails had a brown colored matter under the nails. On 11/3/21 at 10:49 a.m. Resident #27 was in bed. She said she was mostly bed bound, but got up occasionally. She said the caregivers used a mechanical lift to get her up into a shower chair or wheelchair. She said she woke up at 7:00 a.m. and the caregivers cleaned her up and changed her at 10:30 a.m. She said she had to ask to have her hospital gown changed. She said the one she was wearing has been on for two days, and sometimes she wore the same one for three to four days. The gown, which had food stains and brown stains on the chest and neck area of the gown. She said she would prefer to have a new gown daily. She said she had a shower one to two times per week and that was her preference. She said she thought she had a shower last Saturday but was not sure. On 11/4/21 at 8:49 a.m. Resident #27 was in bed, her breakfast tray was finished. Her hair was greasy and uncombed. On 11/9/21 at 1:59 p.m. Resident #27 said on the days they changed her gown or gave her a bath or shower she felt good. She did not recall how often they did that for her. C. Record review Care plan The care plan for ADL's, initiated 9/21/21, revealed ADL self care performance deficit related to limited mobility. Interventions for bathing include to notify nurses immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. There was no other care plan related to shower or bathing preferences or assistance required. Care documentation The EMR task documentation completed by CNA revealed the residents' bathing preferences were not listed. The shower book kept at the nurses station revealed Resident #27's shower preference sheet (dated 10/28/21) indicating her preference of a shower, two times per week on Monday and Saturday in the evenings. August 2021: Revealed zero bathing was provided from admission on [DATE] to 8/31/21. There were no refusals documented. September 2021: Revealed two showers were provided on 9/2/21 at 4:59 p.m. and 9:46 p.m. with total dependence. The resident received zero other bathing in the month of September. There were no refusals documented. October 2021: Revealed zero bathing was provided in the month of October from 10/1/21 to 10/31/21. There were no refusals documented. November 2021: Revealed one sponge bath was provided on 11/7/21 with total dependence (between 11/1/21 and 11/7/21). There were no refusals documented. Resident #27 had received a total of three baths, of any type, since admission on [DATE]. Resident #27 should have received a minimum of 22 showers. She received three out of 22 scheduled showers since August 2021. Progress notes A review of progress notes failed to reveal the resident refused or was offered an opportunity to bathe/shower at another time, on another shift or on subsequent days until she was bathed. There was no shower preference sheet completed upon admission on [DATE]. III. Resident #21 A. Resident status Resident #21, age [AGE], was admitted [DATE]. According to the November 2021 CPO diagnoses included wedge compression fracture of first lumbar vertebrae, unspecified fracture of sacrum, hemiplegia (paralysis of one side of body) affecting left non-dominant side, muscle wasting, difficulting in walking, unsteadiness on feet and acute pain. The 8/18/21 minimum data set (MDS) assessment indicated Resident #21 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance of one staff member for bed mobility, dressing and toilet use. She required extensive assistance of two staff members for transfers and required limited assistance of one staff member for personal hygiene. She required physical assistance of one staff member for bathing. She was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, when moving on and off the toilet and during surface to surface transfers. She had impairment of one side of her lower extremity and used a wheelchair for mobility. B. Resident interview Resident #21 was interviewed on 11/3/21 at 11:39 a.m. She said she was supposed to get a shower twice a week but it usually occurred about every 10 days because, they say they do not have enough help. She said she would feel so much better if I got my showers when I was supposed to. C. Record review Review of the November 2021 CPO indicated Resident #21 was to have spinal precautions with no bending, lifting or twisting, and she was to wear a lumbar brace when out of bed. The care plan initiated and revised on 11/8/21 indicated Resident #21 had an activities of daily living (ADL) self care deficit and required the assistance of one to two staff members. According to the shower preference sheet, signed by the resident, she requested showers on Sunday and Wednesday evenings. Review of the certified nurse aide (CNA) shower documentation since her admission in May 2021 revealed the following missed shower opportunities: -May 2021- She received one shower out of nine scheduled. -June 2021- It was documented she refused one shower, however there was no nursing documentation of the refused shower or of what