**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews, the facility failed to provide adequate supervision to prevent elopement for one out of three sampled residents as evidenced by; on 08/21/2025 at 6:22 AM Resident # 5, a newly admitted resident who is cognitively intact, exited the building undetected through the door used for the linen delivery that was left open and eventually exited the facility's grounds through the back gate. There were four residents at risk for elopement residing in the facility at the time of the survey. The findings include.Observation on 08/22/2025 at 12:55 PM revealed the door Resident # 5 exited through has an alarm system.Review of a photograph provided by the facility's Administrator revealed Resident # 5 wearing blue short sleeved with horizontal stripes, green cargo pants, black socks and black sandals, exiting the facility at 6:22 AM through the emergency exit door that was wide open.Record review of Resident # 5's medical records revealed the resident was admitted to the facility on [DATE] to a room on the facility's first floor. On 08/21/2025 Resident # 5 eloped. Resident # 5's clinical diagnoses include but not limited to non-Pressure related Chronic Ulcer of Right Heel and Midfoot, adverse effect of other Antipsychotics and Neuroleptics, Schizophrenia unspecified, and other Specified Persistent Mood.Review of Resident #5's Physician orders included: Risperidone 2 milligrams (mg) oral tablet-Give 1 tablet by mouth two times a day related to adverse effect of other Antipsychotics and Neuroleptics, Order dated 8/20/2025 21:00-Valproic Acid 250 mg oral capsule-Give 1 capsule by mouth two times a day related to Specified Persistent Mood.Review of the Social Services Baseline Care Plan documentation indicated: (Mood and Behavior): Resident exhibits a potential for alteration in mood and/or behavior. Resident will maintain current level of mood state and will not exhibit adverse behaviors. Resident will refrain from harming self/others.On 08/22/2025 at 1:14 PM, the Nursing Home Administrator (NHA) revealed, the incident occurred yesterday at approximately 7:00 AM and the patient is alert, oriented and make his own decision. He was admitted on 08/19/ 2025 from [local Hospital] for an arterial wound on the right foot he ambulated through the entire facility, and on 8/21/2025 he woke up at around 6:00 AM asked for towels to take a shower; at 7:13 AM the nurse did a head count and noticed he was not in bed at that point she told the supervisor, and the supervisor called a code green. I was notified by the maintenance we called the relative on file to check if he was with her, at this time we are treating it as a missing person. The last person that saw him was the laundry vendor and he did not know he was resident. The resident went through the back gate after he exited through the laundry room exit. The RCA (Root Cause Analysis): [Staff D, Floor Tech] should have stayed at the door when he opened and disarmed it. The CNA (Certified Nursing Assistant) have at least 11 residents and she was taking care of other residents, so she was not really at fault. Security had a delivery for dietary so he was not able to be at the laundry, and the Floor tech should have stayed and monitor. Floor tech was suspended pending further investigation. Interview on 08/22/2025 at 2:15 PM, Staff A, Certified Nursing Assistant (11:00 PM to 7:00 AM shift) stated: I got to know him for a short period of time before that happened he wanted to know where the front patio and back patio was located this was on the 20th at approximately 2:00 AM he asked if there is a place to go out to have some fresh air I told him it too late to go out on the patio, he said he was hungry and we gave him some apple sauce, he ate the applesauce and he said he was still hungry so the supervisor went to the kitchen got two sandwiches and gave them to him he ate and went to sleep. Before I left at the end of my shift, I changed him and left him in his room. The next day (08/21/2025) when I came in at the start of my shift he was on the back porch with the security guard and other residents, he said he was hungry, and we gave him some apple sauce and he said he was still hungry so he supervisor went with the supervisor to the kitchen, and he got two sandwiches he ate the and went to bed. On the 21st He woke up early in the morning and went to take a shower the nurse was with him, and we gave him towels he dressed himself, about 6:30 AM he went through the double doors, and I continued working with my other patients. The other shift came, and they were asking if we saw [Room Number], I never