**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure recommendations from the Preadmission Screening and Resident Review (PASRR) Level II were incorporated into the care plan for one Resident (#46) out of eight residents sampled. Findings included: Review of Resident # 46's admission Record showed she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to major depressive disorder, recurrent, moderate, bipolar disorder, current episode manic without psychotic features, severe, other schizophrenia, unspecified psychosis not due to a substance or known physiological condition, generalized anxiety disorder. Review of the Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report showed a level II determination dated 1/21/2020, with the following service recommendations to be added on the patient's Comprehensive Persons Centered Nursing Care plan - Psychiatric Medication Management, and Supportive Counselling. In addition, recommendations for staff to continue monitoring the patient closely for mood and behavioral issues, and to inform the licensed mental health professional of any changes or difficulties in managing Resident # 46 symptoms. Review of the Electronic Health Record (EHR) for Resident #46 under care plans showed there was no evidence of the PASRR Level II recommendations incorporated into the care plan. During an interview on 1/30/2025 at 12:35 pm with the Director of Nursing (DON), Social Service Director (SSD), and Social Service Assistant (SSA). They all stated they were not aware the recommendations from Resident # 46's Preadmission Screening and Resident Review (PASRR) Level II needed to be added to her care plan. The facility did not have a PASARR policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to provide or assist with shaving facial hair for two residents (#72 and #78) of three reviewed for Activities of Daily Living (ADL) care. Findings Included: 1. During an interview and observation on 1/27/25 at 1:35 P.M. Resident #72 was lying in bed wearing a hospital gown, his facial hair on his neck and the sides of his face were approximately ½ inch in length and appeared unkept. Resident #72 said he would like the hair under his chin and neck to be shaved and staff have not offered to assist him. During an interview and observation on 1/28/25 at 11:15 A.M. Resident # 72 said he does not like the hair on his face and neck, when I get a shower it [facial hair] softens up. Resident #72's unkept facial hair remained unchanged on 1/29 and 1/30. During an interview on 1/30/25 a 2:34 P.M. the Director of Nursing (DON) said staff are expected to offer to shave residents during their shower task. Review of the admission Record showed #Resident # 72 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #72's 5-day Minimum Data Set (MDS) dated [DATE], showed Section C - cognitive patterns, a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Section GG - functional abilities showed Resident #72 required partial or moderate assistance with shower/bath. Review of the ADL care plan showed a focus for Resident #72 dated 1/4/25 , showing has a potential for Activities of Daily Living (ADL) self-care deficit related to chronic medical conditions, cerebrovascular accident (CVA), and limited mobility. The care plan's goal showed Resident #72 will improve ADL functioning through next review date. The interventions included ADL Care: may need limited to extensive by 1-2 staff members for ADL care. Review of the facility's 2nd floor shower schedule showed Resident #72 was scheduled for showers on Tuesdays and Fridays. Review of Resident #72's documentation survey report v2, dated January 2025 showed full bed bath was provided on 1/3, 1/7, 1/10, 1/14, 1/17, 1/28 and a shower on 1/24. There was no documented evidence Resident #72 received facial hair care. 2. During an interview and observation on 1/28/25 at 10:06 A.M. Resident #78 was lying in bed, wearing a hospital gown with unkept facial hair. He said he would like his facial hair shaved, he does not remember when he was last shaved, and staff has not offered to assist him. The hair on his cheeks and both sides of his neck is approximately 3/4 -1 inch long. The same observations was made on 1/29/25 and 1/30/25. Review of the admission Record showed Resident # 78's was admitted to the facility on [DATE] with a primary diagnosis of Parkinson's disease with Dyskinesia without mention of fluctuations. Review of Resident #78's admission 5-day MDS dated [DATE], showed in section C- cognitive patterns a BIMS score of 12 which indicated moderate cognitive impairment. Section GG, functional abilities showed Resident #78 is dependent (helper does all the effort) to shower/bathe self. Review of the ADL care plan dated 12/18/24 showed a focus for Resident #78, as follows has an ADL self-care deficit related to ADL needs and participation vary - Dx (diagnosis) Parkinsons. The care plan's goal was Resident #78 will improve ADL functioning through the next review date. The interventions included ADL Care: may need limited to extensive by 1-2 staff members for ADL care. Review of the facility's 2nd floor shower schedule showed Resident #78 was scheduled to shower on Mondays and Thursdays. Review of Resident #78's documentation survey report v2, dated January 2025 showed full bed bath was provided on 1/6, showers on 1/2 and 1/16 and he refused on 1/20. There was no documented evidence Resident #78 received facial hair care. During an interview on 1/28/25 at 10:50 A.M. with Staff E, Certified Nursing Assistant (CNA), He said residents are offered and assisted with shaving on their shower day. He said residents in A beds are showered during the 7:00 A.M.- 3:00 P.M. shift and B beds are showered during the 3:00 P.M. -11:00 P.M. shift. During an interview on 1/30/25 at 10:28 A.M Staff B, CNA said residents shaving is offered during showers . She provides showers for Resident #78, and he has never requested assistance with shaving. Staff B confirmed she had not offered Resident #78 assistance with facial care. During a tour on 1/30/25 at 10:40 A.M. an interview was conducted with staff, C, Licensed Practical Nurse (LPN), Unit Manager (UM) and Resident #78 and #72. Staff C said, Resident #78 stated he would like to be shaved and Staff C, LPN, UM said I will get his CNA to shave him. Resident #72 said he would like to be shaved and does not know what time. Staff C, LPN, UM said she will follow up later. Review of a facility policy standard and guidelines: Activities of Daily Living (ADL) Care and Services, revision date 1/2004 showed: residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Under guideline - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal, and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a) Hygiene ( bathing, dressing, grooming, nail care and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to stop bleeding, protect wounds from infection, and promote healing for one resident (#73) of one reviewed for non-pressure related wound care and failed to follow physician orders related to wound care for one resident (#4) out of 6 residents sampled. Findings included: During an interview and observation on 1/27/25 at 10:15 A.M. Resident #73 was lying in bed wearing a hospital gown. Multiple areas with various shades of pink and purple bruising to both arms and hands were observed. On his arms and hands and right cheek there were many lines of crusted brown and black blood, and multiple areas of blood oozing onto his gown and sheet. There was dried blood caked under his nail and around his nailbeds. His linen and gown had numerous areas of moist and crusted blood. Resident # 73 said hi and was unable to provide additional information. Review of the admission record showed Resident #73's initial admission date to the facility was on 9/27/24 with diagnoses to include urinary tract infections, atrial fibrillation, congestive heart failure, dementia, anemia, peripheral vascular disease, neuromuscular dysfunction of the bladder, and diverticulum of the bladder. Review of Resident #73's order summary report dated 12/1/24 -1/31/25 showed the following orders: apply zinc skin protectant cream to buttocks and sacrum skin areas daily and as needed (PRN) every shift, observe for signs and symptoms of excessive bruising, hematuria, hemoptysis, or other bleeding, immediately report abnormalities to the physician. Weekly skin checks every Thursday morning, Aquaphor External ointment to both arms, chest and back every day and evening shift for xerosis (dry skin), Plavix 75mg daily for peripheral artery disease, order dated 1/28/25, cleanse bilateral arms with wound cleanser, apply Xeroform and ABD pad and wrap with kerlix every day shift and PRN (as needed). Review of Resident # 73's care plan, focus dated 1/24/25 showed: has a skin impairment related to picking at his skin causing scabs, mostly to BUE (bilateral upper extremities). The goal is Resident #73 will show signs and symptoms of healing/resolution without complications by next review date. The interventions included the following: apply lotion to dry skin after activities of daily living, monitor the resident's changes in skin condition, and pain levels. Report changes to the physician, monitor and observe skin while providing routine care, notify nurse of any area of concern as indicated, skin checks weekly and as indicated, report any signs or symptoms of breakdown to the physician or wound team as indicated, treatments as ordered/indicated and as tolerated by the resident, initiated 1/24/25. Review of Resident #73's care plan focus: has a rash of the xerosis on both arms, chest and back, Goal: rash will heal by review date, Interventions to include: administer medications as ordered, avoid scratching and keep hands and body parts from excessive moisture, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected, initiated 12/27/24. Review of Resident #73's Skin Check, dated 12/26/24, 1/2/25, 1/9/25,1/16/25, and 1/24/25 did not show there were new skin issues to his arms. During a telephone interview on 1/27/25 at 1:15 P.M. Resident #73's Case Manager said, he picks at his skin and when she visits his sheets are often not clean. She stated she had discussed these concerns with the unit manager and social services. During an interview on 1/28/25 at 10:12 A.M. with Staff D, Registered Nurse (RN) said she was aware of the bleeding and [medicated moisturizer] is currently ordered for Resident # 73's arms and hands. During an observation on 1/28/25 at 10:12 A.M. Resident #73 was lying in bed with his eyes closed with scattered open wounds oozing blood on both arms and hands draining on his hospital gown and linen. During an interview on 1/28/25 at 10:12 A.M. with Staff E, Certified Nursing Assistant, said they are not able to treat the bleeding areas Resident #73's arms, it is continuous. During an interview on 1/28/25 at 4:06 P.M. Resident # 73's family member said prior to Resident #73's admission to the facility his arms were covered to prevent bleeding from scratching. The family member visits 3-4 times weekly and said during her visits she asks staff about the care for Resident #73's bleeding areas and they [the facility] do not do anything. During an interview on 1/29/25 at 7:40 A.M. Staff H, Licensed Practical Nurse (LPN), wound care nurse, said on 1/28/25 an order was received to place the following dressing on Resident # 73's arms apply collagenase ointment, cover with an absorbent dressing and wrap with a gauze roll. During a telephone interview on 1/30/25 at 11:29 A.M. Resident # 73's Physician Assistant (PA) said his skin condition was chronic, and she had just updated the orders following surveyor inquiry. The PA stated she would have expected the wounds to be covered. During an interview on 1/30/25 at 2:34 PM, the Director of Nursing (DON) said staff are expected to immediately notify the physician or wound care nurse, get orders and cover the wounds. Review of the facility's policy titled, Wound Care and Treatment, revised 1/2024 showed the following: Standard: The purpose of this procedure is to provide guidelines for the care of wounds and promote healing. 2. During an observation on 01/27/25 at 11:15 a.m. and on 01/28/25 at 10:15 a.m., an attempt was made to interview Resident #4, and she was not able to answer any questions regarding her care. Review of Resident #4's admission record revealed an admission date of 05/30/23 with diagnoses of unspecified protein-calorie malnutrition, adult Failure to thrive, age-related osteoporosis without current pathological fracture, major depressive disorder, recurrent, mild, vascular dementia, severe, with other behavioral disturbance, and muscle weakness (Generalized). Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section M - skin conditions, formal assessment instrument/tool (e.g., [name of assessment tools], or other), Clinical assessment, risk of pressure ulcers/injuries, was marked Yes. Risk of Pressure Ulcers/Injuries: unhealed pressure ulcers/injuries was marked Yes. Number of Stage 3 pressure ulcers 1. Skin and Ulcer/Injury Treatments: pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet. Review of current physician orders for Resident #4 revealed: Order Start Date: 01/27/25 Enhance Barrier: Encourage and assist residents to maintain enhanced barrier precaution daily. every shift for Right hip wound. Order Start Date: 01/16/25 Right Hip- Clean with wound cleanser, Santyl, calcium alginate, cover with composite dressing, change daily and PRN. Every day shift for Wound Care. Order Start Date: 01/06/25 Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate)) Apply to BLE/feet topically two times a day for xerosis Order Start Date: 12/31/24 Right Hip- Clean with wound cleanser, apply collagen, cover with composite dressing, change every other day and PRN. Every day shift every Mon, Wed, Fri, Sun for Wound Care. Discontinued on 12/31/2024. Order Start Date: 12/25/24 Right Hip- Clean with wound cleanser, apply xeroform, cover with composite dressing, change every other day and PRN. Every day shift every Mon, Wed, Fri, Sun for Wound Care. Discontinued on 12/30/24. Order Start Date: 12/12/24 Right Hip- Clean with NS, apply Santyl, calcium alginate, cover with composite dressing, change daily and PRN. Discontinued on 12/12/24. Order Start Date: 12/05/24 Treatment: Right Hip- Cleanse with Normal Saline, Pat dry, apply Santyl with calcium alginate, skin prep to peri-area; cover foam silicone border ;( may substitute dry dressing if silicone not available) Daily and or if becomes dislodged or soiled. Discontinued on 12/05/24. Order Start Date: 11/10/24 Right Hip- Clean with NS, apply Santyl, calcium alginate, cover with composite dressing, change daily and PRN. Discontinued on 11/10/24. Review of the Treatment Administration Record (TAR) for Resident #4 for January 2025 revealed wound care was missed as follows: Right Hip- Clean with wound cleanser, Santyl, calcium alginate, cover with composite dressing, change daily and PRN. Every day shift for wound care order was not completed on 1/19/25, 1/25/25 and 1/26/25. Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate) Apply to Bilateral (BLE) feet topically two times a day for xerosis order was not completed on 01/06/25 at 1700, 01/07/25 at 900 and 1700, 1/8/25 at 900, 01/11/25 at 900, 1/12/25 at 900 and 1700, 1/25/25 at 900, and 1/26/25 at 900. Review of Resident #4's Treatment Administration Record (TAR) for December 2024 revealed wound care was missed as follows: Right Hip- Clean with NS, apply Santyl, calcium alginate, cover with composite dressing, change daily and PRN. Every day shift for wound care order was not completed on 12/02/24 and 12/14/24. Right Hip- Clean with wound cleanser, apply xeroform, cover with composite dressing, change every other day and PRN. Every day shift every Mon, Wed, Fri, Sun for Wound Care was not completed on 12/29/24. During an interview on 01/30/25 at 8:44 a.m., Staff I, LPN, stated the nurses put in the orders from the physician. She stated once the order is put into their documentation software, it is added to the TAR. Once the order is on the TAR they then will document as needed. She stated if the order was for a wound, the wound nurse typically documents the treatment that is completed. She stated if anyone other than the wound nurse was doing rounds and a wound needed to be addressed for any reason, they would be the ones to treat and document. During an interview on 01/30/25 at 9:45 a.m., the Director or Nursing (DON), she stated it was the nurses' responsibility to follow an order. She said if it was a treatment, or something related to the wound they could talk to the wound care nurse to make sure they have what they needed. She stated she would expect the nurses to be documenting on the TAR. She reviewed Resident #4's TAR for January 2025 and December 2024 and identified there where holes where the nurse did not document if treatment was given for both months. Review of the facility policy dated 01/01/24, titled, Wound Care Treatment, revealed: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Under Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time of the wound care was given. 3. The name and title of the individual performing wound care. 4. Any change in the resident's condition. 5. Any problems or complaints made by the resident related to the procedure. 6. If the resident refused the treatment and the reasons why. 7. The signature and title of the person recording the data. Review of the facility policy dated 1/20/24, titled, Physician Orders, revealed: Guideline: orders and administration of medications and treatments will be consistent with principles of safe and effective order writing. Procedure: 9. Physician order should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the party responsible if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident # 7's admission record showed she was admitted to the facility originally on 9/15/23 and readmitted on [DATE] with diagnoses to include but not limited to bipolar disorder current episode mixed, unspecified, adjustment disorder with depressed mood, adjustment disorder with anxiety. Review of Resident #7 's Preadmission Screening and Resident Review (PASARR) Level I dated 9/13/23 showed in section A. Mental Illness (MI) or Suspected MI was blank. The review showed qualifying diagnoses were not checked. During an interview on 1/29/25 at 4:00 p.m. with the Director of Nursing (DON), she stated she was not aware Resident #7's Level I PASARR did not have her Mental illness (MI) diagnoses listed. She stated this was an oversight on their part and that it needed correction. 4. Review of Resident #86's admission Record showed an original admission date of 12/18/24 with a readmission date of 01/04/25. Resident #86 had the following diagnoses to include but not limited to depression unspecified, anxiety disorder unspecified and unspecified dementia mild without behavioral ,psychotic, mood and anxiety disturbances. Review of Resident's #86's Preadmission Screening a Resident Review (PASARR) dated 12/11/24 showed in Section A- MI (Mental Illness) or suspected MI (check all that apply) did not have Depressive disorder checked as a mental illness. The review showed the Level I PASARR was incomplete. Review of Resident #266's admission record showed an original admit date of 9/11/24 with a readmission date of 01/23/25. Resident #266 had the following diagnoses to include by not limited to epilepsy unspecified not intractable without status epilepticus and depression unspecified. Review of Resident #266's PASARR dated 8/07/24 did not have depression checked in Section A nor epilepsy checked in Section B related conditions. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration. Review of Resident #43's admission record showed an admission date of 11/18/24. Resident #43 had the following diagnoses to include but not limited to dementia in other diseases classified elsewhere unspecified severity with agitation, bipolar disorder current episode manic without psychotic features unspecified, insomnia unspecified, and anxiety disorder unspecified. Review of Resident #43's PASARR dated 11/12/24 did not have bipolar disorder, insomnia nor anxiety checked in Section A for mental illness or suspected mental illness. The review showed the Level I PASARR was incomplete. On 01/30/25 at 1:13 p.m., an interview was conducted with the DON. The DON acknowledged Resident #266's history of epilepsy and had stated the resident has had this since he was twenty-four years old. She stated the resident will require a Level 2 PASARR. The DON agreed Resident #43 had an incomplete PASARR and stated a Level 2 would be triggered once a properly identified Level I PASARR was completed. The DON acknowledged the lag in updated PASARRs and stated we have recognized the need to complete and update PASARRs. A request was made for the facility's policy and procedures related to PASARRs. The facility did not have a policy. Based on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for eight (#81, #7, #10, #63, 86,#16, #266 and #43) of 12 residents reviewed for PASARRs. Findings included: 1. Review of the admission record showed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia - 5/8/24, anxiety disorder - 5/8/24, major depressive disorder - 5/8/24 and Epilepsy - 5/8/24. Review of a level I PASARR for Resident #81 dated 5/8/24 revealed a blank PASARR and the qualifying diagnoses were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. An interview was conducted on 1/30/25 at 12:34 p.m. with the Director of Nursing (DON), Social Services Director (SSD), and the Social Services Assistant (SSA). After reviewing Resident #81's Level I PASARR, the DON said in November 2024 the facility identified the diagnoses needed to be corrected. The DON confirmed a level II had not been submitted for consideration. 3. Review of Resident #6's admission record revealed an original admission date of 5/9/22 and a readmission date of 1/14/25 with diagnoses to include major depressive disorder - 8/9/23, other schizophrenia - 10/12/23, generalized anxiety disorder - 8/9/23, bipolar disorder current episode mixed, severe, with psychotic features - 5/9/22. Review of the Level I PASARR, dated 08/26/2022, showed in Section I showed only Schizoaffective Disorder was marked. Other diagnoses of , generalized anxiety disorder, bipolar disorder, and current episode mixed, severe, with psychotic features were not checked. The resident had a Parkinson's diagnosis 5/14/24, which was not indicated under other neurological conditions. The review showed a level II evaluation which was submitted in 2022, prior to the newly acquired qualifying diagnosis. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following newly acquired diagnoses. Review of Resident #10's admission record revealed an admission date of 7/14/24. Resident #10 was admitted to the facility with diagnoses of major depressive disorder - 7/9/24, dementia unspecified Severity, with psychotic disturbance - 7/14/24, Dementia in other diseases classified elsewhere with mood disturbance - 7/14/24, unspecified psychosis - 7/9/24 and generalized anxiety disorder - 7/9/24. Review of the Level I PASARR, dated 6/14/2024, only depressive disorder diagnosis was checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. Review of Resident #63's admission Record revealed an admission date of 11/30/24 with a primary diagnosis of Neurocognitive Disorder with Lewy Bodies - 11/30/24, and other diagnoses to include bipolar disorder - 11/30/24 and insomnia -11/30/24. Review of the Level I PASARR, dated 11/29/24, revealed the bipolar disorder was not checked and in section II, dementia was marked as primary. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration related to the dementia diagnosis. During an interview on 1/30/25 at 12:34 p.m., with Director of Nursing (DON), Social Services Director (SSD), and the Social Services Assistant (SSA), The DON stated on admission, the SSA checks the PASARRs with the 3008. The SSA reviews the PASARRs at the morning meeting with the DON. They stated they compare the diagnoses in the residents' charts and the PASARRs and then follow up with the DON so she can update them. The DON stated Resident #6 did not have a diagnosis of dementia. The DON reviewed Resident #6's chart and did not see the diagnosis on any of her admission paperwork. The SSA stated Resident #63's and #10's PASARRs were identified in their audit for being blank and needed to be updated to match current diagnosis. The DON stated she was behind with updating PASARRs.