alternatives were offered. She received three showers out of nine scheduled. -July 2021- She received two showers out of eight scheduled. -August 2021- She received one shower out of nine scheduled. -September 2021- She received five showers out of nine scheduled. -October 2021- She received two showers out of eight scheduled. -November 2021- She received zero showers out of two scheduled. IV. Resident #56 A. Resident status Resident #56, age [AGE], was admitted [DATE]. According to the November 2021 CPO diagnoses included hemiplegia following cerebral infarction (stroke) affecting left non-dominant side, muscle wasting, muscle weakness, unsteadiness on feet and chronic pain syndrome. The 10/8/21 MDS assessment indicated Resident #56 was cognitively intact with a BIMS score of 15 out of 15. He required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. He was dependent on one staff member for bathing. He had impairment on one side of his upper and lower extremities and used a wheelchair for mobility. B. Resident interview Resident #56 was interviewed on 11/3/21 at 3:56 p.m. He said he was supposed to get a shower two to three times a week but did not get them. He said he goes to dialysis on Mondays, Wednesdays and Fridays and would like a shower the day before those appointments because I just feel better if I am clean when I go. C. Record review The care plan, initiated 8/23/21 and revised 9/14/21, indicated Resident #56 had an ADL self care deficit related to left sided weakness and he required extensive assistance with bathing/showering. According to the 7/15/21 shower preference sheet signed by the resident he requested a shower two days a week in the mornings. Review of the CNA shower documentation since his July 2021 admission revealed the following missed shower opportunities: -July 2021- He received one sponge bath on 7/21/21 and one full bed bath on 7/25/21, out of eight scheduled showers. -September 2021- He received two showers and three sponge baths out of nine scheduled showers. -October 2021- He received four sponge baths out of eight scheduled showers. -November 2021- Documentation indicated the resident refused a shower on 11/3/21 however there was no nursing documentation of the refusal or what alternatives were offered. V. Staff interviews The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 11/9/21 at 9:21 a.m. They said showers were to be given per resident preference. They said they did not use a shower aide and showers were the responsibility of the CNAs. They said if a resident refused a shower the CNA was to encourage the resident throughout their shift to accept the shower. They were to document in the resident record that they refused and notify the nurse so she can investigate the reason for the refusal and offer alternatives. They said, In a perfect world the nurses were to document the refusal and what options were offered. The DON said her plan going forward was for all showers to be coordinated with the weekly skin checks so the nurses would be involved on shower days. They acknowledged the facility has had an issue with showers being given routinely and per resident preference for quite some time. CNA #5 was interviewed on 11/9/21 at 9:38 a.m. She said shower preferences were first determined at admission and can be updated monthly if needed. If the resident refused she would ask when they would prefer a shower and try multiple times. She said she would then document the refusal. She said she documents in the electronic medical record (EMR) task section. She documents how much help the resident needs and the type of shower or bath they received. CNA #4 was interviewed on 11/9/21 at 9:39 a.m. She said the CNAs were aware of when residents were to receive a shower by checking the shower binder at the nurses station. She said if a resident refused a shower they did not give it and they were to document it as refused in the computer and let the nurse know. She was unaware of how the nurse handled shower refusals. Registered nurse (RN) #1 was interviewed on 11/9/21 at 9:42 a.m. She said shower preferences and shower schedules were in a shower book. She said there was also a different body sheet for a CNA to fill out and give to the nurse if they notice a wound, sore or a scrape on the body. The CNA then documented the shower in the electronic medical record (EMR) in the task section. The CNA's record what kind of bath or shower and how much help the resident needed. She said refusals were also documented in the task section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in two out of three units. Specifically, the facility failed to: -Place symptomatic resident in isolation (#369) -Change gloves from dirty to clean and perform hand hygiene during wound care with Resident #60, -Ensure residents hands were cleaned before meals, -Ensure shared equipment of blood pressure cuff was cleaned after use, and; -Ensure appropriate personal protective equipment (PPE) masks were worn properly in the facility. Finding