knew he would leave because he was compliant. Interview on 08/22/2025 at 2:28 PM Staff B, Registered Nurse (RN)- Day Shift stated, On that day the outgoing nurse told me I can do my rounds, and I asked her where he (Resident #5) was, and she told me he may be on the patio. She told me that the last time she saw the resident was about at 6:30 AM. I told her I needed to see the patient because I did not know him. When I went to his room he was not there. I called the supervisor and the DON (Director of Nursing); and the outgoing nurse stayed and helped to look for him, but we did not find him, so they called code green (elopement code). I did not know him, and they showed me his picture when we were searching for him.During a telephone interview on 08/23/2025 at 9:55 AM, Staff C, RN-Night Shift Supervisor revealed: The resident (Resident #5) is very alert, and he is close to the kitchen most of the time and he walks around the facility socializing with everyone. He was not an exit seeking resident and never gave problem. I usually sit downstairs when I finish my rounds, when I did my second round he was in his room the patient (Resident #5) asked for food and security opened the kitchen and I got some sandwiches and gave the food to him (Resident #5) in his room. During my third round at about 7:10 AM the nurse came and told me a resident was missing, and I called a code green. I called maintenance and looked at the camera showing him leaving through the laundry room exit. Interview on 08/23/2025 at 9:58 AM, the Risk Manager revealed the elevators are not equipped with [wander alert system] . the exit doors are alarmed and will sound when approached. Resident #5 was alert, did not have and did not have a [wander alert system] in place. He eloped during a laundry delivery through the back door after asking for food. The resident has a known history of elopement and has not yet been located. Interview on 08/23/2025 at 10:03 AM the Maintenance Director revealed all exit doors on the first floor are equipped to detect the [wander alert] and will alarm when triggered. If the door is pushed, it must be held for 15-30 seconds before a loud alarm will sound. A key is required by maintenance staff to reset the stairwell alarms.Telephone interview with translation assistance by the NHA on 08/23/2025 at 10:05 AM, Staff D, Floor Tech revealed, on 08/21/2025 around 6:00 AM to 6:15 AM the security called and asked him to open the laundry door because he was dealing with another delivery in the kitchen. Staff D, Floor Tech revealed unlocked and disarmed the door and did not stay during the delivery because he went to pick up the soiled linen. Staff D, Floor Tech revealed he does not remember shutting and locking the door and gate and did not see the resident leaving.On 08/23/2025 at 10:41 AM Staff E, Certified Nursing Assistant (7:00 AM to 3:00 PM shift) stated: I remember the resident, he is alert and like to walk around the facility. Wednesday (8/20/2025) was the first time I worked with him. After I changed him that afternoon, he asked for food around 2:00 PM and he sat on the patio where they smoked, and I left at about 3:15 PM. On Thursday (8/21/2025) at the start of my shift when I did my rounds I did not see him in his room so I asked the nurse where is my resident because he was not in bed; the nurse said he just had a shower and because he is always walking back I went looking for him and did not see him so I tell the nurse and the nurse told the supervisor then they called a code green and we searched for him, I drove in my car all the way past [streets] and around but did not find him we kept searching the police came and still not find him. Telephone interview on 08/23/2025 at 10:50 AM Staff F, Licensed Practical Nurse (7:00 PM t0 7:00 AM shift) revealed, on 08/20/2025 to 08/21/2025 I worked with him he is alert he followed instruction; I administered medication to him, and he took them one by one. Around 2:00 AM, he was walking back and forth and was given two sandwiches after he ate, he went back to bed. Around 6:00 AM He showered himself and after his shower when I did rounds, he was in his room in the bed. During shift transfer we did not see him I told the supervisor, and a code green was called.On 08/23/2025 at 11:41 the DON revealed: On Thursday (08/21/2025) I got a call that there was a missing resident. I told them he always goes to sit on the patio, the code green was already started and once I got here we created a command center. Record Review of the facility's policy titled: Safety and Supervision of Residents indicate:Policy StatementOur facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation Facility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure medications were stored in accordance with professional standards, as evidenced by unsecured medications observed at the bedside in one out of eight sampled residents. There were 257 residents residing in the facility at the time of the survey. The findings included: Observation on 06/23/2025, at 9:59 AM, Resident #97 was observed lying in bed, there was a bottle labeled for congestion treatment on the window ledge and an unlabeled transparent medication bottle containing an unidentified tablet at the resident's bedside. Observation on 06/23/2025, at 12:06 PM and 06/24/2025 at 2:11 PM in Resident #97's room revealed the bottle labeled for congestion treatment on the window ledge and the unlabeled transparent medication bottle containing an unidentified tablet remained on the shelf at the resident's bedside. Record review revealed Resident #97 was admitted on [DATE]; the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively intact and requires staff assistance with activities of daily living, Review of the care plan revealed no documentation indicating Resident #97 was assessed or authorized to self-administer medications. Interview on 06/24/2025 at 2:17 PM, Staff A, Registered Nurse (RN) revealed residents are not permitted to keep medications in their rooms. Staff are expected to remove any medications found and store them properly. On 06/25/2025, at 2:58 PM, Staff B, RN reported it is unsafe for residents to keep medications in their rooms and revealed the resident's wife routinely brings in unauthorized items, including medications. Review of the facility's policy titled Medication Labeling and Storage indicates: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE] at 10:48 AM, observation of Percutaneous Endoscopic Gastrostomy (PEG) tube care for Resident #243 performed by Staff M, Registered Nurse (RN). Staff M, Registered Nurse gathered peg tube supplies, knocked on Resident #243's door provided privacy, explained the care that will be provided, provided privacy, washed hands, put on gloves, gown and face mask. Staff A removed the old peg tube dressing dated [DATE] and discarded it in a red biohazard bag, removed soiled gloves and put on a new pair of gloves; cleaned the skin around the peg site three times and discarded the soiled gauzes. Staff A, RN removed soiled gloves, put on a new pair of gloves, and applied new peg tube dressing; Staff A, RN removed the gloves, gown and face mask and discarded them in the red biohazard bag . Review of Resident #243's clinical records revealed the resident was admitted to the facility on [DATE]; medical diagnoses included but not limited to Gastronomy Status and Dysphagia. Review of Resident # 243's Physician Orders for [DATE] revealed an order for enteral feeding every 24 hours . Review of Care Plan for Resident #243 dated [DATE] revealed the resident is at high nutritional and hydration risk .with diagnosis and past medical history of dependence for enteral nutrition. Goals include providing local care to tube site as ordered and monitoring signs and symptoms of infection. Registered dietitian consult as needed. Interview on [DATE] at 11:07 AM, Staff M, RN stated: After removing gloves during care, I must wash my hands and then put on new gloves anytime you are changing gloves, hand hygiene is very important. On [DATE] at 03:10 PM, the Nursing Supervisor revealed: Staff always needs to wash hands or use hand sanitizer after removing soiled gloves and before donning new ones . Interview on [DATE] at 10:11 AM, Staff O, Certified Nursing Assistant (CNA) revealed Hand hygiene should be done frequently. It should be done before and after one is in contact with a patient, and when changing gloves. It is essential in our work to prevent any type of infection . On [DATE] at 09:25 AM during a facility tour an empty antibiotic intravenous (IV) bag with uncapped tubing hanging on IV pole was observed in a resident's room on the first floor of the North Wing unit (photographic evidence). On [DATE] at 12:18 PM another facility tour the empty antibiotic IV bag with uncapped tubing was observed hanging on IV pole in the same resident's room on the first floor North Wing (Photographic evidence). On [DATE] at 05:37 PM, a third facility tour was conducted and the empty antibiotic IV bag with uncapped tubing was observed hanging on IV pole in the same resident's room on the first floor's North Wing unit (Photo evidence). Interview on [DATE] at 02:22 PM, the Director of Nursing (DON) revealed: When IV bags are empty, they should be discarded immediately along with the IV tubing as well. IV tubing should be dated, and tubing port should be capped when not in use. Interview on [DATE] at 09:18 AM, Staff N, Licensed Practical Nurse (LPN) revealed: I would follow hand hygiene any time before and after touching a resident and before and after using gloves. We should also make sure to always use aseptic technique when handling IV bags and tubing. IV tubing ports should always be capped when not in use or thrown away upon completion or when they are expired. Review of the facility's policy titled: Infection Prevention and Control Program dated 12/2023 Policy states: 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. 