Based on observation interview and record review, the facility failed to ensure proper monitoring of sanitation solution for the dish machine in 1 of 1 facility kitchens. Findings Included: During a kitchen tour on 01/27/2025 at 9:50 a.m., Staff F, Dietary Aide, stated the dish machine is a low temp machine. He stated he does not normally record the temps or the sanitizing parameters for the machine. He pointed at the Certified Dietary Manager (CDM) and stated he (CDM) fills out the log. Staff F, Dietary Aide, was not sure what the rinse cycle water temp needed to be at. Staff F, Dietary Aide started a wash cycle and checked the sanitation level. The test strip stayed white during the testing, showing there was no sanitation. The sanitation bucket which was located below the dish machine was noted empty. Review of the Dish Machine Temp Log revealed and entry for Breakfast on 01/27/2025. 120 Min Wash had a recording of 125 temperature, 120 Min Rinse and a recording of 123. Sanitaization level was recorded as 50 PPM (Parts Per Minute). During an interview on 01/27/2025 at 9:55 a.m., The CDM stated staff should be checking the sanitation levels daily and record them on the log. During an interview on 01/30/2025 at 9:15 a.m., The CDM stated the person who is doing the dirty side of the dishes is the one who was responsible for filling out the log, because that is the initial side of dishes. He said it should be checked before each meal service such as before breakfast and lunch. He stated he was not sure who filled out the log for Monday at breakfast. He stated he does check the logs, and it was part of his daily routine. He stated he could not remember if he checked the log that morning, and he had not seen that the sanitation was empty. He stated he did not have a set expectation for the sanitation to be checked, but he would not expect it to be changed if it is a quarter full. During an interview on 01/30/2025 at 10:58 a.m., the Nursing Home Administrator (NHA), stated the CDM should be following up on the log and making sure the dishes are being cleaned and sanitized and the machine was in good repair. (Photographic Evidence Obtained)

Based on observation, record review, and interview, the facility failed to maintain equipment as evidenced by one of two laundry washers not working; two of three laundry dryers not working; one of one unclean gas stove; one of one exhaust hood with peeling paint over stove; and a leaky garbage disposal. Findings included: On 04/15/2024 at 9:55 a.m., an interview was conducted with Staff A, Laundry Aid #1. She stated she had come in early because we (laundry department) were so backed up. One washer and two dryers were not working. They had not been working for almost two weeks. On 04/15/2024 at 10:00 a.m., an interview was conducted with Staff B, Laundry Aid #2. She stated the washer had been down since last Thursday, it had been breaking down on and off, ongoing for the past year. The dryers had been down since Friday, they too, worked on and off. She stated, It is frustrating, we cannot get the laundry done. They will send the family members down to us, and they will scream at us. She said, corporate had known about it. They would blame it on maintenance. She stated, The problem is, we will call the repair people, everyone in the book. They will not come out because they say they have not been paid for the last repair job. We have no hot water. It has been going on over one week. An observation of the laundry room conducted on 04/15/2024 at 10:00 a.m. revealed out of order signs on one of two washers. Bagged and unbagged laundry was observed in front of the washers. Two of three dryers had out of order signs on them. Photographic evidence obtained. On 04/15/2024 at 10:55 a.m., a tour of the kitchen was conducted with the Certified Dietary Manager (CDM) and the Senior Dietary Manager (SDM). The six-burner gas stove was observed to have heavy black debris build up on the flat surface near the burners. The back splash guard on the stove was unclean with black, brown drippings present. The air hood directly over the gas stove was observed to have peeling paint on approximately 20 % of the surface. The Hood and Exhaust Cleaning label on the side of the hood was date punched with a last service date of February 2023, with no written Next Service Date identified. The CDM confirmed the unclean stove surface. A black plastic pan, approximately, 24 inches by 18 inches by 8 inches deep was observed under the garbage disposal near the wash machine. The CDM said the garbage disposal was leaking, the pan would be emptied at the end of the day. (Photographic evidence obtained). On 04/15/2024 at 11:10 a.m., an interview was conducted with the Nursing Home Administrator (NHA), she stated the Maintenance Director had resigned last week, she had a former Maintenance Director she could reach out to if there were any questions An interview was conducted on 04/15/2024 at 2:10 p.m. with the NHA, she stated she would locate the person for Maintenance, he had stepped out to get a part for the washer machine, it was just a little hose. On 04/15/2024 at 2:33 p.m., an interview was conducted with the Interim Maintenance Director. He confirmed the Maintenance Director for the building left last week. He stated he normally was located in a nearby building and had been called to fill in. When asked if the laundry had hot water, he stated he could not answer that, but the laundry had chemicals, and so hot water was not necessary. He stated for the washer, I just replaced the compartment at the bottom of the washer, what will happen is a comb or such will get caught in the trap and the washer will not work. He said for the dryers, one had a broken belt and one had a broken ignition. He stated, The belt will be here tomorrow. The ignition will take a little longer. He confirmed the chipped paint over the gas stove, and the interior of the hood needed to be painted. He confirmed the gas stove needed cleaning. He stated he just found out about the garbage disposal today, 04/15/2024, and he would look at it. He stated if the maintenance requests were not put into the (electronic maintenance request system) the maintenance department would not know about it. On 04/15/2024 at 3:50 p.m., the Interim Maintenance Director confirmed the work orders for the latter items, the washer, the dryers, the stove, the peeling paint, and the garbage disposal were not in the (electronic maintenance request system) for the maintenance personnel to know to work on them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility record review, the facility failed to ensure resident spaces and equipment were clean and maintained related to: 1. Twelve of thirty-three wheelchairs observed with cracked and torn armrests; 2. Three of seven resident room over the bed tables observed with peeled surfaces, and uneven surfaces; and 3. One resident room, room [ROOM NUMBER] observed with heavy water saturation damage with biogrowth on both the door wall and the ceiling. Observations revealed the above concerns in four of four halls during two of two days observed, on (10/30/2023 and 10/31/2023). Findings included: 1. On 10/30/2023 at 9:45 a.m., 1:00 p.m., and again on 10/31/2023 at 7:55 a.m., and 10:00 a.m. the following resident rooms were observed and revealed: 1. Resident room [ROOM NUMBER] (window bed) was observed with the Left wheelchair armrest cracked and torn. The resident was noted to use the wheelchair. 2. Resident room [ROOM NUMBER] (door bed) was observed with the Left wheelchair armrest cracked and torn. It was noted the resident utilized the wheelchair. 3. Resident room [ROOM NUMBER] (door bed) was observed with both the Right and Left wheelchair armrests cracked and torn. It was noted the resident utilized the wheelchair. 4. Resident room [ROOM NUMBER] (window bed) was observed with the Left wheelchair armrest cracked and torn. It was noted the resident had utilized the wheelchair. 5. Resident room [ROOM NUMBER] (door bed) was observed with the Right wheelchair armrest cracked and torn. 6. Resident room [ROOM NUMBER] (window bed) was observed with both the Left and Right wheelchair armrests cracked and torn. Resident noted to utilize the wheelchair. 7. Resident room [ROOM NUMBER] (window bed) was observed with both the Left and Right wheelchair armrests cracked and torn. It was noted the resident had utilized the wheelchair. 8. Resident room [ROOM NUMBER] (window bed) was observed with the Left wheelchair armrest cracked and torn. 9. Resident room [ROOM NUMBER] (door bed) was observed with the Right wheelchair armrest cracked and torn. It was noted the resident utilized the wheelchair. 10. Resident room [ROOM NUMBER] (window bed) was observed with the Left wheelchair armrest cracked and torn. 11. Resident room [ROOM NUMBER] (door bed) was observed with the Left wheelchair armrest cracked and torn. 12. Resident room [ROOM NUMBER] (window bed) was observed with both the Right and Left wheelchair armrests cracked and torn. It was noted the resident had utilized the wheelchair. Photographic evidence obtained. 2. On 10/30/2023 at 9:45 a.m., 1:00 p.m., and again on 10/31/2023 at 7:55 a.m., and 10:00 a.m. the following resident rooms were observed and revealed: 13. Resident room [ROOM NUMBER] (door bed) was observed with an over the bed table that had plastic surfaces peeling and peeled, leaving sharp edges, as well as a non cleanable surface. The span of the peeled surface reached from one side of the table to the other. There was a resident who resided in that room bed at the time of the observation. 14. Resident room [ROOM NUMBER] (window bed) was observed with a wooden surfaced over the bed table with plastic/rubber molding peeled up and off the table leaving a non cleanable surface. The surface of the table could no longer be level and with one side of the table pointed downward approximately ten to fifteen degrees. 15. Resident room [ROOM NUMBER] (door bed) was observed with a wooden surfaced over the bed table with plastic/rubber molding peeled up and off the table leaving a non cleanable surface. The surface of the table could no longer be level and with one side of the table pointed downward approximately ten to fifteen degrees. Photographic evidence obtained. 3. On 10/30/2023 at 9:45 a.m., 1:00 p.m., and again on 10/31/2023 at 7:55 a.m., and 10:00 a.m. the following resident rooms were observed and revealed: 16. Resident room [ROOM NUMBER] (door bed) was observed with the bedside and door side wall with heavy water saturation and water staining which covered approximately three feet up from the floor and approximately three quarters of the length of the wall. Further, the plastic/rubber baseboard was observed peeled slightly from the water saturated area and with black biogrowth spanning three quarters of the length of the wall. Also, the ceiling area directly above this water saturated wall was observed with water staining and some water saturation. The area on the ceiling measured approximately two feet across by one foot wide. There was a resident who resided in the door bed at the time of the observation but was not able to give an interview. Photographic evidence obtained. On 10/31/2023 at 9:00 a.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) provided the maintenance work order report for the month of 10/2023. The report identified the room number, date of job open, the closed date and status. The following was revealed to include but not limited to: 1. Work order 9850 - room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; wall needs attention the high wall needs attention. It is discolored, wall adjoining wall. Report work order status was reviewed as closed. 2. Work order 9860 - The Bathroom room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; the wall behind the toilet is discolored mush-like both doors need to be painted. Report work order status was reviewed as closed. 3. Work order 9862 - room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; Hole in the wall to left of A/C. Report work order status was reviewed as closed. 4. Work order 9863 - room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; Touch up paint needed to right of A/C. Report work order status was reviewed as closed. On 10/31/2023 at 11:30 a.m., an interview was conducted with the Maintenance Director. He revealed there were guardian angel rounds conducted by specific employees for each room. If there were things identified that needed repair, staff would put in a work order through the [electronic work order system], and the Maintenance Director would follow up with those concerns based on a priority status. The Maintenance Director confirmed the four job orders related to room [ROOM NUMBER], which included job orders 9850, 9860, 9862, and 9863. He revealed the jobs were completed by his staff and marked as status complete, as of 10/5/2023, which was twenty-six days ago from today, 10/31/2023. The Maintenance Director did not remember exactly what the job orders for that room entailed. He could not speak to the wall and baseboard saturation and biogrowth, nor could he speak to a ceiling leak and water stained ceiling. The Maintenance Director reviewed the work order sheet and confirmed none of the work orders were related to the current observations in the room with saturated walls, biogrowth, and a leaky ceiling. The Maintenance Director confirmed it had not rained in the area for over a week and confirmed the areas of concern in room [ROOM NUMBER] should have been brought to his attention by the guardian angel staff, so he could have taken care of it immediately. On 10/31/2023 at 1:20 p.m., the Regional Nurse Consultant, by way of the Nursing Home Administrator, provided the Maintenance Service policy and procedure dated 2001. The policy stated; Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy interpretation and implementation section revealed; 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but not limited to; (a.) Maintaining the building in compliance with current federal, state, and local laws, regulation and guidelines. (b.) Maintaining the building in good repair and free from hazards. (c.) Establishing priorities in providing repair service. (d.) Providing routinely scheduled maintenance service to all areas. (e.) Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interview and record review the facility failed to resolve a grievance in a timely manner for one resident (#315) out of four grievances reviewed. Findings included: Review of the Grievance Form, dated 9/4/22, related to Resident #315 revealed Person making complaint and relationship to resident [Name of Resident #315's family] (responsible party) Detail of complaint/grievance: . 3 at time of visit [family member] upset that Res's [Resident's] chain and ring is missing and called 911 police in bldg. [building] to speak to NSG [nursing] re [regarding] missing items. What shift did the complaint/grievance occur? 7-3 [7:00a.m.-3:00p.m.] Person completing this form: Social Services Director (SSD) (family member) in building to pick up al packed belongings . Person investigating complaint/grievance: form does not indicate who investigated Grievance Official Follow-Up: 9/6/22 Gold chain w/cross [with cross] found and confirmed from appro. [appropriate] disciplines that it is the identified chain-[family member] in bldg. on 9/6/22 and denies that chain is his [Resident #315]. 9/7/22 SSD and Admis. Dir [Administrative Director] spoke to fam [family] (via telephone)- [family member] (name of Resident #315's other family member) declines to have Pt [patient] return to facility (currently in hospital . Resident/ Responsible party notification of resolution name and signature: [names of Resident #315's two family members] (refused to sign) Date Resolved: no date indicated NHA (Nursing Home Administrator) Reviewed and Approves Resolution: signed and dated 9/12/22 Handwritten on bottom of form 9/8/22 still ongoing. Review of a late entry note dated 9/6/2022 at 8:52 p.m. by the SSD revealed, SSD informed from Unit Manager that Customer's necklace and 1 ring is not able to be located upon being discharge to the hospital. Unit Manager also immediately informed NHA and Dir. [Director] of Nursing. SSD contacted family to inform them that a gold chain and cross was recently brought to SS Dept. (Found in the laundry and unclaimed) Customer's gold necklace with cross was identified and confirmed by several disciplines that it indeed belonged to resident who has been (previously) seen wearing it daily (it was found in the laundry and brought to SS dept. to be identified. On 9/6/22 at 4:45 p.m., the 2nd [Resident #315's family member] who lives locally came to the facility stating he was here to pick up all of his [Resident #315's] belongings. Inappropriate language used several times toward In-house Maint. Direct [Maintenance Director] who escorted SSD. SSD politely asked Resident #315's [family member] if he had a moment to stop by the SS Dept. to identify the un-claimed gold cross and chain. [Family member] denied that it was his [Resident #315's] chain and stated that his [Resident #315's] ring was 4,000 dollars and demanded the facility reimburse for the amount stating, yeah tell me who is going to pay for that? [Family member] also verbalized he had pictures of the ring and chain and then quickly became easily annoyed speaking in a very loud contentious voice and mannerism; talking over the SSD dismissing the question of providing pictures of the items. [Family member] stated the chain was 300.00 but quickly again became irate when encouraged to (when available) to provide some form or copy of receipt which would be helpful to add to the grievance. [Family member] standing in the hallway saw DON (Director of Nursing) who came and stood by SSD. [Family member] stated who is she .SSD stated in a calm voice this is our D.O.N you spoke to her earlier today. [Family member] turned and walked away stating I don't care who she is. During this intense full interaction, SSD remained calm, spoke in a soft non-confrontational voice and reminded [family member] that she was the Social worker who routinely at least once a week would speak to him and have his [Resident #315] and her 'favorite' C.N.A [Certified Nursing Assistant] come to the SS [social service] office (per his request) to telephone call him to confirm that [Resident #315] was happy always having her eyeglasses on and jewelry with matching clothes on a routine basis. [Family member] did not respond and left the facility. There are 2 other [family members] which live out of state who have both confirmed that their [name of Resident #315's family member] can become emotionally unstable and erratic at times. Per conversation with both [family members], both [family members] have stated although their brother can become easily annoyed, no matter what they will always hold truth to much of what he says regarding [Resident #315] until proven otherwise. Based on review of Resident #315's admission Record she was admitted from an acute care hospital on 5/13/2022 and discharged on 9/12/2022. She had medical diagnoses which included but were not limited to aphasia, lack of coordination, muscle weakness, cognitive communication deficit, Alzheimer's disease with early onset, unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #315's Valuables Listing dated 6/26/2021 revealed a blank document. Review of Resident #315's SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form, dated 9/3/2022 revealed, Personal Belongings Sent with Resident/Patient eyeglasses and jewelry were checked. An interview was conducted on 12/07/22 at 1:11 p.m. with the Social Serviced Director (SSD) she indicated, I am very familiar