include I. Facility policy The Infection Control Prevention and Control Program policy and procedure, revised 5/20/21, was provided by the nursing home administrator (NHA) on 11/8/21 at 12:56 p.m. It read in pertinent part, Residents who have signs and symptoms of COVID-19 must be tested. While test results are pending, residents should be placed on transmission-based precautions pending the results of testing. Facility will take appropriate action based on results once results are obtained. The Vital Sign Parameters policy and procedure was requested from the director of nursing (DON) 11/4/21 at 3:14 p.m. However, it was not provided during or after the survey. The hand hygiene policy, dated August 2014, provided by the nursing home administrator (NHA) on 11/10/21 at 4:00 p.m., read in pertinent part; The facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least sixty two percent alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, and before handling clean or soiled dressings, gauze pad, etc.; before moving from contaminated body site to a clean body site during resident care, and after contact with blood or bodily fluids. The wound management policy revised 2017 as provided by the nursing home administrator (NHA) on 11/10/21 at 4:00 p.m., read in pertinent part; All treatments involving breaks in the skin require a clean technique, unless otherwise ordered by the physician. The cleaning and disinfection of resident care items and equipment policy, no date, was provided by the nursing home administrator (NHA) on 11/10/21 at 4:00 p.m., read in pertinent part; Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Center for Disease Control (CDC) recommendations for disinfection. II. Professional standards The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, (updated 9/10/21), retrieved on 11/11/21 from:https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Older adults with SARS-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for SARS-CoV-2 infection. According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings: Patients guidance, last reviewed: 3/15/16, retrieved on line 11/15/21 from: https://www.cdc.gov/handhygiene/patients/index.html Clean Hands Count for Patients. Patients should clean their hands: Before preparing or eating food. Before touching eyes, nose, or mouth. After using the restroom. After blowing their nose, coughing, or sneezing. After touching facility surfaces. According to the CDC, Hand Hygiene Guidance, last reviewed 1/30/2020, retrieved 11/10/21 online from https://www.cdc.gov/handhygiene/providers/guideline.html, recommendations for appropriate hand hygiene for infection control included in pertinent part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient, -Before performing an aseptic task or handling invasive medical devices, -Before moving from work on a soiled body site to a clean body site on the same patient, -After touching a patient or the patient's immediate environment, -After contact with blood, body fluids, or contaminated surfaces, -Immediately after glove removal, Healthcare facilities should: -Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations: -Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled, -Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered, -Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. III. Resident #369 A. Resident status Resident #369, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included fracture of left femur (thigh), fracture of left ulna (arm), hip joint replacement, status post fall. The 11/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Eating required setup help and supervision. B. Resident observations and interview On 11/4/21 at 8:49 a.m. observed newly admitted , unvaccinated Resident #369. Resident was not initially in quarantine due to COVID-19 recovery and her vital records revealed the resident had a 99 degree Fahrenheit (F) temperature on 11/2/21, 11/3/21, and 11/4/21 (see record review below). There was no personal protective equipment (PPE) outside the door of Resident #369 room. Resident #369 said she went to therapy daily. On 11/4/21 at 3:11 p.m. Resident #369 was observed in the therapy gym/department. She was not wearing a mask and was not encouraged to do so. On 11/8/21 at 11:32 a.m. Resident #369 was observed in the therapy gym/department not wearing a mask and not encouraged to do so. C. Record review COVID-19 status-Review of resident profile reveals she was COVID-19 recovered 9/27/21. Review of immunization records indicates refusal of SARS-COV-2 (COVID-19) (Dose one). Vitals Temperature-11/2/21 99.6 degrees F; 11/3/21 99.5 degrees F; and III. Resident #369 A. Resident status Resident #369, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included fracture of left femur (thigh), fracture of left ulna (arm), hip joint replacement, status post fall. The 11/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Eating required setup help and supervision. B. Resident observations and interview On 11/4/21 at 