7. Prevention of Infection a. 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 respiratory hygiene to visitors and family members. 7. implementing appropriate enhanced barrier and transmission-based precautions when necessary. Based on observations reviewed and interview, the facility failed to implement infection prevention and control practices as evidence by respiratory equipment left exposed next to a rat trap and other non-clinical items on a chair in Resident #97's room and staff failure to perform hand hygiene between glove changes. These deficient practices potentially increases the risk for contracting and spreading diseases. There were 257 residents residing in the facility at the time of the survey. The findings included: On [DATE] at 9:59 AM, Resident #97 was observed in bed, a pungent fecal like odor was noted in the room, a nebulizer machine with tubing and mask, was observed uncovered beside a rat trap on a chair. Observations on [DATE] at 12:06 PM, the resident remained in bed the uncovered nebulizer equipment remained on the chair in the same location next to the rat trap. Review of Resident #97's clinical records revealed the resident was admitted on [DATE]; clinical diagnoses include Chronic Obstructive Pulmonary Disease (COPD). Review of physician's order for [DATE] revealed an order dated [DATE] for Ipratropium-Albuterol Inhalation Solution, to be administered via nebulizer every 6 hours as needed. Review of the Annual Minimum Data Set (MDS) dated [DATE] indicate the resident is cognitively intact, requires assistance for hygiene care and transfers. Review of Resident # 97's care plan with start date [DATE] and completion dated [DATE] indicate: Administer nebulizer treatments as ordered, monitor effectiveness and potential side effects, observe signs of respiratory infection or distress, and maintain oxygen saturation monitoring and proper positioning. Interview [DATE] at 2:17 PM, Staff A, Registered Nurse (RN) reviewed the photographic evidence and revealed the respiratory supplies should be kept in a labeled, closed bag and must be dated. On [DATE] at 2:58 PM, Staff B, RN supervisor acknowledged the identified concerns and revealed the nebulizer supplies must not be left uncovered on furniture and must be stored properly to prevent contamination. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment classifies respiratory therapy equipment as semi-critical and requires cleaning and disinfection per CDC (Centers for Disease Control and Prevention) and OSHA (Occupational Safety and Health Administration) standards. The policy mandates that these items must be stored and maintained in a manner that prevents cross-contamination and microbial growth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that the facility failed to provide a clean environment and housekeeping services for resident's equipment (Resident #258 and Resident #158). There were 266 residents residing in the facility at the time of the survey. The findings include: On 02/19/2024 at 10:09 AM. It was observed that Resident #258's feeding pump had dried enteral liquid on the feeding pump and pole. (see photo evidence) On 02/19/2024 at 11:24 AM. Observation revealed Resident #182 feeding pump had dried enteral liquid and dark matter on the floor. (See photo evidence) On 02/19/2024 at 12:03 PM. In room [ROOM NUMBER], it was observed that the oxygen concentrator was on and covered with dust with no nasal cannula attached. (see photo evidence) On 02/19/2024 at 05:24 PM. In room [ROOM NUMBER], it was observed that the oxygen concentrator was on, covered with dust, and no nasal cannula tubing attached. On 02/20/2024 at 09:21 AM. It was observed that Resident #182's floor had dark substance on the floor. On 02/21/2024 at 08:30 AM. It was observed that Resident #182's feeding pump had dried enteral liquid and dark matter on the floor. On 02/21/2024 at 08:33 AM. In room [ROOM NUMBER], it was observed that the oxygen