with Resident #315. She came to us, had a [family member] who lives locally. The local [family member] was the caregiver for many, many years then the POAs (power of attorneys) decide they wanted to move their [Resident #315] from the local [family member's] care to our care. I had a CNA who would bring the patient to my office two times a week so she could speak to her local [family member]. Throughout her stay she adjusted well to her surroundings. The local [family member] would call the other [family members] and say the pictures on the wall are missing or the quilt was missing. So, I would go to the room, and I would see the quilt on the bed, the pictures on the wall I would call the two [family members] and the local [family member] to let him know the items are where they are supposed to be and this went on her whole stay. The local [family member] had a verbal altercation with an off hours nurse. There was a cross that she would always wear, and I found the cross and I kept the cross and everyone confirmed that was Resident #315's cross and there was a ring. I thought there were four rings and [family member] said no there were three rings. Then at one point he said there were four rings and that ring was $15-$20,000 dollars. The other [family members] said she had three rings but the local [family member] said there were four rings. But he actually said there were three rings before too. So, the local [family member] comes in after she went to the hospital. I had all her stuff in my office because I wanted to keep a close eye on all her stuff. He came in to pick the belongings. I had maintenance come with me. I gave him back the cross and he said that is not Resident #315's necklace. The [family member] refused to take the cross. He took the chain but not the cross because he said that was Resident #315's chain, but the cross wasn't hers. I even asked the CNAs who's cross is this and they all said its Resident #315's. I called the [family member], and he said I have three rings. I don't have the 4th ring and he said I'm coming in there to see what you got, where is Resident #315's cross and I said I have the cross and that's when he came in and got her stuff, but he never took the cross only the chain. The SSD further said, Typically, when something is missing, I find it right away. I take them to the laundry and find it. If I can't find it I get permission from the Director to reimburse the resident or family. On admission we discourage anyone from bringing in expensive items because we have a lot of dementia residents. If they insist on having expensive items then we can provide a lock box to them if they want it. I think at one point the [family member] took the rings home to be cleaned and sized. I wrote a note about that. She confirmed her note then added, But he brought them back. She confirmed there was no documentation the [family member] brought the rings back. She also confirmed the resident's inventory sheet was blank. Review of Resident #315's progress note dated 3/3/22 by the SSD revealed, RE (regarding): 2 Gold Wedding Bands. SS spoke to [family member's name] today via telephone who states he was in this week to visit his [Resident #315] and took them home to clean. Also said they seem to be loose so he will also provide them with a ring size adjuster to attach to the ring. Customer showing no distress. [Family member] expressed no concerns. An interview was conducted with the Nursing Home Administrator (NHA) on12/7/22 at 2:41p.m. She indicated, on 9/4/2022 law enforcement came into the facility for an investigation in regard to an allegation related to care and missing items. He did not communicate what the missing items were. I called the DON and had her come in and she came and spoke with the officer when he was here. I requested the police report, but I do not have it yet. I did the reportable, an immediate was filed and the missing items were not identified in that report. But after investigation there was a missing necklace and a missing ring. We investigated the care . We obtained statements related to the care . According to Staff S, LPN (Licensed Practical Nurse) statement, after [Resident's family member] left, he kept calling the facility over and over yelling at her that he wanted his [Resident #315's] diamond rings by 10:00 a.m. And kept calling over and over throughout the night until about 11:00 p.m. that he wanted the rings. The NHA indicated at that time Resident #315 went out, I don't believe she had the rings or necklace on her. She reviewed her statements and said no one indicated they saw those items on her. She then confirmed there was no mention of the missing items on the resident. The SSD, who was present at the time of the interview, indicated, The week before I saw the rings on the resident. The NHA said to the SSD, But at the time of the statements no one mentioned seeing or not seeing the jewelry. The NHA stated the necklace and cross were found and the [family member] took the chain, but he insisted the cross was not Resident #315's and refused to take that. The NHA did not have an answer for where the rings were. She confirmed there was no inventory sheet. The NHA further indicated there was a note the [family member] took two of the rings home at one point to get cleaned and resized. The SSD at this time said, But he brought them back. I saw her with the three rings on the week before she was discharged when she was in my office. The SSD stated at this time that she had a soft file that may indicate an inventory of her belongings, But there was no grievance related to this. The SSD returned with an email from one of the resident's out of state [family member] dated 10/23/21. The email revealed the local [family member] of the resident told them there were pictures and a quilt missing . also, we purchased my Resident #315 another necklace with a cross, then all of a sudden, the one that was missing showed up in the nursing station. So, then she had two of them and now it's missing again. Let me know what you find out, thanks. Further review of the provided email revealed handwritten 5 pics baby, 1 neck w/cross, 1 blanket, 5 shirts, 2 pants, 1 dress, 5 dress, 5 pic baby, 4 rings (1 at home to be sized.) further review revealed handwritten correction 3 rings signed and dated 7/3/22. On 12/7/22 at 2:47 p.m. the NHA and the SSD stated the process for taking inventory of personal belongings is the nurses are supposed to take an inventory list upon admission. Expensive belongings are not encouraged to be at the facility because we have residents with dementia. A lock box is provided to residents who insist on having expensive items. The SSD said if we had an inventory list on [Resident #315] it would have saved our department a lot of documentation as well. A phone interview was conducted with the DON on 12/08/22 at 10:50 a.m. she indicated, I do not have knowledge of the ring. I spoke with the POA who lives in another state he had no concerns with jewelry. There was some jewelry that was a cross that the SSD had but the [family member] said it was not Resident #315's. Law Enforcement was here for an abuse and neglect call and missing jewelry. He did not seem concerned about the jewelry he didn't do room searches or anything like that. He was here for about an hour. I printed him some information from the medical file. He did have conversations with the family and the one [family member] was not cooperative. The [family member] came in the next Monday, and he did not recognize me and did not want to speak. He asked about her funds and how he could get that; he was on the resident fund management system so he had the ability to get her funds so that was given to him and he left. On 12/08/22 at 10:55 a.m. and interview with the NHA was conducted and she confirmed there are still concerns related to if the resident had a ring, or not, or where it was. She stated they have started education on completing a valuables list for the residents. Review of the facility's policy, Grievances/Complaints, Filing, dated April 2017, revealed: Policy Statement Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman) Policy Interpretation and Implementation .2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. .7. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is Director of social services . 8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review And investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. 9. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations all alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. 10. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. .12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator, or his or her designee, will make such reports orally within reasonable timeframe of filing of the grievance or complaint with the facility b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. Review of the facility's Personal Property policy, revised on September 2012, revealed Policy Statement Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. Policy Interpretation and Implementation .5. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished; resident and/or responsible party are encouraged to notify staff when items are provided. 6. The facility will promptly investigate any concerns of missing items of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure a trauma-based care plan related to a Post-Traumatic Stress Disorder (PTSD) diagnosis was implemented for two residents (Resident #73 and #58) of two residents sampled. Findings included: 1. During facility tours on 12/05/22 at 12:43 p.m., 12/06/22 at 9:36 a.m., 12/07/22 at 12:10 p.m., and 12/08/22 at 8:20 a.m. Resident #73 was observed in her room sitting in her wheelchair. Resident #73 was noted withdrawn and avoiding eye contact. The resident was not watching TV or interacting with staff or her roommate. The resident appeared guarded and was hesitant to answer questions. Review of Resident #73's admission Record showed the resident was admitted to the facility on [DATE] with a diagnosis to include Post Traumatic disorder (PTSD). An Annual Minimum Data Set (MDS) assessment, dated 11/5/22, showed under Section C - Cognitive Patterns the resident has a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Section C1310 under Delirium showed the resident was assessed as not having difficulty focusing and not experiencing disorganized thinking. Review of current physician orders, dated 12/07/22, showed Psychology to evaluate and treat diagnosis depression and PTSD order, dated 11/03/21. Review of a new evaluation psychology report, dated 11/1/21, showed: [Resident #73] has a past psych history of Parkinson's, anxiety, major depression, and hallucinations. Patient is calm and timid demeanor. Initially treated for depression about five years ago. Patient states, I had a breakdown and was very depressed. Patient does have a history of psychotic features with depression. A couple days ago she was delusional and believed people were dead when they were not. She is depressed and anxious. Her [family member] who was her caretaker was arrested for ***********. Patient is currently treated with Haldol and Lexapro will recommend switching to Seroquel . Review Of Systems showed the resident presented with depressed mood, markedly diminished interest, decreased appetite, insomnia, loss of energy, psychomotor retardation, feelings of worthlessness or guilt, and poor concentration due to depression. Excessive anxiety and worry not able to control worry restlessness or feeling keyed up, being easily fatigued poor concentration due to anxiety irritability muscle tension and social phobia. Delusions of persecution grandeur, jealousy and erotogenic. Chronic aggravating factors included ongoing medical problems and life stresses and being in the facility, age, loss of independence and changed role. Review of a new evaluation psychology report, dated 11/5/21 showed, patient seen today per staff request due to difficulty sleeping. A PTSD assessment showed the patient describes symptoms of PTSD, has a history of experiencing a traumatic event that involved actual or threatened death or serious injury. Afterwards feelings of intense fear and helplessness have been experienced. Patient could not identify the date of the traumatic event. Patient describes symptoms of PTSD including efforts to avoid reminders of the traumatic event, flashbacks, recurrent distressing dreams, hypervigilance, restricted affect, memory issues exclusive to the event. Plan of care to include caregiver education will serve as nonmedical and preventive interventions. Review of a re-evaluation psychology report, dated 12/1/21 showed, . Pt. (patient) still timid, guarded, possible PTSD but does not elaborate on trauma history. Patient has paranoia she states people are telling me, I am an alcoholic and that I have COVID she endorses racing thoughts and anxiety, 7/10. Worried about finances and insurance running out. Psychology plan of care for service dates of 11/16/21 and 12/1/21 showed: Staff to be educated on benefits of implementing the following interventions: Encourage alternative methods of communication with friends and family such as [video conferencing applications] and phone calls, monitor patients for psychosocial changes and observe and report any changes to mental status caused by the situational stress, provide support and allow resident to express feelings fears and concerns, communicate to social service for referral to psychology and psychiatric services providers if needed. Review of Resident #73's care plan, dated 11/1/22, showed: Resident has alteration in mood and psychosocial well-being and behavior related to Parkinson's disease. Pleasant with wandering for short intervals as she prefers to keep busy in her room resident became tearful when she is thinking of something upsetting [family member] in jail she relayed this and she displayed tremors in her arms. When she calmed, the tremors stopped. Goal: Resident will vent feelings regarding life issues and will have psychosocial and spiritual needs met through the next review. Interventions included one-on-one visits for support and promotion of venting feelings, approach in a gentle friendly manner, do not rush decisions or responses, give clear explanation of all care activities prior to, of us like psychology psychiatry services as needed, praise the resident when behavior is appropriate, provide resident with opportunities for choice during care provision, use simple concrete statements Review of Resident #73's care plan with goals initiated and resolved between 10/28/21 and 11/20/22 showed the resident was not care planned related to implementation of a trauma informed care plan related to a PTSD diagnosis. The care plan did not show interventions were in place to identify the history of trauma or interventions to address causes of triggers and traumatization. On 12/07/22 at 12:15 p.m., an interview was conducted with Staff O, Certified Nursing Assistant (CNA). She stated Resident #73 is always crying. Staff O said, An example that happened this morning . she was saying to me; I lied, I know I lied, now they are upset with me. Staff O stated the resident repeated this over and over. She stated when this has happened in the past, she tries to reassure the resident. Staff O said, It's just the way she is. Staff O stated when the resident is stuck in things that are not real, we give her space. Staff O stated she thought the resident was nervous when interacting with strangers and sometimes it is in her head. She stated there has been no training on how to deal with that sort of behavior. Staff O stated she uses her instinct as a caregiver, and nursing responses, and just being kind. On 12/07/22 at 12:39 p.m. an interview was conducted with the Assistant Director of Nursing (ADON) and the Regional Clinical Director. The Regional Clinical Director stated the resident has an extensive history of trauma and is seeing psychology. The Regional Clinical Director was notified the care plan did not show any focus or interventions related to PTSD diagnosis. The Regional Clinical said, Most of her symptomatic behaviors are addressed in the mood/ evaluation focus care plan. She stated she would review if Resident #73 should be care planned for PTSD. Review of psychology and psychiatry progress notes from visits conducted on 11/30/22, 11/23/22, 11/16/22, and 10/31/22 showed the resident received on-going CBT (cognitive behavioral) therapy, psychoeducation, and stress management during the treatment sessions. On 12/07/22 at 3:21 p.m., an interview was conducted with the Regional Clinical Director. She stated Resident #73 was here for placement since the [family member's] arrest. The Regional Clinical Director stated the resident was evaluated by psychology and seen by a psychiatrist, was fitted with a wander guard due to wandering behaviors. She stated the resident has a lot of anxiety. She continues to be afraid to get out of her room. She stated psychiatry saw Resident #73 a month ago and reviewed a recent medication change. She stated the resident did not tolerate the medication change, she had increased hallucinations and the Seroquel was reinstated. On 12/08/22 at 8:20 a.m., Resident #73 was observed in her room, her breakfast tray was in front of her. The resident did not eat her breakfast. Resident #73 appeared emotional; eyes noted tearing up. Resident #73 stated she wanted to go downstairs to look at the Christmas tree. Resident #73 stated she was hoping the tree can be decorated before the guests arrive. Resident #73 appeared timid, teary, and withdrawn. On 12/08/22 at 12:49 p.m. an interview was conducted with the ADON and Staff E, Registered Nurse (RN)/Unit Manager. The ADON stated they have behavior monitoring for medication side effects but did not have monitoring related to PTSD/trauma. Staff E stated the resident does not have behaviors on a daily basis, she is quiet, with a private demeanor. Staff E, RN stated Resident #73 was not really showing any psychosis behavior for them to address. The crying, isolation and being withdrawn was her usual self. On 12/08/22 at 1:15 p.m., an interview was conducted with the Social Services Director (SSD). She confirmed Resident #73 was admitted with a diagnosis of PTSD. She stated the staff would know if the resident is being triggered; if they see anxiety increasing, shaking, wandering, rapid thoughts, incoherent, not present conversations. The SSD stated the PTSD was related to the [family member] exploiting her financially and him being arrested. She had gone through the investigation, which is a source of anxiety. If the resident encounters anyone asking her questions, she can be easily triggered. The SSD stated the resident was care planned specifically to mood and depression. She stated they do not have to care plan specific to PTSD diagnosis. The SSD stated they will update the care plan to include behavioral interventions. She stated the treatment interventions should have a way to monitor and report triggering behaviors. An interview was conducted with the MDS Director on 12/08/22 at 1:11 p.m. She confirmed they did not have a care plan for Resident #73 related to PTSD or trauma. She stated they should have a care plan specific to the diagnosis, because it has a significant effect on the resident's day-to-day. She stated Resident #73 should have been assessed upon admission and interventions to manage her behaviors put in place. The MDS Director stated they would review their assessments to cover the history of trauma. The MDS Director stated they are not used to working with residents with the diagnosis of PTSD / Trauma, but that was not a reason not to care plan the resident. During an interview with the Nursing Home Administrator (NHA) on 12/08/22 at 1:57 p.m. She stated they should be care planning PTSD and resident with trauma. She stated Corporate just started the discussion on trauma- based-care. The NHA stated they are working on updating their facility policies and assessments. Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, is developed and implemented for each resident. (9.) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. (10.) Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the end point of an interdisciplinary process. (11.) Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making when possible, interventions addressed the underlying sources of the problem area not just addressing only symptoms or triggers. (13.) Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. (14.) The Interdisciplinary Team must review and update the care plan . when the desired outcome is not met. 2. On 12/5/2022 at 1:20 p.m. Resident #58 was observed in the secured/dementia unit and seated in a chair in the hall, across from the secured unit activities room. She was seated with other residents and just watching everything going on around her. She would speak with other residents near her. In an attempt to interview her it was determined she was confused and not interviewable. On 12/6/2022 at 12:04 p.m. Resident #58 was observed in the secured dining room participating in a group activity. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] and was currently in the facility for long term care services and resided in the secure dementia unit. Review of the current Quarterly MDS assessment, dated 10/7/2022, revealed a BIMS score of 1 out of 15, indicating she had severe cognitive impairment and mood and behaviors were indicated as none. In Section I - Active Diagnosis Post Traumatic Stress Disorder was selected. Review of the psychological assessment, dated 4/28/2021, revealed Resident #58 was assessed by the psychologist with relation to PTSD/Trauma. The assessment revealed a history and present illness with comments to include: The resident has previously been diagnosed with dementia, anxiety and PTSD. The recommendations revealed: Continue to assess for appropriateness and to continue with psychiatric evaluation for medication management, with an anticipated length of treatment for three months. The treatment plan included: The resident was referred for an evaluation due to symptoms of anxiety. She presented as alert, Ox 2 (times two) with confusion, mildly circumstantial thoughts, elevated and anxious mood, mobile affect, impaired memory. She has previously been diagnosed with PTSD, anxiety and dementia. She has also been diagnosed with a TBI (traumatic brain injury). The resident may benefit from a psychiatric evaluation for medication management. Ongoing assessment to determine if she may benefit from individual psychotherapy. This assessment was completed twenty-six days after the resident was admitted to the facility. On 12/8/2022 at 8:50 a.m. an interview with the Staff G, Registered Nurse/Unit Manager and she revealed Resident #58 was newer to the secured unit and she was normally pleasant and does ambulate throughout the unit and participates in group activities. Staff G revealed at times she (Resident #58) can be resistive to care and with some aggression. Staff G indicated Resident #58 was easily redirected. Staff G was not aware of Resident #58's diagnosis of PTSD/Trauma or behaviors related to the diagnosis. She looked at the electronic medical record under the diagnosis tab and did confirm there was a diagnosis of PTSD/Trauma, but was unaware why the resident had the diagnosis and further confirmed she could not find an assessment or care plan with relation to PTSD/Trauma. On 12/8/2022 at 9:30 a.m. Staff G provided a Social Service Note and indicated she found some information related to Resident #58's trauma. The note revealed: 3/29/2022 12:19 (p.m.) Social Service Note - Resident #58 was involved in a serious car accident years ago that led her into a coma with a TBI, Resident recovered and went back to work as a Licensed Mental Health Tech. Staff G confirmed she was still not knowledgeable of this until just now. She further explained she has worked in the secured/dementia unit for about three months and would not know what type of behaviors to look for related to Resident #58 and her PTSD/Trauma diagnosis. On 12/8/2022 at 9:01 a.m. an interview Staff F, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) revealed she was aware of Resident #58 and that Resident #58 is usually pleasant and interacts well with staff and other residents. Staff F explained Resident #58 has been on her daily work assignment many times and she interacts with her daily, even if not on her assignment. Staff F confirmed she was not aware of Resident #58 having PTSD/Trauma and has not exhibited with any types of behaviors or observations that would make her believe she had any current or past psychosocial trauma. Staff F further indicated she has not had any specific training and or in-services that would provide her with education on how to handle residents with PTSD/Trauma. On 12/8/2022 at 9:08 a.m. an interview with Staff K, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) confirmed she has Resident #58 on her assignment routinely and she knows the resident to be pleasant but confused and interacts well with all the residents and staff on the unit. Staff K also confirmed Resident #58 has presented with some refusal of care behaviors and some aggression but has been easily redirected. Staff K confirmed she was not aware Resident #58 had past PTSD/Trauma and would not know what to look for or how to handle a resident who has PTSD/Trauma. On 12/8/2022 at 10:45 a.m. an interview with both the Staff E, LPN and the Assistant Director of Nursing (ADON) was conducted. Staff E was aware Resident #58 had a diagnosis of PTSD/Trauma and indicated it had been brought to his attention that the resident was involved in a car accident many years ago and was in a coma and had a TBI. He revealed there is no current PTSD/Trauma assessment for Resident #58. The ADON was also involved in this interview and also confirmed she knew about Resident #58's PTSD/Trauma and that related to an accident years ago, but also confirmed there was no assessment to indicate this, other than a social service note and a diagnosis of PTST/Trauma. Staff E and the ADON also confirmed there were no current or past care planning problem areas with interventions related to PTSD/Trauma. On 12/8/2022 at 2:00 p.m. during an interview, the Nursing Home Administrator confirmed Resident #58 was not assessed for PTSD/Trauma upon her admission on [DATE], but was assessed by a psychologist on 4/28/2022, which was twenty-six days after Resident #58's initial admission. The Nursing Home Administrator revealed the resident was not care planned with problem areas and interventions related to the resident's past PTSD/Trauma.

Based on observations, interviews, and record review the facility failed to provide respiratory care consistent with professional standards of practice related to not notifying the physician of an episode of respiratory distress and did not following physician oxygen orders for one resident (#95) out of two residents reviewed for oxygen for two out of three observations made of Resident #95. Findings included: Review of Resident #95's admission Record revealed she was admitted from an acute care hospital on 7/13/2022 with diagnoses that included but are not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, anxiety disorder, major depressive disorder, recurrent, unspecified dementia with other behavioral disturbances. Review of Resident #95's Minimum Data Set Section C Cognitive Patterns, dated August 30, 2022, revealed a Brief Interview for Mental Status summary score of 4 out of 15, indicating severely impaired cognition. On 12/05/22 at 10:06 a.m. Resident #95 was overheard repeatedly yelling from her room Please someone, help me please. Call light was not on. Upon entry into the resident's room, she continued to call out please help me, please help me. Her call light was observed on her bed up by her pillow. The resident had her phone in her hand and was pushing buttons on the phone. She was noted to have her nasal cannula (NC) on, but it was not in her nostrils. She appeared in respiratory distress with an increased respiratory rate. She stated help me; I can't breathe, I can't breathe. The oxygen concentrator was observed to be on 2.5 liters (L) with the nasal cannula not in her nose. This surveyor went and got the nurse, Staff H, Licensed Practical Nurse (LPN), at 10:07 a.m. The nurse went into the room checked the resident's oxygen saturations, placed the NC on her, instructed her to take a few deep breaths in through her nose and out of her mouth and rechecked her oxygen saturations. She reassured the resident she would be just outside of her room and to use her call light for assistance. Immediately after the nurse left the resident's room on 12/05/22 at 10:07a.m. an interview was conducted with Staff H, LPN she stated the resident has COPD, her saturation when I went in was 87% and then came up to 96%. She always pulls her NC out of her nose. She has anxiety so when she pulls her NC out, and her saturations drop she gets confused and anxious. I just gave her an inhaler earlier this morning. Further observation was conducted on 12/06/22 at 11:18 a.m. Resident #95 was observed to be dressed lying in bed, not in any respiratory distress. Resident #95 was observed to have her NC on and in her nose, the oxygen concentrator was set on 3L. Resident #95 stated she was feeling as good as she can feel with her breathing. On 12/08/22 at 8:30 a.m. Resident #95 was observed to be sitting on the side of her bed with increased work of breathing asking where her youngest [family member] was. Staff E, LPN/Unit Manager was next to the resident an observed to put her oxygen cannula back on the resident and telling her to take slow deep breaths. Staff E stated Resident #95 was set on 2L and that she should be on 3L and he adjusted the oxygen. The resident began to relax and her increased work of breathing was better controlled. Staff E was interviewed at this time and he stated when he found the resident she was walking to the nurses station without her oxygen on. He escorted her back to her room placed the nasal cannula back on the resident. He said she will take off her oxygen and she becomes hypoxic and very confused. We added the order to monitor her oxygen every shift because we had a care plan meeting with the family, and we told them that she has been taking off her oxygen and becoming hypoxic and confused. So, I added that order and told the family because it looked like maybe when she came back from the hospital the order got missed or dropped off. I'm not sure, but it's on there now. She also used to be at the end of the hall, and she would walk up to the nurses' station without her oxygen on and that is not good. It was way too long of a walk for her without her oxygen so we moved her closer to the nurses station. Review of Resident #95's physician orders for December 2022 revealed an order with a start date of 7/18/2022 and a discontinuation date of 12/07/2022 for respiratory-Oxygen: NC (nasal cannula)/mask. Encourage and assess resident to use O2 (oxygen) at 3L (liters) via NC continuous for SOB (shortness of breath) and O2 sat (oxygen saturation) less than 90 every shift for O2 sat less than 90 / SOB. Further review of the physician orders, dated 12/8/22, revealed an order, with a start date of 12/07/2022 with no end date, for Respiratory-Oxygen: NC/mask. Encourage and assess resident to use O2 at 3L via NC continuous for SOB and O2 sat if less than 90% every shift for O2 sat less than 90 / SOB. Review of Resident #95' care plan, revised on 8/15/2022, revealed: Focus: resident is at risk for altered respiratory status/difficulty breathing related to anxiety, COPD/emphysema, and history of acute/chronic respiratory failure. Goal: The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions with an initiation date of 8/15/2022 included but were not limited to: Administer oxygen as ordered. Monitor O2 saturations as ordered/PRN (as needed); Monitor s/sx (signs and symptoms) of respiratory distress and report to MD PRN [Medical Doctor as needed]; Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic Pain; Accessory Muscle usage; Skin color changes to blue/gray. Review of Resident #95's behavior care plan, initiated on 12/6/21 and revised on 8/19/22, did not reveal any indication the resident has behaviors of changing her oxygen settings or removing her nasal cannula. Review of Resident #95's progress notes from 12/01/2022 to 12/08/2022 (survey exit date) did not reveal notification to the physician of an episode of desaturation on 12/5/2022. Review of Resident #95's Treatment Administration Record for December 2022 revealed an order with a start date of 7/18/2022 and a discontinuation date of 12/07/2022 for Respiratory-Oxygen: NC/mask. Encourage and assess resident to use O2 at 3L via NC continuous for SOB and O2 sat less than 90 every shift for O2 sat less than 90 / SOB. On December 5, 2022, it was documented on the 7:00 a.m.to 3:00 p.m. dayshift the oxygen saturation was 98%. Further review of documentation provided by the facility after the survey exit revealed a physician note dated 12/9/2022, Patient with chronic SOB 2/2 COPD/lung nodules, not always compliant with O2, 2/2 dementia. She is known to remove her O2 as well as adjust her settings on her O2 tank PCP [Primary Care Physician] has been made aware of this, as well as patient's family. An interview was conducted with the Nursing Home Administrator on 12/8/2022 at 6:01 p.m. she indicated it would be her expectation the physician should have been notified of hypoxic episodes and the resident should receive the ordered amount of oxygen. Review of the facility's policy titled, Oxygen Administration, revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. .General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. .b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band place around the resident's head. . Steps in the Procedure 1. Wash and dry your hands thoroughly. 2. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 3. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen perfect physician orders. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, revealed: Policy Statement Orders for medication and treatments will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure staff were qualified with competencies related to trauma-based care and treatment for Post-Traumatic Stress Disorder (PTSD) diagnosis for two residents ( #73 and #58) of two residents sampled. Findings included: 1. Review of Resident #73's Electronic Medical Record (EMR) showed the resident was admitted to the facility on [DATE] with a diagnosis to include Post Traumatic disorder (PTSD). An annual minimum data set (MDS) dated [DATE], showed under section C the resident has a brief interview for mental status BIMS score of 13, indicating intact cognition. During facility tours on 12/05/22 at 12:43 p.m., 12/06/22 at 9:36 a.m., 12/07/22 at 12:10 p.m., and 12/08/22 at 8:20 a.m. Resident #73 was observed in her room sitting in her wheelchair. Resident #73 was noted withdrawn and avoiding eye contact. The resident was not watching TV or interacting with staff or her roommate. The resident appeared guarded and was hesitant to answer questions. Review of a new evaluation psychology report, dated 11/5/21 showed, patient seen today per staff request due to difficulty sleeping. A PTSD assessment showed the patient describes symptoms of PTSD, has a history of experiencing a traumatic event that involved actual or threatened death or serious injury. Afterwards feelings of intense fear and helplessness have been experienced. Patient could not identify the date of the traumatic event. Patient describes symptoms of PTSD including efforts to avoid reminders of the traumatic event, flashbacks, recurrent distressing dreams, hypervigilance, restricted affect, memory issues exclusive to the event. Plan of care to include caregiver education will serve as nonmedical and preventive interventions. Psychology plan of care for service dates of 11/16/21 and 12/1/21 showed: Staff to be educated on benefits of implementing the following interventions: Encourage alternative methods of communication with friends and family such as [video conferencing applications] and phone calls, monitor patients for psychosocial changes and observe and report any changes to mental status caused by the situational stress, provide support and allow resident to express feelings fears and concerns, communicate to social service for referral to psychology and psychiatric services providers if needed. On 12/07/22 at 12:15 p.m., an interview was conducted with Staff O, Certified Nursing Assistant (CNA). She stated Resident #73 is always crying. Staff O said, An example that happened this morning . she was saying to me; I lied, I know I lied, now they are upset with me. Staff O stated the resident repeated this over and over. She stated when this has happened in the past, she tries to reassure the resident. Staff O said, It's just the way she is. Staff O stated when the resident is stuck in things that are not real, we give her space. Staff O stated she thought the resident was nervous when interacting with strangers and sometimes it is in her head. She stated there has been no training on how to deal with that sort of behavior. Staff O stated she uses her instinct as a caregiver, and nursing responses, and just being kind. On 12/07/22 at 12:39 p.m. an interview was conducted with the Assistant Director of Nursing (ADON) and the Regional Clinical Director. The Regional Clinical Director stated the resident has an extensive history of trauma and is seeing psychology. The Regional Clinical Director was notified the care plan did not show any focus or interventions related to PTSD diagnosis. The Regional Clinical said, Most of her symptomatic behaviors are addressed in the mood/ evaluation focus care plan. She stated she would review if Resident #73 should be care planned for PTSD. Review of psychology and psychiatry progress notes from visits conducted on 11/30/22, 11/23/22, 11/16/22, and 10/31/22 showed the resident received on-going CBT (cognitive behavioral) therapy, psychoeducation, and stress management during the treatment sessions. The review did not show staff received competencies for trauma informed care. On 12/07/22 at 3:21 p.m., an interview was conducted with the Regional Clinical Director. She stated Resident #73 was here for placement since the [family member's] arrest. The Regional Clinical Director stated the resident was evaluated by psychology and seen by a psychiatrist, was fitted with a wander guard due to wandering behaviors. She stated the resident has a lot of anxiety. She continues to be afraid to get out of her room. She stated psychiatry saw Resident #73 a month ago and reviewed a recent medication change. She stated the resident did not tolerate the medication change, she had increased hallucinations and the Seroquel was reinstated. The Regional Clinical Director did not indicate their plan of care at the facility in assisting the resident to manage the effects of her trauma day-to-day. On 12/08/22 at 8:20 a.m., Resident #73 was observed in her room, her breakfast tray was in front of her. The resident did not eat her breakfast. Resident #73 appeared emotional; eyes noted tearing up. Resident #73 stated she wanted to go downstairs to look at the Christmas tree. Resident #73 stated she was hoping