8:49 a.m. observed newly admitted , unvaccinated Resident #369. Resident was not initially in quarantine due to COVID-19 recovery and her vital records revealed the resident had a 99 degree Fahrenheit (F) temperature on 11/2/21, 11/3/21, and 11/4/21 (see record review below). There was no personal protective equipment (PPE) outside the door of Resident #369 room. Resident #369 said she went to therapy daily. On 11/4/21 at 3:11 p.m. Resident #369 was observed in the therapy gym/department. She was not wearing a mask and was not encouraged to do so. On 11/8/21 at 11:32 a.m. Resident #369 was observed in the therapy gym/department not wearing a mask and not encouraged to do so. C. Record review COVID-19 status-Review of resident profile reveals she was COVID-19 recovered 9/27/21.Review of immunization records indicates refusal of SARS-COV-2 (COVID-19) (Dose one). Vitals-Temperature-11/2/21 99.6 degrees F; 11/3/21 99.5 degrees F; and 11/4/21 99.5 degrees F Progress notes There was no physician notification for three days (11/2/21, 11/3/21, 11/4/21) of temperatures over 99.0 degrees F until brought to the facility's attention. (cross-reference F580, failed to notify the physician) Progress note (daily skilled note) on 11/3/21 (the very first progress note upon admission) revealed a vital sign temperature of 99.6 degrees F via the temporal artery route on 11/2/21 at 7:15 p.m. Vital signs do not show any fluctuations from baseline that require intervention(s). Progress note (daily skilled note) on 11/4/21 revealed a vital sign temperature of 99.5 degrees F via the temporal artery route on 11/4/21 at 12:10 a.m. Vital signs do not show any fluctuations from baseline that require intervention(s). The medication administration record (MAR) revealed a vital sign temperature of 99.5 degrees F on 11/3/21. D. Staff inteviews for isolation RN #1 was interviewed on 11/4/21 at 3:01 p.m. She said Resident #369 should be isolated if there was a fever to find the root cause and the nurse should call the physician. RN #1 said she did not know that Resident #369 had a fever so she did not call. The DON was interviewed on 11/4/21 at 3:14 p.m. She said if a resident had a fever it would be reviewed in the morning meeting. She said the nurse should notify the doctor when the temperature was over 100 degree F. She said she did not know the facility vital sign parameter ranges of when to call the physician. She said she gave the nurses the power to put the resident in isolation or not. LPN #2 was interviewed on 11/4/21 at 3:32 p.m. She said if vital signs are out of range she would recheck. She said she would call the physician if there was a fever over 99.0 degrees F. RN #2 was interviewed on 11/4/21 at 3:39 p.m. She said she would call the physician if a resident had a temperature over 99 degrees F. The infection preventionist (IP) was interviewed on 11/4/21 at 3:48 p.m. She said if a resident was COVID recovered and unvaccinated they need to wear a mask. She said she gave a report daily that they should wear a mask. It should be in the care plan to encourage residents to wear a mask. If you ask the resident and they refuse, they have a right to refuse. She said everyone should have vital signs taken two times per day. She said the nurses had been working on what the vital sign parameters were. She said she had a call out to the doctor to check. She said the nurses should phone the physician to follow up if a resident had a temperature. She said if the resident was on routine Tylenol or Ibuprofen the nurse would know to call the physician if they had a fever because the medications can lower fever symptoms. The IP and clinical consultant (CC) were interviewed on 11/8/21 at 11:36 a.m. She said if a resident came and had a temperature and multiple symptoms, like respiratory distress, she would call the physician. She said when she had looked at Resident #369 in bed, she had lots of blankets on. She said the nurses continued to monitor and the resident had no other symptoms. She said three days of fever was pretty normal for her. The CC was interviewed on 11/8/21 at 1:29 p.m. She acknowledged the CDC guidance which would indicate that Resident #369 should have been placed in isolation as a precaution following more than two days of temperatures >99 degrees F. She said she had not been familiar with this guidance prior. She said she had called to notify the physician after the third day of fever after it was brought to her attention. The rehab director was interviewed on 11/9/21 at 9:56 a.m. She said we try to offer masks to residents. She said we will still bring unvaccinated residents down to the therapy gym even if they refuse a mask but we try to have six feet of distance. She said she was not aware that Resident #369 had a temperature >99 degrees F on 11/2/21, 11/3/21, and 11/4/21. She said she had assumed that the nurses were monitoring. IV. Wound observations and hand hygiene Wound #1 left foot Registered nurse (RN) #1 was observed on 11/4/21 at 3:30 p.m. performing