machine was on and was covered with dust. On 02/21/2024 at 08:49 AM. It was observed that Resident #258's feeding pump had dried enteral feeding liquid (See photo evidence) Record review of Resident #258's physician orders revealed an order for enteral feeding liquid via feeding tube at 50 milliliters ml an hour with water flush at 30 milliliters an hour. Record review of Resident #182's physician orders revealed an order for enteral feeding liquid at 70 milliliters an hour and water flush at 30 milliliters an hour. Record review of Residents #143's and Resident #146's physician orders revealed no physician orders for oxygen therapy. On 02/21/2024 at 10:40 AM. In an interview with the Environmental Services Director was asked: What is the routine for housekeeping services for cleaning resident rooms, enteral pumps and equipment? The Environmental Services Director stated Every day the pumps and poles are to be checked with daily cleaning. We have a multi-surface cleaner to clean them. We did an in-service on 2/14/2024 about environmental cleaning techniques. Basically, cleaning techniques for how to clean the room from cleanest to dirtiest. On 02/21/2024 at 11:09 AM. In an interview Staff E, LPN (Licensed Practical Nurse) was asked if the oxygen concentrator was on or off, and which resident has orders for oxygen? Staff E, LPN stated: The oxygen concentrator is on and working. It's dusty and it needs to be cleaned. Staff E LPN reviewed the medical chart for Resident #143 and Resident #146 and stated: Both residents do not have physician orders for oxygen. On 02/21/2024 at 11:29 AM. In an interview Staff A, Nurse Manager, was asked about the two enteral feeding pumps that were found with dried enteral liquid in room [ROOM NUMBER], the dirty oxygen concentrator that was on but there were no orders for either of the residents. When Staff A was asked what the routine for cleaning enteral feeding pumps and oxygen concentrator. Staff A stated: These medications and feeding liquid can be so sticky. I will discuss this with the Housekeeping Director. Sometimes, the resident is on as-needed oxygen for three days and the order expires. The nurse is to remove the nasal cannula tubing and the oxygen concentrator from the room. A safe environment is for everyone. I'm going to do an in-service with nurses and certified nursing assistants. If you see something, you need to report it. So, the job can be done. I will talk with all of them. Review of document titled general environmental cleaning techniques. The identification of high touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures as theses will often differ by room and facility. Perform assessment and observations of workflow in consultation with clinical staff in each patient care area to determine key high touch areas. Common high touch surfaces include, iv poles, counters where medications and supplies are prepared, patient monitoring equipment. Review of document titled; Spot check of staff revealed a checklist of steps: proper cleaning chemicals uses and areas to clean in the room. Sprays down appropriate areas to clean and lets the chemical sit for at appropriate time. Wipe dry all chemically treated areas. Floor is mopped thoroughly with fresh disinfectant. Review of facility policy titled Cleaning and disinfecting residents room. Revised August 2013. The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. In the section titled general guidelines: 1) housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. 2) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled. 3) Manufacturer's instructions will be followed for proper use of disinfecting products. Review of facility's policy titled Cleaning and disinfection of resident care items and equipment. The policy statement stated resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. In section titled policy interpretation and implementation. B) Semi critical items consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. C) Noncritical items are those that come in contact with intact skin but not mucous membranes. 2) Non -critical environmental include surfaces bed rails, bedside table. 