the tree can be decorated before the guests arrive. Resident #73 appeared timid, teary, and withdrawn. An interview was conducted on 12/08/22 at 8:30 a.m., with Staff H, Licensed Practical Nurse (LPN). She stated she works with the resident quite often. She stated the resident is always like that. When asked what like that meant, Staff H said, She is sad, confused, cries a lot, she hallucinates, talks about things that are not real. Staff H, LPN stated she tries to redirect her. She stated she knows how to work with someone with PTSD from schooling, not necessarily from training at the facility. She stated her response is to redirect her and encourage her to get out of her room. Staff H said, I invite her to sit in the hallway so she can watch me pass medications. On 12/08/22 at 8:34 a.m., an interview was conducted with Staff O, CNA who was assigned to Resident #73. She stated the resident was teary again this morning. She was confused. She believes she is at her house and is decorating her house for Christmas. Staff O stated the resident was anxious and has been asking to go outside. Staff O stated if the resident asks to go outside, they redirect her to stay in. Staff O stated the resident is not in reality. Staff O said, I don't know what we can do for her. It is very sad. During an interview on 12/08/22 at 9:30 a.m. with the Assistant Social Services Director (ASD), she stated Resident #73 likes to stay in her room and sometimes she asks to go out. The ASD stated she had not heard from staff that she was confused or experiencing any changes. The ASD stated the resident is at her baseline with anxiety and confusion. The ASD stated if the resident experiences behavioral concerns nursing staff should report to the Unit Manager, who should let social services know. The ASD stated the CNAs should communicate with social services so they can get the resident psych help. She stated she did not know if the facility provided behavioral training, but the CNAs should let them know if they have training needs. On 12/08/22 at 12:49 p.m. an interview was conducted with the ADON and Staff E, Registered Nurse (RN)/Unit Manager. The ADON stated they have behavior monitoring for medication side effects but did not have monitoring related to PTSD/trauma. Staff E stated the resident does not have behaviors on a daily basis, she is quiet, with a private demeanor. Staff E, RN stated Resident #73 was not really showing any psychosis behavior for them to address. The crying, isolation and being withdrawn was her usual self. Staff E stated he had not been part of any behavioral trainings. He confirmed they had not provided training related to trauma. During an interview with the Nursing Home Administrator (NHA) on 12/08/22 at 1:57 p.m. She stated their annual training covers some trauma informed care. The NHA stated the training is not detailed or specific but, it address some expectations. The NHA presented a document titled, Annual Education, showing the facility's education plan on culturally competent trauma informed care. The NHA said, This does not show the details but, we are working on competencies and will roll them out soon. The NHA stated the ADON has started in-services, but not prior to the survey. Review of an undated document titled, Facility Assessment, showed the nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The purpose of the assessment is to determine what resources are necessary to care for residents completely . Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Review of Section 1.3 showed under common diagnoses, a list of diagnoses that the facility would commonly accept. PTSD and trauma were not listed. Section 1.4 showed if a resident had a condition not listed in the facility assessment, the facility would review clinical data to ensure the facility is able to care accordingly for the patient, determine if they have or can reasonably obtain staff competencies/resources to meet that patient's needs. 2. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] and was currently in the facility for long term care services and resided in the secure dementia unit. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] and was currently in the facility for long term care services and resided in the secure dementia unit. Review of the current Quarterly MDS assessment, dated 10/7/2022, revealed a BIMS score of 1 out of 15, indicating she had severe cognitive impairment and mood and behaviors were indicated as none. In Section I - Active Diagnosis Post Traumatic Stress Disorder was selected. On 12/8/2022 at 9:01 a.m. an interview Staff F, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) revealed she was aware of Resident #58 and that Resident #58 is usually pleasant and interacts well with staff and other residents. Staff F explained Resident #58 has been on her daily work assignment many times and she interacts with her daily, even if not on her assignment. Staff F confirmed she was not aware of Resident #58 having PTSD/Trauma and has not exhibited with any types of behaviors or observations that would make her believe she had any current or past psychosocial trauma. Staff F further indicated she has not had any specific training and or in-services that would provide her with education on how to handle residents with PTSD/Trauma. She did not remember completing any competencies related to this area. On 12/8/2022 at 9:08 a.m. an interview with Staff K, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) confirmed she has Resident #58 on her assignment routinely and she knows the resident to be pleasant but confused and interacts well with all the residents and staff on the unit. Staff K also confirmed Resident #58 has presented with some refusal of care behaviors and some aggression but has been easily redirected. Staff K confirmed she was not aware Resident #58 had past PTSD/Trauma and would not know what to look for or how to handle a resident who has PTSD/Trauma. She confirmed she has not received any education and or in-services related to PTSD/Trauma. She did not remember completing any competencies related to this area. On 12/8/2022 at 10:45 a.m. an interview with both the Staff E, LPN and the Assistant Director of Nursing (ADON) was conducted. Staff E was aware Resident #58 had a diagnosis of PTSD/Trauma and indicated it had been brought to his attention that the resident was involved in a car accident many years ago and was in a coma and had a TBI. He revealed there is no current PTSD/Trauma assessment for Resident #58. The ADON was also involved in this interview and also confirmed she knew about Resident #58's PTSD/Trauma and that related to an accident years ago, but also confirmed there was no assessment to indicate this, other than a social service note and a diagnosis of PTST/Trauma. Staff E and the ADON also confirmed there were no current or past care planning problem areas with interventions related to PTSD/Trauma. The ADON and Staff E did not know if there were any specific trauma/PTSD education competencies passed to direct care floor staff. On 12/8/2022 at 2:00 p.m. during an interview, the Nursing Home Administrator confirmed Resident #58 was not assessed for PTSD/Trauma upon her admission on [DATE], but was assessed by a psychologist on 4/28/2022, which was twenty-six days after Resident #58's initial admission. The Nursing Home Administrator revealed the resident was not care planned with problem areas and interventions related to the resident's past PTSD/Trauma. In addition, the NHA could not provide any education to show Staff F or K have had competencies related to Trauma/PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 43's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified, major depressive disorder, anxiety disorder, peripheral vascular disease and type 2 diabetes mellitus with diabetic neuropathy, unspecified. A review of the Medication Regimen, dated 8/1/2022, revealed the pharmacist recommendation was as follows: Currently receiving Diazepam 5mg daily for anxiety. Minimal recent episodes documented in clinical record. Increase risk of respiratory depression with concomitant opioid and gabapentin. Please evaluate continued need, consider trial discontinue if, appropriate. The provider marked disagree with no reason stated. The recommendation was signed on 9/1/22. A review of the Medication Regimen, dated 9/01/2022, revealed the pharmacist recommendation was as follows: Currently receiving Morphine as a standing order. Please evaluate current need. Pain score often recorded as 0. Consider taper to as needed, if appropriate. The recommendation was signed by ARNP (advanced registered nurse practitioner) as verbally order and not dated. A review of the Medication Regimen, dated 11/2/2022, revealed the pharmacist recommendation was as follows: Currently has an active order for Diazepam prn (as needed) without a specified stop date. Please note that CMS (Centers for Medicare and Medicaid Services) guidelines do not allow open ended order for PRN psychotropics. Please evaluate and consider adding stop date or discontinuing the order for Diazepam prn, if appropriate. The provider marked disagree with no reason stated. The recommendation was signed on 11/4/22. A review of the Medication Regimen, dated 10/3/2022, revealed the pharmacist recommendation is as follows: Currently with active order for basal insulin coverage along with routine fingersticks with sliding scale insulin coverage. Fingerstick blood glucose readings are frequently above 200mg/dl (decilitre). Please evaluate and consider increase dose of basal insulin to 12 units daily, if appropriate. The recommendation was signed by ARNP (advanced registered nurse practitioner) as verbally order and not dated. A facility policy titled, Medication Regimen Reviews, dated April 2007, was reviewed. The policy stated the following: 5. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. A facility policy titled, Drug Regimen Review-Monthly, was reviewed. The policy stated the following: Prescriber/Licensed Designee: 1. Shall act upon the Drug Regimen Review findings/recommendations in a timely manner of 7-14 days or less. Shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation and provide a brief clinical rationale if no change is to be made. Based on record review and interviews the facility did not ensure the attending physician provided rationale for disagreeing with the pharmacist recommendations as part of the Drug Regimen Review for two residents (#94 and #43) out of five residents reviewed for unnecessary medication. Findings included: 1. A review of pharmacy recommendations for Resident #94 revealed the following recommendations: * Medication Regimen Review, dated 8/1/2022: Currently receiving Temazepam 15mg (milligrams) at bedtime for insomnia. Long term use not recommended. Please evaluate, consider trial taper to 7.5mg at bedtime, if appropriate. The provider marked disagree with no reason stated. The recommendation was signed on 9/2/22. * Medication Regimen Review, dated 10/3/22: Currently receiving Pantoprazole. Long term use of PPI's (proton pump inhibitors) has been associated with increased risk of pneumonia, c. difficile (clostridioides difficile), hypomagnesemia, fractures, and both B12 and iron deficiency. Please evaluate current need. Consider trial taper to every other day for 14 days then discontinue, if appropriate. The provider marked disagree with no reason stated. The recommendation was signed by ARNP (advanced registered nurse practitioner) as verbally order and not dated. A review of the admission Record indicated Resident #94 was admitted on [DATE] and readmitted on [DATE] with diagnoses including insomnia, gastro-esophageal reflux disease without esophagitis, pneumonitis due to inhalation of food and vomit, and anemia. An interview was conducted with the Regional Nurse on 12/8/22 at 1:50 p.m. She confirmed there was no further documentation in the record noting the provider's rationale for disagreeing with the pharmacy recommendations for Residents #94 and #43. She stated the process is the pharmacy recommendations come to the Director of Nursing (DON.) The DON then divides them up by unit and gives them to the Unit Managers (UMs) The UMs ensure the providers see and complete the forms within two weeks. The forms are returned to the unit managers to verify the orders are in and forms are completed. The Regional Nurse stated the provider should give a reason if they disagree with the recommendation. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/8/22 at 2:10 p.m. The ADON confirmed the process described by the Regional Nurse. She also stated the provider should fill out a reason if they disagree with a recommendation. On 12/8/22 at 3:50 p.m. an interview was conducted with the facility's Consultant Pharmacist. The pharmacist stated medication reviews are completed monthly and her recommendations are sent to the facility. She stated the physician will review the recommendations and it is at their discretion to agree or disagree. The physician will sign and date the recommendation. She stated it is a physician's choice to disagree with the recommendation, but a reason should be notated. She stated the completed forms are in a binder the pharmacist reviews. She stated they use the reason for disagreement noted by the physician to make notes for themselves and to follow up with the DON or physician if needed. An interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 12/8/22 at 4:36 p.m. Staff C stated they receive the pharmacy recommendations from the DON and give them to the providers. After the forms are signed by the provider the unit managers verify the orders are updated as needed. Staff C stated most providers put a reason they disagree, but the UM does not check for that. Staff C stated they did not know they were supposed to ensure a reason was listed for disagreement. Staff C stated no one has ever told them a rationale was required and they were not trained on that. Staff C stated now that they know it is needed, they will check that it is done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/5/22 at 9:56 a.m. an observation was made in Resident room [ROOM NUMBER]. A section of baseboard was sticking off the wall near the residents' sink. The loose baseboard had finish nails sticking out of the backside. (Photographic Evidence Obtained.) On 12/5/22 at 12:29 p.m. an interview was conducted with Resident #461 and #94. They stated maintenance fixed a piece of baseboard that was coming off in their room two weeks ago. They stated maintenance never came back, finished the job, and cleaned up. An observation was made of blue tape on the baseboard and floor behind the bed of Resident #461. Both residents were also concerned that their closest was missing half of the door. They stated they have not ever been able to close the closet with their stuff inside. (Photographic Evidence Obtained.) On 12/6/22 at 12:00 p.m. an additional interview was conducted with #94. She stated she is unhappy because her privacy curtain has feces on it. She stated she has asked multiple times over the last week or two for it to be changed and it has not been. She stated the CNA (certified nursing assistant) was changing her and had feces on her hand; she wiped her hands on a towel then grabbed the curtain. A dark brown spot was observed about shoulder height on the privacy curtain nearest the door. An interview and tour was conducted with the Maintenance Director on 12/8/22 at 2:19 p.m. he observed the closet of Residents' #461 and #94. He stated he thought they had replaced all the broken metal doors and didn't know they had missed one. He said they have been replacing the old metal doors with wooden doors. He also observed the blue tape on the wall and floor behind the bed of Resident #461's bed. He stated they would get that cleaned up. He confirmed there was a dark brown spot on the privacy curtain and stated it was not on his list to be changed, but he would get it done today. The Maintenance Director observed the loose baseboard in room [ROOM NUMBER]. He confirmed there were nails sticking out the back. He pushed it back to the wall and said he would get it fixed immediately. He stated the baseboards are old and do come off. The Maintenance Director stated a lot of staff want to tell maintenance verbally about issues. He said they have been trying to get staff to enter issues in the [electronic work order] system. He stated staff do not always pass information from residents to maintenance to get things fixed. He said there is a communication problem. 3. An interview with Staff F, CNA was conducted on12/05/22 at 10:51 a.m., she indicated a couple weeks ago or so she put in the computer that the sink in the dining room on the locked unit won't drain. They told her it would be fixed but they have not fixed it yet. She said the sink is used to wash the staff hands and the resident's hands during dining. On 12/08/22 at 9:44 a.m. an interview was conducted with the Director of Facilities Management, the Nursing Home Administrator (NHA) and the Regional [NAME] President. They stated the locked unit's (Caring Way) sink in the dining room was added to the building. The water comes in and then it drains out on a separate pump so we cannot work on that pump. We have a plumbing company that comes out and fixes the sink when the pump gets clogged. The plumbing company does not come on a maintenance schedule, they come out when we have problems. That sink backs up all the time with sewage because the pump gets clogged. There are dementia residents back there so straws and other items get put down the sink and the pump will clog. We have a good rapport with the plumbing company but at times we have to use the chain of command to expedite getting invoices paid before he will come back out when payment is behind. On 12/08/22 at 10:19 a.m. an observation was made of the sink in the Sunrise Room on the locked unit. The sink was observed to have brown, black water in it. Staff F, CNA confirmed the sink has been this way for about three months. Maintenance will come and look at it and they say they need to call the plumber to come look at the pump because I guess the pump gets clogged, but I don't know if the plumber has come or not but it's been this way for about three months. This room is where the residents eat and we wash their hands and our hands in this sink during dining but we can't use the sink for that when it doesn't work. (Photographic Evidence Obtained) Review of the maintenance work orders from August 2022 to December 2022 revealed: 8/6/22 location: Caring Way Unit please be advised sink clogged in sunshine .residents being kept across the hall till corrected to prevent possible flooding of room. Closed date 9/6/22. 9/6/22 location: Caring Way sink smells and backing up Closed date 9/6/22. 9/22/22 location: Caring Way dining immediate situation in the caring way sink of dining room. Strong odor, black water coming up from sink. Closed 10/11/22 10/4/22 location: caring way dining caring way dining sink full of black nasty. Closed 10/11/22. 