wound care for Resident #60. She collected the wound supplies, prepared the bedside table with a covering and put the supplies for the wound care on there. Resident #60 had a zip lock bag with his name on it specific to him with his wound supplies. Woundone was on his left foot. RN perform hand hygiene, donned gloves and removed the soiled dressing with scissors. She cleaned the wound with a wound spray. During the wound care she put her dirty gloved hand in her pocket to get her key out and handed the key to the director of nurses (DON) to go and get more supplies. The DON had bare hands and took the key. RN #1 continued to use the same gloved hands and dirty scissors to cut the sterile gauze and applied it to the wound. -She failed to change her gloves and perform hand hygiene in between dirty to clean processes. She also failed to clean the scissors used. Wound #2 right outer foot At 3:45 p.m. RN #1 performed wound care on the right foot. She took off the soiled dressing to the right foot with the same gloved hands from wound #1. She cleaned the wound and applied new dressings. -She failed to change gloves from dirty to clean and failed to perform hand hygiene in between wounds Wound #3 left hand At 3:55 p.m.RN #1 performed wound care on the left hand. She used the same scissors, cut off the gauze, cleaned the wound and applied a new dressing. She did not change her gloves and no hand hygiene was completed from dirty to clean. She doffed gloves at the end of this wound care and washed her hands in the sink. Wound #4 upper back At 4:00 p.m. RN #1 reached into her pocket and took out a pair of gloves. She donned the gloves and performed wound care to the upper back. She cleaned the wound and applied a new dressing using the same contaminated gloves. Wound #5 bottom At 4:15 p.m. RN #1 continued to go from wound #4 to wound #5 with the same gloves. There was no soiled dressing on this bottom wound. She cleaned the wound, touched the bed controls and reached into her pocket all with the same dirty gloves on. She cut the sterile dressing with the same dirty scissors and wore the same gloves and applied the dressing to the wound. -She failed to change gloves between dirty and clean procedures, failed to perform hand hygiene and failed to clean the scissors from dirty to clean processes. The scissors were placed back into the resident's wound supply bag used for him only. IV. Meals Observations on 11/3/21 at 12:10 p.m., revealed no hand hygiene offered to residents on the High Peak unit prior to the lunch meal. Observations on 11/4/21 at 8:42 a.m, revealed no hand hygiene offered to residents on the Spartan unit prior to the breakfast meal. -On 11/13/21 at 8:55 a.m. and 11:45 a.m no hand hygiene was offered to residents on the Spartan unit prior to breakfast and lunch meals. V. Blood pressure cuff observations RN #2 was observed on 11/4/21 at 9:28 a.m. to use the blood pressure vital machine equipment on three residents. She failed to disinfect the equipment before or after it was used on each resident. VI. Mask Observations Certified nurse aide (CNA) #1 was observed on 11/3/21 throughout the day to wear her mask underneath her nose. Resident was observed on 11/3/21 at 8:30 a.m. to leave the facility and he did not wear a mask. Several other residents were seen not wearing masks upon entering the facility. No encouragement from staff to have residents wear a mask. On 11/3/21 at 10:30 a.m. an unidentified staff member was seen walking with a resident in the hallway. Her mask was below her nose and the resident was not wearing a mask. Another unidentified resident passed them and he was not wearing a mask. There was also an unidentified male resident seated at the front entrance area not wearing a mask, with several other residents and staff walking near him. An unknown staff member was seen escorting a female resident down the hall in her wheelchair as well as an unknown male resident propelling himself in a motorized wheelchair, neither resident was wearing a mask. The staff members did not encourage the residents to apply masks. -At 10:34 a.m. an unidentified housekeeping staff member was seen on Spartan Street hall with her mask below her nose and two unidentified residents were in the hall near her, not wearing masks. She did not encourage them to apply a mask. -At 10:38 a.m. an unidentified male resident was seen propelling himself in a wheelchair on Spartan Street hall, his mask was below his chin. An unidentified staff member passed him and did not encourage him to raise the mask over his mouth and nose. -At 10:41 a.m. an unidentified certified nurse aide (CNA) was seen walking with a male resident down Spartan Street hall, the resident was not wearing a mask. Another unidentified staff member escorted a male resident to his room in his wheelchair, the resident was not wearing a mask. An unidentified male resident passed staff and other residents in his motorized wheelchair and he was not wearing a mask. Staff did not encourage the residents to apply