3) Non-critical items require cleaning followed by either low or intermediate level disinfection following manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 263) out of one resident MDS assessment that was reviewed at the time of survey. There were 266 residents residing in the facility at the time of survey. The findings included: Review of Resident #263's admission Record revealed the resident was admitted to the facility on [DATE] and discharged on 11/24/2023. Medical diagnosis included, but not limited to, Diabetes mellitus (DM), chronic obstructive pulmonary disease and cerebral infarction. Review of Discharge Return not Anticipated Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to Short-term/General Hospital. Review of the Care Plan initiated on 07/07/2023 with revision dated 01/02/2024 indicated: [Resident #263] is here for long term placement due to resident/representative desire to remain in long term facility. Goal: Resident's Psychosocial needs will be met daily with assistance from staff through the next review. Interventions: Encourage socialization with peers in the facility. Review of Social Services progress note dated 11/22/2023 and time stamped documented: Discharge Activity Planning: Resident and daughter are requesting discharge to an Assisted Living Facility (ALF). Resident requested to be discharged after Thanksgiving. Resident will be provided medication scripts and discharge folder on discharge date . Review of Discharge Summary progress note dated 11/24/2023 time stamped 12:49 documented: Resident is discharged from the facility to an Assisted Living Facility (ALF) in stable condition with all her belongings and regular medications accompanied by two family 's members with good attitude. Skin is intact, no edema. Vitals are in normal limit. During an interview on 02/21/2024 at 12:20 PM, the MDS Coordinator stated she has been in charge of MDS for 12 years. Oh my God, I see this was my mistake, I will fix it, I'm sorry. Review of the facility's MDS Policy and Procedure revealed: Resident assessment Policy Statement A complete assessment of every resident's needs is made at intervals designed by Omnibus Budget Reconciliation Acts (OBRA), and Palliative Performance Scale (PPS) requirements. Policy Interpretation and Implementation: OBRA-Required Assessments - Are Federally Mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing home. PPS Assessments - Provide information about the clinical condition of beneficiaries receiving part A Skilled Nursing Facility (SNF)-level care in order to be reimbursed under SNF PPS for both SNFs and Swing Bed providers. OBRA required assessments conducted for all residents in the facility: Discharge Assessment (return anticipated and return not anticipated). The interdisciplinary team uses the Minimum Data Set (MDS) from currently mandated by federal and state regulations to conduct the resident assessment. All persons who have completed any portion of MDS resident assessment form must sign the document attesting to the accuracy of such information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide devices for an accident-free environment for one out of nine sampled residents (Resident#32). There were 266 residents residing in the facility at the time of survey. The findings included: On 02/19/2024 at 8:28 AM in room [ROOM NUMBER] bed A, Resident #32 was observed lying in bed. One floor mat was located on the right side of the bed. (see photo evidence) On 02/20/2024 at 9:18 AM in room [ROOM NUMBER] bed A, Resident #32 was observed lying in bed. One floor mat was located on the right side of bed. (see photo evidence) On 02/21/2024 at 3:03 PM in room [ROOM NUMBER] bed A, Resident #32 was observed lying in bed. One floor mat located on right side and left side of bed. Record review of demographic face sheet revealed Resident #32 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Hemiparesis affecting left dominant side, Seizure, and Glaucoma. Record review of Resident #32's Quarterly Minimum Data Set (MDS) dated [DATE], section C for cognitive patterns revealed a Brief Interview for Mental Status (BIMS) score of 15 on a scale of 0-15, indicated no cognitive impairment. Section E for Behaviors revealed no potential indicators of psychosis, no behavioral symptoms or rejection of care. Section GG for Functional Status revealed Resident #32 required substantial assistance for transferring and rolling from left to right on the bed. Section J for Pain Management revealed Resident#32 had one fall since admission. Review of Resident #32's Care Plan with initial date of 3/31/2022 and revision date of 12/5/2023 for risk for falls related to weakness. Interventions included: Bilateral floor mats. PT (Physical Therapy) screen: Currently on therapy caseload, will reassess functional mobility, maintain bilateral floor mats. Keep bed in low position and locked position. Keep call bell in reach when in room. Perform frequent checks of resident. Review of physician orders revealed orders to keep bed in lowest position and bilateral mats to floor when resident is in bed dated 10/19/2023. Review of