10/10/22 location caring way unit sink in dinning {dining} room is plug in. Dirty closed 10/11/22. Based on observations, record review and interviews, the facility failed to ensure resident rooms and equipment were clean and maintained for four days (12/5/22, 12/6/22, 12/7/22, and 12/8/22) of four days observed, affecting two floors (first floor and second floor) of two floors. It was determined two (100 unit and 2nd floor) of two community shower rooms had a total of four shower chairs in disrepair and soiled; 11 resident rooms (121, 126, 124, 127, 128, 129, 132, 102, 232, 213, and 206) were observed with baseboards in disrepair and ceilings with black bio growth, wall mounted air conditioning (a/c) units were observed with plastic covers in disrepair, a soiled privacy curtain for one resident (#94) and a broken closet door for two residents (#94 and #461) of a total sample of 52 residents. Findings included: 1. On 12/5/2022 at 10:08 a.m., 12/6/2022 at 7:50 a.m., 12/7/2022 at 7:50 a.m., and on 12/8/2022 at 2:55 p.m., facility wide tours in hall 121 - 132 (First Floor -Secured Dementia unit) were conducted. The following resident rooms were observed: - Resident room [ROOM NUMBER]: ceiling was observed with seven small areas chipped and in disrepair. There were pieces hanging and falling down to the floor. The floor was observed with several small pieces of ceiling that fell off. - Resident room [ROOM NUMBER]: PTAC (Packaged Terminal Air Conditioner) A/C wall unit cover was observed loosely fitted and when touched, it fell to the ground, and exposed the internal mechanics of the unit. - Resident room [ROOM NUMBER] bed (b): ceiling area was observed with heavy water staining and with black bio growth spanning approximately two feet wide and three feet long. (Photographic Evidence Obtained) The room's PTAC A/C wall unit cover was observed loosely fitted and when touched, it fell to the ground, and exposed the internal mechanics of the unit. Further observation revealed a waterlogged area below the right corner of the A/C unit, and just above the floor plastic combing. The hole was measured approximately four inches by six inches, leaving a non-cleanable surface. - Resident room [ROOM NUMBER]: ceiling at and between the (a) and (b) bed was observed in disrepair with sections chipped and falling to the floor. The PTAC A/C wall unit was observed hanging off and not secured and leaving the inside of the machine exposed. - Resident room [ROOM NUMBER]: cover to the PTAC A/C wall unit was observed in disrepair and not secured tightly. Once touched, the cover became loose and fell to the floor. Also, the baseboards in the room were observed unattached from the wall and leaving non cleanable areas. - Resident room [ROOM NUMBER]: ceiling above the room sink and in between bed (a) and bed (b) was observed with a long section in disrepair and with holes. Pieces and chunks of the ceiling had fallen off. There were many areas of brown and black bio growth spotted throughout as well. - Resident room [ROOM NUMBER]: entire ceiling was observed with black bio growth. (Photographic Evidence Obtained) Further observation revealed the wall mounted PTAC A/C unit with the cover housing placed on the floor in front of the unit. It had fallen off the unit and exposed the entire inside of the unit. - On 12/5/2022 at 1:20 p.m., on 12/6/2022 at 7:48 a.m., and on 12/7/2022 at 2:55 p.m. the 100 unit community shower room, next to the unit station was observed. Upon entering this shower room, there were four plastic shower chairs and two of them had cracks and tears on the plastic seats. The shower chairs were noted to be use for residents upon showering/bathing. The cracks and tears were observed sharp in nature and the seats were no longer cleanable. Further, the chair legs near the wheel castors were observed with black and pink bio growth. (Photographic Evidence Obtained) - Resident room [ROOM NUMBER]: baseboard wall near the closet and room sink in disrepair and with blue tape holding the wall in place. On 12/6/2022 at 9:27 a.m., and 12/7/2022 at 9:30 a.m., a facility wide tour was conducted on the second floor and the following was observed: - The second floor community shower room was entered and two of the three plastic shower chairs had cracks and tears, leaving the seat not cleanable. The shower chairs are used for residents on this unit. (Photographic Evidence Obtained) - Resident room [ROOM NUMBER] bed (b): ceiling area observed in disrepair with holes and chipped strips of ceiling. Also, there was black bio growth spotting. - Resident room [ROOM NUMBER] bed (b): ceiling area over the head of the bed in disrepair and peeling and cracking. Further observation revealed sections of black bio growth spotting. On 12/8/2022 at 2:55 p.m. an interview with the Director of Facilities Management (DFM)/Maintenance Director revealed he was the Environmental Services and Housekeeping Director as well. He confirmed the areas as listed above and did not have any current work orders related to those areas. He indicated he would take care of the areas and the ceiling with bio growth was noted as identified and they have been trying to remove popcorn from the ceilings. He did not have any documentation to support this area of concern having already been identified. The DFM confirmed the shower chairs as being soiled and in disrepair. He revealed the shower chairs are deep cleaned once a month but should be cleaned each day. He did not have documentation to show any cleaning schedules for the shower chairs. The DFM revealed he has been short in maintenance staffing and he is in the process of having new staff in the maintenance/housekeeping department. The DFM confirmed the PTAC A/C wall mounted units in the secured/dementia unit should be securely attached for resident safety and confirmed most of the housing covers were unattached and falling or fell to the floor. He did not know why the unit covers were loose and said he would take care of it. He did not have any documentation to show the PTAC A/C units are monitored and audited at times for cleanliness and general maintenance. He confirmed the wall mounted PTAC A/C units would be under the responsibility of the maintenance department and not nursing. He also confirmed nursing staff see units not in good repair, they should report it to his department. He did not have any current work orders that supported in-progress maintenance with PTAC A/C unit covers. A review of the policy and procedure titled, Maintenance Service, dated December 2009, revealed: Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintain the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but not limited to: (b) Maintaining building in good repair and free from hazards. (d) Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. (i) Providing routinely scheduled maintenance service to all areas. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe operable manner. 8. The maintenance director is responsible for maintaining the following/reports. (a) Inspection of the building. (c) Maintenance schedules.

Based on observations, staff interviews and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner as evidence by: 1. the dish washing machine was not receiving sanitizer via the liquid sanitizer delivery system for three wash cycles observed and washing temperatures were not meeting the required temperature; 2. one of one walk in freezers had a large amount of ice buildup; and 3. black bio growth built up on a wall near and behind the dish washing machine, for two days (12/5/2022 and 12/6/2022) of four day observed. Findings included: 1. On 12/5/2022 at 9:20 a.m. the kitchen was toured with the facility's Dietary Manager. Upon entering the kitchen and meeting with the Dietary Manager, he indicated the kitchen utilizes a low temperature dish washing machine, and Staff I, Dietary Aide and Staff J, Dietary Aide were at the time in the process of operating the machine. The Dietary Manager also revealed the dish washing machine's wash temperature cycle was expected to reach at least 120 degrees Fahrenheit (F), and the rinse temperature cycle was to reach at least 120 degrees F. The dish washing machine also delivered a sanitizer via a pump and bucket, through plastic tubing lines. The Dietary Manager confirmed the sanitizer must reach at least 50 - 100 parts per million (PPM) after the wash and rinse cycle. He revealed they have a heating booster and the dish washing machine has to be primed several times before use, in order to get the wash and rinse temperatures per the requirement. He indicated the dish washing machine had already been primed and was operating appropriately. Review of the specification plate on the dish washing machine, revealed the machine is a low temperature machine with the wash temperature at 120 degrees F, and the rinse temperature at 120 degrees F. At this time, Staff I and J were observed to have already run four plastic crates of soiled dishes through the dish washing machine and were ready for drying. Staff I confirmed the machine was a low temp (temperature) dish washing machine. Staff I and J both confirmed the machine was operating appropriately and they had run several crates of dishes through the machine. Staff J also confirmed the machine had been boosted, to ensure the required wash and rinse temperatures were reached. Staff I and J were further interviewed and asked what the required temperatures needed to be with each wash/rinse cycle. Both answered, Wash at 120 degrees F., and rinse at 120 degrees F. Staff I, Staff J and the Dietary Manager were then asked about the sanitizer. Staff I and Staff J both confirmed they had been trained and in serviced on how to test the machine with the sanitizer test strips but did not know exactly what the appropriate test range should be. Staff J then said, 100 parts per million (PPM). Staff J said, I have not tested the sanitizer with the test strips yet. Staff I did confirm she ran four crates of dishes through the machine and did not test the sanitizer. At this time the Dietary Manager took his right hand and flipped a toggle switch labeled Sanitizer several times. He said, It helps the sanitizer not get stuck in the lines. The Dietary Manager flipped the switch approximately seven times and confirmed this should not be the process for each wash cycle. Staff I was asked if she flips the sanitizer switch and she revealed that she did not. At 9:30 a.m. Staff I, Dietary Aide ran a crate of dishes through the machine and the following was observed: The first demonstration indicated the wash temperature reached 115 degrees F and the rinse cycle reached 120 degrees F. After the wash/rinse cycle, the Dietary Manager tested the sanitizer with the test strip in a water pooled section of a plate cover. Once he placed the strip on the plate cover, the white test strip did not change color at all and remained white. (Photographic Evidence Obtained) The Dietary Manager confirmed and indicated there had been some problems with the sanitizer lines and the maintenance company came out and had to replace the lines to ensure sanitizer was de-clogged. He said this happened about two weeks ago. He confirmed the wash temperature did not reach at least 120 degrees and also confirmed that sanitizer was not being delivered from the bucket, through the pump and to the machine. He also confirmed if the sanitizer was working and delivered properly, the test strip would turn a shade of purple indicating at least 50 parts per million (PPM). At 9:32 a.m. the Dietary Manager ran a second demonstration and the dish machine wash temperature reached 118 degrees F and the rinse temperature reached 120 degrees F. The Dietary Manager again tested the sanitizer via a white test strip. He placed the strip on a water pooled section of a dish and the test strip remained white in color and did not change color to indicate a sanitizer level of at least 50 PPM. He again started to flip the sanitizer toggle switch many times to try and unclog the clogged lines. The Dietary Manager then confirmed again that they had been having a clogging problem and the dish machine maintenance company had been out within the past few weeks to correct it. He did not know how long the sanitizer had not been effectively delivered to the machine. The Dietary Manager and Staff I, Dietary Aide both confirmed the sanitizer was not tested with the strip prior to the demonstrations and there had been four crates of dishes run through the dishing washing machine and deemed as cleaned. Staff I and the Dietary Manager also confirmed they did not know the sanitizer was clogged again and did not check it this morning. On 12/7/2022 at approximately 1:45 p.m. the Dietary Manager confirmed he goes by what the dish machine specification plate says; which is affixed to the front of the machine and he goes by what the dish washing machine maintenance company directs. He revealed the dish machine maintenance company suggests operating the machine per the specifications with no adjustment. 2. During the kitchen tours on 12/5/2022 at 9:30 a.m. and again on 12/7/2022 at 1:45 p.m., an observation revealed an approximately two feet wide, and three feet in length section of the wall, behind and to the left side of the dish machine with heavy black bio growth build up. This was confirmed by Staff I, Dietary Aide and the Dietary Manager. (Photographic Evidence Obtained) The Dietary Manager revealed the kitchen is cleaned daily per the schedule and did not know how the wall accrued this black bio growth. Staff I was not aware of the large section of black bio growth. 3. During a kitchen tour on 12/5/2022 at 9:30 a.m. the walk in freezer was observed and the temperature per review of the internal thermometer, was at 0 degrees F. Further observations of the inside of the freezer revealed an internal motor housing hanging from the ceiling at the left side of the freezer. The pipes leading from the motor and down to the back wall revealed a large amount of ice buildup measuring approximately seven inches across and six inches hanging down. (Photographic Evidence Obtained) Interview with the Dietary Manager at this time revealed he chips away at the ice from time to time and the freezer door had been replaced recently, but ice still builds up and he nor the maintenance man are sure why the ice is building up. On 12/8/2022 at 1:25 p.m. the Dietary Manager provided the undated policy titled, PROCEDURES FOR LOW TEMP SANITIZER, for review. The policy revealed if temperatures fall below NSF (National Sanitation Foundation) specifications, to check for 50 ppm available chlorine in final rinse. The procedure further indicated it is recommended emergency chemical sanitizing guidelines: Sanitizer required in final rinse: Minimum 50 ppm available chlorine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#363, #362 and #361) of three residents sampled. Findings included: 1. On 12/06/22 at 10:04 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She presented a list of residents who have recently signed arbitration agreements. The NHA stated they have one resident who is currently in the dispute process, their case has not been resolved. The NHA stated all residents review and sign arbitration agreements upon admission. The NHA stated it was optional. Review of the admission Record for Resident #363 revealed an admission date of 11/21/22 with diagnoses to include failure to thrive, and chronic obstructive pulmonary disease. The Responsible Party/Guarantor listed indicated it was not Resident #363. Review of the admission Agreement attachment titled, Attachment K Alternative Dispute Resolution Agreement Between Resident and Facility, was signed by Resident #363 and the Business Office Manager on 11/23/22. On 12/07/22 at 4:15 p.m., an interview was conducted with Resident #363. The resident stated he signed a bunch of papers on admission. He stated he does not know exactly what he signed. He remembers the lady going through all the papers. Resident #363 stated, Yes, I signed all of them. The resident stated he remembers signing some agreement. Resident #363 stated he was not sure what that was or what it means. The resident was shown the copy he signed. Resident #363 stated he does not remember signing that. Resident #363 said, She was talking too fast. I just wanted to rest. Review of an admission Minimum Data Set (MDS) for Resident #363, dated 11/30/22, showed Resident #363 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. 2. Review of the admission Record for Resident #362 revealed an admission date of 11/23/22. Review of an admission Minimum Data Set (MDS), dated [DATE], showed Resident #362 had a BIMS score of 15 out of 15, indicating intact cognition. Review of the admission Agreement attachment titled, Attachment K Alternative Dispute Resolution Agreement Between Resident and Facility, was signed by Resident #362 and the Business Office Manager on 11/28/22. On 12/07/22 at 4:32 p.m., an interview was conducted with Resident #362. The resident reviewed a copy of the agreement she signed. Resident #362 stated, Yes, I signed this. Did I do something wrong? The resident stated she did not know what the agreement meant. Resident #362 said, To be honest, I was foggy that night. I arrived very late in the evening, the lady read through the forms. I was out of it. I don't know what that means. The resident stated she would like someone to explain the form again. Resident #362 stated she would revoke the Arbitration agreement if it didn't affect her stay. The resident stated she just wants to get well and get back home. 3. Review of the admission Record for Resident #361 revealed an admission date of 11/29/22. Review of an admission Minimum Data Set (MDS), dated [DATE], showed Resident #361 had a BIMS score of 04 out of 15, indicating severe impairment. Review of the admission Agreement attachment titled, Attachment K Alternative Dispute Resolution Agreement Between Resident and Facility, was signed by Resident #361's Responsible Party (RP) and the Social Work Assistant on 11/30/22. On 12/07/22 at 4:36 p.m. a telephonic interview was conducted with Resident #361's RP. The RP stated he signed the paperwork for the resident. The RP stated he brought the resident to the facility on admission day. The RP stated [Resident #361] was not well at the time. The RP stated the admissions staff went over all the forms. The RP repeatedly said, I don't understand the lingo. This is new to me. I didn't know what I was signing or how it would affect [Resident #361]. He stated he does not remember if he was told it was optional. He said, To be honest, I was just trying to get [Resident #361] into the facility and I'm happy with the care so far. The RP stated he did not anticipate any problems but if they arise, he will deal with it. The RP stated he hoped he did not make a bad decision. The RP said, I didn't understand half of everything I signed. In an interview on 12/08/22 at 10:09 a.m. with the Business Office Manager (BOM), she stated she helps the admission department when they are out marketing or when they are not available. The BOM stated she explains the arbitration agreement to the resident and then asks them to sign. The BOM sated she explains that they are agreeing to settle grievances through mediation instead of the court system. She stated she makes sure they understand. The BOM stated no one asks questions, they just sign. The BOM said, Some of them say they won't be here long, they don't anticipate any problems, and they do not refuse to sign. On 12/08/22 at 10:35 a.m., an interview was conducted with the Admissions Coordinator (AC). The AC stated they have a 72-hour window to meet with the resident, generate the packet and present the arbitration agreement along with admission agreement. The AC stated she tells them it's optional. She stated when they are signing, they are agreeing that they will not go to court and will settle their case through mediation. She stated 90% of the residents don't ask questions. The AC stated sometimes the residents present with confusion, but she has to follow their 72-hour deadline. The AC stated they have them sign acknowledging receipt and review of the agreement. The AC said, There are many residents who do not seem to understand, I do my best to explain it to them. I can see how their cognition and health status can impact decision making. On 12/08/22 at 10:17 a.