masks. Licensed practical nurse (LPN) #1 was observed on 11/3/21 at 12:15 p.m. assisting residents at lunch and she wore her mask underneath her nose. On 11/4/21 at 9:20 a.m. multiple residents were seen throughout the facility not wearing masks. Many staff members interacted with them and did not encourage them to apply a mask. -At 11:47 a.m. an unidentified male resident was seen in the therapy gym working on a hand cycle machine, he was not wearing a mask, and the therapy staff did not encourage him to apply one. -At 11:56 a.m. two unidentified male residents were seen seated in the front lobby area talking with each other and neither was wearing a mask. Several staff members passed the residents and did not encourage them to apply masks. -At 12:59 p.m. two unidentified male residents were seen seated in the front lobby, neither were wearing masks. The nursing home administrator (NHA) and another staff member passed both residents and did not encourage them to wear a mask. The male resident in room [ROOM NUMBER] exited his room not wearing a mask. He talked to an unidentified nurse in the hallway that was standing next to her medication cart. He then proceeded down the hall to the front of the building. The nurse did not encourage him to apply a mask. Residents were observed at 1:35 p.m. to wear no masks in the common area near the dining room. -At 1:45 p.m. an unidentified male resident was seen seated at and using a hand cycle machine. He did not have a mask on. Another unidentified resident was seated behind him also not wearing a mask. Two therapy staff members were in the gym as well and one of them lowered her mask to talk to the resident. Neither staff member encouraged the residents to apply masks. -At 2:01 p.m. an unidentified therapy staff member was seen in the therapy gym working with a resident who was not wearing a mask. The staff member was standing in front of the resident with her mask below her chin tossing a balloon to the resident who held a pool noodle used to hit the balloon. The staff member did not raise her mask to cover her mouth and nose nor encourage the resident to raise her mask above her mouth and nose. -At 3:20 p.m. two unidentified female residents were seen in the therapy gym seated facing each other and neither resident was wearing a mask. Therapy staff did not encourage them to apply masks. An unidentified male resident was seen at the front desk talking to a staff member, he was not wearing a mask and the staff member did not encourage him to apply one. -At 3:49 p.m. three unidentified male residents were seen seated in the front lobby talking with one another, they were not wearing masks. The assistant director of nursing (ADON) walked past all three residents and did not encourage them to apply masks. On 11/8/21 at 8:45 a.m. an unidentified male resident was seen seated in the hallway across from the activity office, he was not wearing a mask. The activity director (AD) was in the hall talking to him, she did not encourage him to apply a mask. -At 8:51 a.m. multiple residents were seen returning to their rooms from the main dining room, none not wearing masks. One of the residents was escorted by a dietary staff member who did not encourage the resident to wear a mask. -At 10:15 a.m. an unknown staff member was seen exiting a residents room with the resident in a wheelchair. The resident was not wearing a mask and the staff member did not encourage her to wear one. She proceeded down the hall with the resident passing other staff and residents. VII. Nurse observations On 11/4/21 at 8:19 a.m. registered nurse (RN) #2 was observed during medication pass for Resident #21. The resident's oxygen tubing/cannula had fallen onto the floor. The RN picked the tubing up off the floor and replaced the cannula into the resident's nose. She did not clean the cannula or obtain a new one. -At 8:36 a.m. RN #2 obtained a blood pressure reading on the resident in room [ROOM NUMBER]-A. She placed the blood pressure cuff on the resident's bare upper arm. She then exited the room with the vital signs machine, and positioned the machine next to her medication cart. She did not clean the cuff after she obtained the reading and used the same blood pressure cuff on three other residents. VIII. Staff interviews RN #1 was interviewed on 11/4/21 at 4:30 p.m., she said she knew she needed to change her gloves and wash her hands when performing wound care for Resident #60. She said there was a potential for contamination because she did not wash her hands and changed her gloves. She had additional training today on hand hygiene. CNA #8 was interviewed on 11/8/21 at 11:53 a.m She said the residents had a choice to wear the masks or not. She said they encouraged the residents to wear the mask and to social distance but they refused. The director of nursing (DON) and the ADON were interviewed on 11/9/21 at 10:00 a.m. They said if a resident were to drop their oxygen cannula onto the floor the nursing staff were to replace the tubing and