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated she would expect the residents are given an opportunity to ask questions, and to ensure that they understand they are waiving the right to go to court and instead go through arbitration. The NHA stated they would review their practices to ensure the agreement is explained accordingly and the residents understand they do not have to sign. The timing could impact residents if they are on medications or have just been released from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/6/22 at 8:41 a.m. an observation was made of Staff L, Registered Nurse (RN) during medication administration. The nurse was preparing medication for Resident #36. She took the resident's blood pressure, then proceeded to remove six pills from the blister pack directly into her ungloved hand. She then placed the pills from her hand into a medication cup and administered them to Resident #36. Staff L then moved on to prepare medication to be administered to Resident #15. Prior to retrieving the resident's medication Staff L took Resident #15's blood pressure. The nurse used the same blood pressure cuff used on the previous resident without sanitizing it in between uses. On 12/6/22 at 9:03 a.m. an interview was conducted with Staff L, RN. She stated the pills should be popped from the blister back straight into a medication cup and she knows she shouldn't handle them. She also confirmed she did not clean the blood pressure cuff in between resident use. She said she had been trained on sanitizing equipment prior to each use and on medication administration. An interview was conducted with the Regional Nurse on 12/8/22 at 1:50 p.m. She confirmed nurses should not put pills in their hands. She stated the nurse let her know what happened during medication administration and they have begun educating on the proper way to pop pills out of the blister packs into the medication cup. She stated a nurse should not touch the medication. A facility provided policy titled Medication Dispensing System was reviewed. The policy stated the following: All medications will be prepared (blister card, vials, [dose] box) and administered in a manner consistent with the general requirements outlined in this policy. Procedure B.4. Do not touch the medication when opening a bottle or unit dose package. A facility policy titled, Cleaning and Disinfecting of Resident-Care Items and Equipment, dated July 2014, was reviewed. The policy stated the following: 1.d. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment.) 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident. An interview was conducted with the ADON on 12/8/22 at 2:10 p.m. She said a nurse should not be handling pills for the residents with their hands. She stated they should be put directly in the medication cups. She agreed this is an infection control concern. On 12/5/22 at 9:35 a.m. two clean linen carts were observed outside of room [ROOM NUMBER]. One of the linen carts had partial used skin protectant, perineal cleaner and skin/hair cleaner sitting on the shelf with the clean linen. (Photographic Evidence Obtained) On 12/7/22 at 10:15 a.m. an observation was made of a clean linen cart sitting outside of room [ROOM NUMBER]. The linen cart had barrier cream, a writing pen, and skin check/shower sheets sitting on the shelf with the clean linens. The clean linen cart sitting outside of room [ROOM NUMBER] had a cup of ice water sitting on the shelf with the clean linen. A clean linen cart sitting outside of room [ROOM NUMBER] was observed to have partially used barrier cream, perineal cleaner and hair/skin cleaner on the shelf with clean linen. (Photographic Evidence Obtained) On 12/7/22 at 10:21 a.m. a clean linen cart sitting outside of room [ROOM NUMBER] was observed to have used bottle of fragrance mist, perineal cleaner, and skin cleaner sitting on the shelf with the clean linen. (Photographic Evidence Obtained) On 12/7/22 at 10:29 a.m. a clean linen cart sitting outside of room [ROOM NUMBER] was observed to have a personal zip up sweatshirt and a used hairbrush on the shelf with clean linen. (Photographic Evidence Obtained) On 12/8/22 at 10:30 a.m. an observation was made of a clean linen cart near room [ROOM NUMBER]. The cart had used barrier cream and a hairbrush inside. The linen cart outside of room [ROOM NUMBER] had half a tube of barrier cream on the shelf with the clean linen. An interview was conducted with Staff A, CNA on 12/7/22 at 1:22 p.m. She observed the linen cart with barrier cream inside. She stated some CNAs keep the bottles in their pocket and keep them in the linen cart. She stated the CNAs do take them in resident rooms, use them while cleaning/changing a resident then put them back in the linen cart. She said now that she says that out loud, she can see how that would be an infection control problem. She confirmed she is aware nothing should be kept in the cart with the clean linen. An interview was conducted with Staff B, CNA on 12/8/22 at 10:46 a.m. She stated barrier cream is sometimes in the clean linen cart. She confirmed it does go back and forth between resident room and the cart. She stated items should not be stored in the clean linen carts and there have been in-services about clean linen before. An interview was conducted with Staff C, LPN/Unit Manager on 12/8/22 at 10:49 a.m. She stated nothing should be in the cart with clean linens except clean plastic bags. She stated the CNA made her aware of the concern and she cleaned the carts out herself. On 12/8/22 at 11:12 a.m. an interview was conducted with the Regional Nurse. She stated perineal and skin cleaners should be in drawers in the resident's rooms, not kept in the clean linen carts. She stated there is a break room for staff to keep personal items in. She confirmed the only thing that should be in the cart with clean linen is clean plastic bags that are used to bag up dirty linen. An interview was conducted with Staff D, CNA on 12/8/22 at 11:37 a.m. She said some CNAs do keep items in the linen carts, but nothing should be kept there. She stated We do know better. We have been educated. On 12/8/22 at 11:39 a.m. an interview was conducted with Staff E, LPN/Unit Manager. He stated perineal cleaners and barrier creams should not be in the clean linen carts. As far as those and personal items in the carts he said ,That's a no go, and he will start education. A facility policy titled, Departmental- Laundry and Linen, dated January 2014, was reviewed. The policy stated the following: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Washing linen and other soiled items 7. Clean linen will remain hygienically clean through measures designed to protect it from environmental contamination, such as covering linen carts. Based on observations, interviews, record review and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to 1. ensure staff wore wearing well-fitting masks during a COVID-19 outbreak and one staff member's (H) mask was clean and unsoiled on one unit (100 Hall) of four units; 2. ensure one staff member (K) performed hand hygiene during meal service; 3. ensure one staff member (L) sanitized multi use blood pressure cuffs in-between residents (#36 and #15), 4. ensure staff wore appropriate personal protective equipment (PPE) to prevent the spread of COVID-19 while in a COVID-19 positive resident room, 5. ensure staff wore appropriate PPE prior to entering a resident room (Resident #160) with active clostridium difficile colitis (C.Diff) and extended spectrum beta-lactamase (ESBL), 6. ensure 8 of 12 clean linen carts were free of staff belongings and resident hygiene products two floors (1st and 2nd) of two floors, 8. mitigate COVID-19 by ensuring room doors were closed on the COVID-19 unit (200 Hall) which also had five persons under investigation (PUI) residents during a COVID-19 outbreak of 15 residents. Findings included: 1. On 12/5/22 at 10:50 a.m. an observation was conducted of the first floor MISSION MATTERS DIRECT RESIDENT CARE - STAFF ON DUTY board, dated 12/5 shift 7-3, and revealed, Staff Must Wear N95 Mask! (Photographic Evidence Obtained) On 12/05/22 at 10:51 a.m. Staff H, Licensed Practical Nurse (LPN) was observed to go into Resident #95's room located on the first floor to assess her respiratory status prior to walking into the room she was noted to have a surgical mask on and there was a vertical stain on the mask from below the nose midway down the mask. On 12/05/22 beginning at 11:30 a.m. multiple observations were made of Staff H wearing a surgical mask on the resident care unit. Staff H was observed repeatedly removing her mask to blow her nose, discarding her soiled tissues in a receptacle on her medication cart, not performing hand hygiene after blowing her nose before continuing on with her tasks including contact with items on her medication cart. On 12/05/22 at 12:17 p.m. an interview was conducted with Staff H, LPN. She was observed to be at her medication cart with a blue surgical mask on, with a stain on the mask that appeared just below her nose and ran midway down the mask. During the interview she continued to cough and sniffle. She said, I woke up at 3:00 a.m. this morning coughing and a runny nose. I took Mucinex, Sudafed and even Loratadine, but I can't get my nose to stop running. It's so moist in this mask. She was asked if that was a stain on her mask? She said, Oh is it stained? She removed her mask and confirmed her mask was stained and she did not know. She threw the surgical mask away and put on a new surgical mask. Staff H, LPN stated, A while ago I was getting bad headaches from whatever they spray in the N95 masks. My doctor said they aren't all sprayed with stuff but it's so hard to find a mask that isn't sprayed on the inside. So, I just wear this [indicating her surgical mask]. Staff H, LPN continued to say I spoke with the DON [Director of Nursing] and she wanted me to write something saying I can't wear the N95s but I'm not going to lie. I haven't gotten around to that yet. But, when I came in we do the questions and the temperature and I got a COVID test this morning and it was negative or else I wouldn't be here I'm in compliance with my surgical mask, I think, I'm not around the COVID residents and if I do I have this N95 mask here on my medication cart and I would just put it over my surgical mask. On 12/8/22 at 3:30 p.m. an interview was conducted with the facility's Assistant Director of Nursing (ADON), who was also the Infection Preventionist. She indicated the facility had 15 residents in the building positive for COVID-19. She further indicated, dirty masks should be discarded and a new one should be put on immediately when soiled and the staff have been educated on that The expectation is to wear a gown, N95 mask, gloves, face shield or goggles with a closed eye. The ADON stated it was not appropriate to store personal items on the clean linen cart. She stated I have already provided education before on storage of personal items. The staff have been educated on what PPEs to wear. As soon as they see that yellow bag hanging on the door that is an alarm to them to wear your PPEs. She stated [Staff H, LPN] told me that she has some medical condition related to an allergy. She is supposed to have documentation excusing her from wearing N95s but I don't have documentation of that. My expectation is the staff wear N95 masks right now during our COVID outbreak. She stated the staff are expected to clean blood pressure cuffs in-between residents and they have previously been educated on that. Staff should clean hands after wiping their nose. It is my expectation the doors should be closed while on COVID isolation. Unless the resident is a fall risk then the curtain should be pulled closed. Review of the CDC Infection Control Guidance, updated on September 23, 2022, revealed Patient Placement Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). . Implementing Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing . When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through . Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC. Review of the facility's policy, Infection Prevention and Control Program, revised October 2018, revealed: Policy Statement An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. .11. Prevention of Infection Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (4) Communicating the importance of standard precautions and cough etiquette to visitors and family members; (5) enhancing screening for possible significant pathogens; . (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of the facility's policy, COVID-19 Facility Testing/Isolation Guidelines/Exposure/Return to Work Processes, revised 10/10/2022, revealed .PPE (Personal Protective Equipment) COVID UNIT- if the facility has an active COVID Unit, then facility staff and visitors on the unit should wear full PPE including N95 mask and eye wear. PUI UNIT (new admission/outbreak testing)- If the facility has a PUI (Persons Under Investigation) Unit then staff and visitors on the PUI Unit should wear source control. 2. On 12/5/2022 at 10:20 a.m. Resident #160's room door was open and was observed with hanging Personal Protective Equipment (PPE) and a sign that indicated to Stop and not enter and to see a nurse before entering. Interviews with Staff F, Certified Nursing Assistant (CNA), and Staff G, Registered Nurse (RN) both revealed Resident #160 has an infection to include C-Diff and ESBL in the urine and is on contact isolation precautions and is receiving antibiotic therapy. Observed from the hallway, Resident #160 was noted in her room and lying in bed. On 12/6/2022 at 8:00 a.m. while standing in the hallway in between resident rooms [ROOM NUMBERS], Staff F, CNA and Staff K, CNA were observed going in and out from resident rooms, removing finished breakfast meal trays. Staff K was observed to come out from resident room [ROOM NUMBER] with a tray, put it in the tray cart and then proceeded to walk into Resident #160's room, which was a room on isolation precautions. The door was observed with hanging PPE to include gowns, masks, and gloves. The door had a large sign that had a picture of a red and white STOP sign and read, please see nurse before entering this room. At 8:01 a.m. Staff K, CNA walked into Resident #160's room and did not gown up and only went in the room with PPE to include a N95 mask. She went to Resident #160's bed and picked up the breakfast meal tray and then walked out of the room, opened the tray cart with her right ungloved hand and then placed the tray in the cart and then closed the cart door with her ungloved right hand. Immediately following the observation Staff K was interviewed about isolation precautions in Resident #160's room. Staff K confirmed Resident #160's room was on isolation precautions an explained that she was aware the room was on isolation precautions and the reason she did not gown up or wear additional PPE was because she just went in the room to grab the meal tray. She replied, It's my first day in this hall and I should have gowned up with a gown, gloves, eye protection, but did not. After the interview was completed on 12/6/22 at 8:04 a.m. Staff K, CNA proceeded to walk down the hall and went into Resident room [ROOM NUMBER] and picked up a used meal cart and brought it to the tray cart and open and closed the door with her ungloved right hand, she then went to Resident room [ROOM NUMBER] and did the same. It was observed that Staff K did not wash or sanitize her hands after leaving Resident #160's isolation room, nor did she wash and or sanitize her hands prior to entering and leaving Resident rooms [ROOM NUMBERS], which were not on isolation precautions. At 8:06 a.m. Staff K was asked when she normally washes and or sanitizes her hands. She explained after she leaves each room and after use of resident equipment and resident contact. She was asked if she washed and or sanitized her hands after leaving Resident #160's isolation room and in between and after leaving resident rooms [ROOM NUMBERS]. Staff K replied, I don't remember if I did, but I am supposed to. On 12/7/2022 at 8:30 a.m. an interview with the Staff G, RN confirmed there was one room in the secured unit on isolation precautions. She revealed Resident #160 currently had ESBL in the urine and C-Diff. She confirmed the resident was on contact precautions and anyone who goes in the room are to follow the infection control procedure, as listed on the resident's door. She revealed all staff and visitors must wear PPE upon entering the room and in this case PPE includes a N95 mask, gown, and gloves must be donned. She further revealed staff are to doff the PPE while in the room and then wash their hands prior to leaving. Staff G revealed it is her responsibility to monitor staff throughout the shift and to ensure when someone goes in an isolation room, they don the appropriate PPE. She indicated she also ensures all other departmental staff who come on the unit and go in an isolation room are knowledgeable of the PPE requirements before entering the room. Staff G further indicated she, and all other staff are educated and in-serviced on the importance of PPE, and when to use PPE, especially in rooms that are on infection isolation precautions. Staff G confirmed Resident #160's room had a sign on the door that read; Stop, report to nurse before entering, and also confirmed there was a hanging sleeve on the door with all the required PPE. She revealed Staff K should have donned gown, gloves, had N95 on prior to entering the room and then doffed and washed hands prior to leaving the room, even if only picking up a meal tray. Staff G further explained there should have been another staff member to take the tray, prior to Staff K leaving the room, and prior to her washing her hands. On 12/6/2022 at 2:04 p.m. Resident #160 was not in her room. The room was still observed on infection precautions per the signage on the door and with the PPE hanging on the door. Upon observing down the hall of this secured/dementia unit, Resident #160 was observed standing up in the activity room doorway with Staff F, CNA talking with her. She was observed to re direct the resident and walked her to her room. Resident #160 was not interviewable. On 12/6/2022 at 2:20 p.m. Resident #160 was noted back out from her room and seated at a table with a couple of other residents and participating in a group activity. The activities staff member was in the room. Also, Staff F, CNA was in the room and she did not re direct Resident #160 back to her room. On 12/7/2022 at 8:32 a.m. Resident #160 was observed sitting in the hall outside of activity room next to other unit residents. She was sitting quietly but observed shivering. A resident sitting next to Resident #160 verbalized she was cold and it was making her neck hurt. The resident sitting next to Resident #160 was noted touching her hands and the back of her neck area. On 12/8/2022 at 10:00 a.m. interviews with Staff G, RN, Staff F, CNA and Staff K, CNA all revealed it was hard to keep residents in one place, to include Resident #160, while in the secured/dementia unit. Staff F, CNA revealed she tries to redirect Resident #160 back to her isolation precaution room when she is out of it, but she is confused and leaves her room after being successfully redirected. Staff G, F and K all confirmed Resident #160 is on contact isolation and should stay in her room and not have contact with other residents. They all said, however, Resident #160 continually leaves her room and goes out to the main hallway and into the dining/activity room. Staff G, F and K confirmed Resident #160 was the only resident who was on isolation precautions in the unit. Further interview with Staff G, RN on 12/7/2022 at 10:05 a.m. Staff G revealed if a resident room is placed on isolation precautions and there is PPE to wear prior to entering, staff are to don the required PPE and then doff the PPE prior to exiting the room. She further indicated the Assistant Director of Nursing (ADON), who is also the infection control nurse, is responsible for placing the PPE and signage on the door to each room that is on isolation precautions. Staff G indicated the ADON trains all staff and educates all staff with relation to infection control, COVID mitigation, how to identify and follow isolation precautions and PPE training. Staff G further revealed as a floor nurse, she will continually audit staff as they go into isolation rooms and at this point they only have one resident (#160), who is on isolation precautions. Staff G explained the resident (#160) resides in the secured/dementia unit and she does not listen to staff when asked to remain in room. She does ambulate and walk and leave her room, and staff try to re direct as possible, but there is no way they can keep her in the room, and of course they are not allowed to secure the resident in that room. They try to ensure the resident does not have any close activity and not in close proximation to other residents but again in this unit, residents who have dementia, they cannot redirect all the time. There are no other active dx. of infections in this unit. Staff are continually educated on re directing. Staff G revealed Resident #160 is on contact isolation only and has ESBL and C-DIFF.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/6/2022 at 9:20 a.m. an observation was made in room [ROOM NUMBER]. The A bed's call light was observed missing from the call light system attached to the wall inside room [ROOM NUMBER]. On 11/6/2022 at 9:30 a.m. an interview was conducted with the resident in the A bed. The Resident said she never had a call light in her room and she is independent, so she really doesn't need assistance from the staff. The Resident in the B bed overheard the conversation and said she would usually put the call light on if [Resident A bed] needed assistance from the staff. On 12/6/2022 at 10:00 a.m. an interview was conducted with Staff A, CNA. Staff A said room [ROOM NUMBER] has always had one call light in the room. Staff A said there was a padded call light in the room at first and then they changed that call light out for the regular call light that is in the room now. Staff A confirmed there should be two call lights in the room and said yes if there are two residents in the room both residents should have a call light. Staff A said [Resident in A bed] did not need a call light because she is independent. Based on observations, interviews, and record review the facility failed to ensure a functioning communication system was in place for residents to call for staff assistance from bedside and from toilet facilities on three units (2 South, 2 North, 1 North) out of four units surveyed to include resident rooms room [ROOM NUMBER] A bed and B bed, room [ROOM NUMBER] A bed, room [ROOM NUMBER] and the shared bathroom for resident rooms [ROOM NUMBERS]. Findings included: 1. A tour was conducted of facility unit 2 South on 12/07/2022 beginning at 9:26 a.m. Staff Q, Certified Nursing Assistant (CNA) assisted with testing of resident bedside call light function for room [ROOM NUMBER] & provided witness the call lights for A bed and B bed did not work. When the call button was pressed, the small light on the box on the wall lit up, however the light in the hallway above the room door did not light up. Manual bells were observed at bedside for bed A and bed B. During this observation, Staff C, Licensed Practical Nurse (LPN)/Unit Manger (UM) arrived at the room and stated it had been known since 12/06/2022 the call lights in room [ROOM NUMBER] were not working and had been reported to the facility maintenance team. She stated an audit of call light function for all the rooms in the facility was conducted on 12/06/2022. She said the problem with the call light function in room [ROOM NUMBER] had been ongoing. On 12/07/2022 at 9:58 a.m. Staff C followed up and provided documentation of the call light audit completed on 12/06/2022. Regarding why the audit was done on 12/06/2022, she stated the nurse for room [ROOM NUMBER] bed A had brought to her attention on 12/06/2022 there was no call light for that resident and stated the audit was done because of that report. Review of the audit documents revealed: 228-B Needs New, 226A/B call light stays on & can't be seen on outside of room, next to room [ROOM NUMBER]A was written Bell [electronic work order] notification, next to rooms 118A and 118B was written Call light box needs to be fixed (still working). On 12/07/2022 at 11:40 a.m., the resident in bed B in room [ROOM NUMBER] was heard from outside the hallway yelling, Nurse please help, nurse help. The resident was noted to be in bed and continued to repeatedly call for help and also ring a hand-held manual bell. During this time, six staff members were observed in the nursing station area at the end of hall. It was noted that no one could hear the resident as he continued to ring his bell and call for help. Two CNAs came by the resident's door with a lunch cart. The CNA dropped off the cart and left as the resident continued calling for help. The two CNAs were talking to each other and did not respond to the hand-held manual call bell. The resident continued ringing the handheld bell for approximately15 minutes. On 12/07/2022 at 12:07 p.m. an interview was conducted with Staff Q, CNA and Staff B, CNA. They stated they did not hear the resident calling for help, or him ringing his hand-held manual call bell. They stated sometimes it is loud in the halls and that was why they could not hear the resident in room [ROOM NUMBER] calling for help. They confirmed the hand-held manual bells were not loud enough. On 12/07/22 at 12:03 p.m. Staff R, Licensed Practical Nurse (LPN) heard the resident calling as he walked past the door and responded to the resident's call. Staff R confirmed the room's call light had issues, and the Unit Manager was aware, stating that was why she gave the residents the hand-held manual call bells. Staff R stated he would let the Unit Manager know the hand-held call bells were not loud enough for staff to hear from down the hall. An interview was conducted with the Nursing Home Administrator (NHA), the Director of Facilities Management (DFM)/Maintenance Director, and a facility corporation Regional [NAME] President (RVP) on 12/08/2022 at 9:30 a.m. All parties confirmed they were aware of findings during the survey of the call light system malfunctions. The DFM stated problems with the system function were known and had been ongoing. He stated the system was old, the whole system was scheduled to be replaced, and planning for that had begun a year ago to install a wireless system but it turned out that was not compatible with the facility. So, currently an alternate replacement system was being planned and replacement should be completed within the year. The DFM stated he became aware of problems on the first floor last month and said room [ROOM NUMBER] only became an issue late last week. He stated replacement parts had been ordered for these areas but were found on 12/05/2022 to be incompatible. All parties confirmed that until replacement parts could be secured and until the entire call light system was replaced, those areas identified as not working would continue to not work, additional areas could malfunction, and a temporary solution that met the needs of the residents by ensuring staff could hear and respond quickly would need to be established given the findings of staff not hearing and not responding to use of the manual hand-held bell in room [ROOM NUMBER]. 3. On 12/5/2022 at 10:08 a.m., 12/6/2022 at 7:50 a.m., 12/7/2022 at 7:50 a.m., and on 12/8/2022 at 2:55 p.m. the following was observed: - Resident room [ROOM NUMBER] bed (A) upon attempt to press the call button, while placed on the top of the bed, it did not work. The green, small light on the box on the wall lit up. However, the light in the hallway, above the door did not light up. There was no enunciator as well during the observation. It was also noted through attempt to trigger, the bed (B) call light that it did not work appropriately. The outside of the room light above the door did not light up. At 9:08 a.m. Staff G, Registered Nurse (RN) was interviewed and she, along with Staff K, CNA tested the call lights on bed (B) and bed (A) and found the light above the door in the hall did not light up. They indicated they would notify maintenance immediately. Staff G indicated all call lights are expected to work and even if the residents in the room do not use the call light. - Resident rooms 128/126 shared bathroom was observed with a missing call light system. The wall next to the toilet was only observed with several loose wires hanging out from it. (Photographic Evidence Obtained) It was observed also on 12/7/2022 at 9:02 a.m. the call light system in the bathroom was still missing and only with wires hanging from the wall. Interview with Staff G, and the DFM were not aware of the missing call light system box in the bathroom and would get it fixed. The DFM had no further information with regards to monitoring and checking call lights in resident rooms and bathrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents were referred to the appropriate state designated authority when it became evident after admission that the resident had a mental illness or related condition for 1 of 4 (#77) residents sampled for preadmission Screening and Resident Review. Findings included. Review of Resident #77's face sheet revealed that this resident was admitted to the facility on [DATE] from the hospital, with a primary of Unspecified Dementia Without Behavioral Disturbances, and other diagnosis that included Psychosis, Major Depressive disorder, Psychosis. Review of the Preadmission Screening and Resident Review (PASRR) completed by the facility's representative on 3/3/21 revealed that the resident had Depressive Disorder and Psychotic Disorder checked under section A. MI or suspected MI. The form indicated that under section II that the resident has a primary diagnosis of dementia. Review of Resident #77's current Order Summary Report revealed that she had a current order for Recommend placement on Secured Caring Way Unit related to Diagnosis if Alzheimer's Disease or related dementia. Review of the resident's behavior assessment, dated 3/11/21, revealed that hallucinations were observed, that there was verbal aggression towards others, and wandering occurred daily. Interview on 4/08/21 at 1:22 PM with the Social Service Director revealed that, based on the documentation of the resident's diagnosis that was present on admission, a PASRR level II should have been requested. She reported that she can see now that this is needed and that she will submit for a level II. The facility provided a policy related to PASRR dated November 1, 2019, however, the policy did not address the need or process for a PASRR level II review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement the care plans for two of thirty-two sampled residents (Resident #87) related to the use of an adult monitoring device and contractures (Resident #60) out of the sampled thirty-two residents. Findings included: 1. On 04/06/21 at 11:00 a.m., Resident #87 was observed walking down the unit hallway and asking where the restroom was. Staff E, Licensed Practical Nurse (LPN), reported that Resident #87 often wandered, and had an order for an adult monitoring device. On 04/08/21 at 9:26 a.m., Resident #87 was observed sitting in the family lounge room. An adult monitoring device was observed on his left ankle. The admission Record revealed that Resident #87 was admitted into the facility on [DATE] with a primary diagnosis of Dementia without behavioral disturbance. Section C Cognitive Patterns of the admission Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 04 out of 15, indicating severe impairment. Section P indicated that a wander/elopement alarm was used daily. The Nursing admission Evaluation, with an effective date of 03/04/21, revealed that Resident #87 verbalized a desire to leave the facility. The focus indicated that the resident was noted to wander and required an adult monitoring device. The care plan related to wandering, initiated on 03/04/2, indicated that Resident #87 was noted to wander and required an adult monitoring device. The interventions included, but were not limited to, check adult monitoring device function on 11-7 and check adult monitoring device placement every shift. A review of the current orders (April, 2021) indicated an order for an adult monitoring device and to check placement every shift. There was no order, however, related to checking the functioning of the device. The Treatment Administration Record for March and April 2021 revealed that the placement of the adult monitoring device was checked. There was no documentation, however, related to checking the functioning of the adult monitoring device. On 04/09/21 at 10:52 a.m., Staff B, Certified Nursing Assistant (CNA), reported that she was not responsible for checking the adult monitoring device. On 04/09/21 at 11:05 a.m. Staff C, Registered Nurse (RN), reported that Resident #87 did not have an order in place for checking the functioning of the adult monitoring device. She stated that the night shift was responsible for checking the functioning. Staff C, RN, confirmed that there was no documentation in the resident's medical record related to checking the functioning of the adult monitoring device. The policy provided by the facility Wandering Customer, revised 06/29/17, revealed the following: Check daily, usually night shift for proper functioning following manufacturer recommendation. Staff should document proper function on the TAR. 2. On 04/06/21 at 11:53 a.m., Resident #60's family member reported that he was not receiving therapy or services for the left-hand contracture. The family member stated that he contacted the insurance company and had talked to staff about this concern. At this time, the resident was observed not wearing a splint, hip abduction, or the left knee orthotic, per physician orders. The resident's left hand was observed severely contracted. On 04/08/21 at 9:19 a.m., Resident #60 was observed sitting in the wheelchair next to the bed in his room. The resident was dressed for the day. No splints were observed. On 04/08/21 at 11:25 a.m., the resident was observed outside on the patio with the family member. Resident #60 did not have on a splint, hip abduction, or left knee orthotic. The family member reported he bought the resident a splint, but it is in the closet in his room and he had not seen the resident wearing a splint. The family member reported that Resident #60 used to have something for his thighs and he had not seen that either. On 04/08/21 at 3:08 p.m., Resident #60 was observed in bed. A splint was not observed on the left hand. A review of the admission Record for Resident #60 revealed that he was initially admitted into the facility on [DATE] with diagnoses that included, but were not limited to, contracture of unspecified joint and contracture of muscle at multiple sites. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe impairment. Section O reflected zero no for splint or brace assistance. The care plan related to contractures, initiated on 08/15/19, indicated that the goal was for Resident #60 to tolerate the splint. The interventions reflected that the resident used a left-hand splint, figure 8 splint, and left knee splint. A review of the Order Summary Report with active orders as of 04/09/21 revealed the following order: clarification patient to use hip abduction and left knee orthotic to prevent further contracture and patient to use left hand splint to prevent further contracture, dated 05/15/20. A review of the Treatment Administration Record (TAR) for March and April 2021 found that there was no documentation related to applying the splints or the hip abduction. A review of the Progress Notes for March and April 2021 did not reflect any documentation related to splints and a rationale for why the resident was not wearing the splint or the hip abduction. On 04/09/21 at 11:03 a.m., Staff F, Certified Nursing Assistant CNA, reported that she stopped putting the splint on because of the bruises on Resident #60's hand. On 04/09/21 at 11:05 a.m., Staff C, Registered Nurse (RN) reported that they stopped restorative because of COVID. Staff C stated that Resident #60 was not wearing the splint because of the bruising on his hand. On 04/09/21 at 12:23 p.m., the Director of Nursing (DON) reported that the family member reported concerns to her about why Resident #60 was no longer wearing the brace or splint and he wanted her to look into it. On 04/09/21 at 12:25 p.m., the Director of Therapy (DOT) stated that Resident #60 had bruising and the significant other did not want him to have the splint on. He wanted them to hold off on using them. The DON reported that she thinks the splint got sent to laundry and did not come back. The policy provided by the facility Care Plan: Customer, revised 02/08/19, revealed the following: The center must develop and implement a comprehensive, person-centered care plan for each customer.

Based on observations, interviews, and record reviews, the facility did not ensure that 4 vials of Lorazepam 2mg/ML, a Schedule IV medication, were stored in a permanently affixed compartment, separate from other medications in a locked refrigerator for one of two medication storage rooms (First Floor Medication Storage Room). Findings include: On 4/9/21 at 11:00 a.m. an observation in the first-floor medication storage room was conducted with Staff D, Licensed Practical Nurse (LPN). The refrigerator in the room was found to be unlocked and a clear box was observed inside of the refrigerator. The box was not permanently affixed to the refrigerator and was able to be removed for inspection. The box contained Emergency Drug Kit insulin, a resident bag of medications and Emergency Drug Kit with 4 vials of Lorazepam 2mg/milliliter, a Schedule IV medication. Photographic evidence was obtained. An interview was conducted with Staff D, LPN at the time of the observation, she stated the medications are always stored like that. On 4/9/21 at 11:15 a.m. an interview was conducted with the Director of Nursing (DON). She stated the Consulting Pharmacist had just been in the building and had not identified the narcotics being improperly stored. A request for the policy on medication storage was requested. A review of the policy entitled, Medication Storage in the Facility with an effective date of February 2019 indicated the following: ID2: Controlled substance storage Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures: A-The Administrator and/or Director of Nursing, in collaboration with the Consultant Pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B-Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation. C-Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator in such a manner that prevents its removal for the medication room. On 4/9/21 at 12:04 p.m. a telephone interview was conducted with the Consultant Pharmacist. The Pharmacist stated he had noticed the storage of the Ativan and was aware the medication needed to be in a permanently affixed, separate box from other medications in the refrigerator. He stated he had made a note of this during his March rounds and he would work with the facility to correct this issue.