cannula with a new set. If it touched the floor it would be contaminated and should not be placed back into the resident's nose. They said when a blood pressure cuff was shared among multiple residents it should be cleaned with a disinfecting wipe after each use prior to being used on a different resident.The ADON said they used to have bags that hung on the vital signs machine that contained the disinfecting wipes for cleaning equipment after use, but she was unaware of what became of those bags and she acknowledged there were no disinfecting wipes with the machine. CNA #2 was interviewed on 11/9/21 at 10:20 a.m. She said the blood pressure cuff was cleaned after each use. She used the sani wipes. She said she knew how to clean the equipment from working in the field. CNA #3 was interviewed on 11/9/21 at 10:25 a.m. She said she used alcohol wipes to clean the blood pressure cuffs. She said to clean the vital tower in between resident use. RN #2 was interviewed on 11/9/21 at 11:10 a.m. She said she knew to clean the resident equipment with micro kill wipes every time it was used between residents. She failed to demonstrate cleaning equipment during observation above. The IP was interviewed on 11/9/21 at 11:35 a.m. She said hand hygiene occurred after resident cares, after changing gloves, and anytime there was a potential for contamination. She said blood pressure cuffs were cleaned when visibly soiled. She said unless the cuff touched the residents direct skin it did not have to be cleaned. She said residents were offered hand hygiene before meals and when they go to the bathroom. She said some residents refused to use the hand sanitizer. The masks were resident preference. The facility encourages the residents to wear them but they do not force them. She said residents who were unvaccinated wore them at all times outside of their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Satellite kitchen On 11/11/21 at 4:00 p.m. the satellite kitchen was observed to have several maintenance issues. There were cabinet drawers and cabinet covers missing. The dishwasher had the cover to bottom missing with wires sticking out. There were holes in the wall above the refrigerator that measured approximately an inch in diameter. The tile on the floor in front of the sink was stained and some parts of the tile were loose and coming apart under the dishwasher. The handle to the door entrance to the kitchen was loose and in need of repair. There was an exposed metal strip on the corner edge of the gate entry, loose wall laminate near dishwasher, missing caulk around the sink, loose caulk at the top of the splash board adjacent to the sink countertop. The maintenance director (MTD) was interviewed on 11/11/21 at 4:15 p.m. He said the satellite kitchen had been in terrible condition since he started working there in January 2021. He said he threw out an old stove and microwave that did not work. He said the facility had new ownership as of 4/1/21.He said they had to purchase medication carts and medical supplies like wheelchairs, lifts and hospital beds. He said the company before them had taken all of the supplies with them. He indicated there was no money in the budget left to repair the kitchen. He said he would have more money in the budget in January 2022 to begin the remodel and repairs of the kitchenette. II. Resident rooms and hallways A. Facility policy Facility policy was requested on 11/9/21 at 4:00 p.m. and not provided. B. Observations Observations on 11/4/21 at 12:08 p.m., revealed a strong odor of urine on the Spartan unit at the end of the hallway with 12 resident rooms. The floor in room [ROOM NUMBER] and 24 was sticky when walking on it by the bed and the sink area. There were no visual spills seen on the floor. There was a sign on room [ROOM NUMBER] that read; deep clean was scheduled for 11/4/21. Observations on 11/8/21 at 9:00 a.m., revealed a strong odor of urine on the Sparton hallway and the High peaks hallway. C. Staff interviews An additional environmental tour of the facility was conducted with the maintenance director (MTD) on 11/8/21 at 10:03 a.m. The MTD said he had a maintenance schedule to deep clean all the resident rooms. He said the floors were not properly waxed so they were more susceptible for odors and breakdown. He said the sticky floor was from liquid spills and because the wax was not on the floor it was more noticeable. He said he had not logged at each of the three nurses' stations where staff could write up a work order for any maintenance issue. He said he reviewed each of the logs the first thing each morning. He said staff verbally told him of any maintenance issues. Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for two out of three resident units and hallways. Specifically, the facility failed to: -Ensure shower rooms were clean for resident use; -Ensure areas were free from odors and sticky floors in resident rooms and hallways; and, -Ensure satellite kitchen was in good repair. Findings include: I. Resident shower rooms A. Facility policy A policy related to housekeeping for shared resident areas and a home like environment for a clean and comfortable shower room experience was requested; no related policies or housekeeping procedure was provided. The Resident Rights document dated 10/4/16, was provided by the nursing home administrator (NHA) on 11/9/21 at 1:32 p.m., it read in pertinent part: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. - Safe Environment. You have a right to a safe, clean, comfortable and homelike environment. B. Observations On 11/3/21 at 11:25 a.m. the resident shower room on the Mountain unit for where the majority of the residents were using for their bathing needs. The following was observed: -The shelving holding the resident ' s clean towels was soiled with a light brown/yellowish substance on the shelves and on the decorative hatching on the front facing of each shelf. -There was a large clump of grey hair sitting on the top shelf of the shelving unit holding the residents clean towels. -The sink was soiled with a dried gel like blue substance and was speckled with a black hair like substance substances. -There was a table next to the sink that was covered with a dried whitish substance. -There was a used green hairbrush on the table, full of grey and brown hair; the brush was not labeled for who it belonged to. -There was an unlabeled electric razor in the table; the razor was full of short hairs and the seams in the handle were caked with a whitish grey substance. -The flooring in the shower was scraped up and the scraped areas were soiled with a blackened substance. The grout in the shower was blackened and the floor had black stains over the entire surface. -There was a shampoo bottle in the shower that had a brow-dried substance on it. -There was debris on the floor including a used band aid, some plastic wrappers and a blue piece of plastic. -There was a computer table/rolling cart placed in the middle of the shower room. The shower room was observed a second time on 11/8/21 at 3:41 p.m. The following was observed: -The shelving holding the resident clean towels was still soiled with a brownish/yellow substance. -There sink was still soiled much as like described above, though less of the dried blue substance. -The green hairbrush was still on the table full of grey and brown hair. -The unlabeled electric razor was still in the same condition as described above. -The rolling computer cart was covered with used towels. -The floor was soiled with paper and plastic debris and dried blackened smudges. -The shower floor was in much of the same condition as described above plus there was a wad of used toilet paper by the drain and a large clump of a deep red substance on its surface. C. Resident interviews Resident #40 was interviewed on 11/3/21 at 11:20 a.m. Resident #40 said the facility had two shower rooms and the one by her room was not kept clean. Resident #40 preferred to use the shower on the rehabilitation unit when it was available despite the Mountain unit shower rom being closer to her room, because it was a nicer shower room and the housekeeper assigned to clean that room did a good job. Each time she took a shower in the shower room near her room, Resident #40 said she felt the need to clean the shower first; because the certified nurse aides (CNA) were always too busy to help her when she wanted a shower. Resident #40 said she sprinkled cleanser on the floor and then took a towel and scrubbed the surface running the towel over the surface with her foot. Other residents thank me for cleaning the shower room for them and leaving clean. Resident #18 was interviewed on 11/8/21 at 2:33 p.m. Resident #18 said the shower room was not cleaned well. D. Staff interviews CNA #2 was interviewed on 11/8/21 at 1:01 p.m. CNA #2 said she sanitized and cleaned the shower chair and shower surfaces after each resident use. The CNAs were also to remove any trash, soiled briefs, towels and clothing after assisting a resident with a shower. The housekeepers were responsible for cleaning the room daily. The maintenance director (MTD) was interviewed on 11/9/21 at 8:55 a.m. The MTD said he educated the housekeepers on cleaning the facility. The housekeepers were to use disinfectant with a one minute dwell time for best results. The housekeepers were to clean and disinfect the shower rooms daily. Housekeeper (HK) #1 was interviewed on 11/9/21 at 9:10 a.m. HK#1 said she cleaned the shower and the shower floors but the CNAs cleaned the equipment in the room and took out the linens and trash. The assistant director of nursing (ADON) was interviewed on 11/9/21 at 1:35 p.m. The ADON said the CNAs were expected to sanitize commonly used surfaces and spot clean the show room after each resident use and the housekeeping department was responsible to deep clean the room daily. The ADON was not sure who cleaned the shelving and tables in the shower room, and acknowledged the shelves holding the towels were dirty and should be replaced.