the Incident Log, listed Resident #32 on 10/19/2023. Review of Nursing Note dated 10/19/2023 indicated [Resident #32] was observed next to his bed sitting on the floor pad, he was able to verbalize I slid from the bed. no apparent injury noted. On 02/20/2024 at 9:35 AM, Registered Nurse (RN), Staff A revealed Resident #32 has an order for bilateral floor mats. She is not sure why only one floor mat was present, and she will follow up with rehab to reevaluate Resident #32. On 02/21/2024 at 4:55 PM Staff C, Certified Nursing Assistant (CNA) stated: I am not aware that [Resident #32] needs floor mats. [Resident #32] is a good resident and follows direction. On 02/21/2024 at 5:15 PM, Staff B, RN stated that she is aware that the resident has a physician order for bilateral floor mats when in bed for fall precaution. I do rounds to ensure floor mats are in place and if I notice a floor mat is missing, I notify housekeeping to bring a floor mat. I will reinforce with [Staff C] that [Resident #32] requires floor mats on each side of bed for safety. On 02/21/2024 at 5:45 PM the Director of Nurses (DON) stated: Floor mats are for resident's safety and to prevent injuries. we are not following orders when a resident's order says bilateral floor mats and there is only one floor mat in place. I will investigate to find the reason why only one floor mat was in place. Moving forward I will complete an in-service with licensed staff about following doctor's orders for floor mats and the reason for using floor mats. I will speak to housekeeping to ensure if they remove floor mats for cleaning that they replace them. Review of the facility's Policy and Procedure entitled, Falls and Fall Risk, Managing revised March 2018. Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Review of Policy and Procedure entitled, Safety and Supervision of Residents revised July 2017 Policy statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: Individualized, Resident-Centered Approached to safety: 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communication specific intervention to all relevant staff; d. Ensuring that interventions are implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed, and interviews. The facility failed to obtain physician's orders for oxygen treatment for Resident #211. This practice could affect 266 residents who were residing at the facility at the time of the survey. The findings include: On 02/19/2024 at 12:18 PM. In an observation and interview of Resident #211. It was observed that the resident was on two liters of oxygen via nasal cannula. (See photo evidence). Resident #211 stated the nurse from the night shift had changed the nasal cannula tubing earlier that morning. Observation on 02/20/2024 at 09:43 AM, revealed Resident #211 was not in the room but the nasal cannula tubing was on the bed and the oxygen concentrator was on at two liters. Record review of physician orders revealed no orders for oxygen therapy for Resident #211. On 02/21/2024 at 11:21 AM. In an interview with Staff F, LPN (Licensed Practical Nurse). When Staff F was asked where Resident #211 was and if the resident had physician orders for oxygen treatment. Staff F stated, [Resident #211] is downstairs at Bingo. Sometimes [Resident #211] will place the oxygen on or off per request. Staff F reviewed the medical chart and stated: I'm not seeing any oxygen orders for [Resident #211]. On 02/21/2024 at 11:51 AM. In an interview with the Staff A, Nurse Manager. When asked, When residents are on oxygen do they need physician orders. Are there any physician orders for oxygen for [Resident #211]? Staff A stated: Yes, and reviewed Resident #211's medical chart. The Nurse manager stated: I will talk to the resident's physician to receive an order for oxygen. On 02/21/2024 at 02:09 PM. In an interview with the Nurse Manager, it was stated I talked to the nurse who put the oxygen orders in, and they said it was in the medical record. I told the nurse it wasn't there. I received an order from the physician for oxygen at two liters and the pulse oxygen machine as needed for oxygen saturation lower than 92% Record review of Resident #211 medical diagnosis revealed cerebral infarction (Stroke). Record review of physician orders revealed no orders for oxygen administration except to change the oxygen cannula every Sunday and as needed. Review of the care plan revealed Resident #211 had potential for complications of respiratory distress related to the diagnosis of episode of shortness of breath. Interventions were oxygen saturation as ordered. Administer oxygen as ordered. Goal was Resident #211 will remain free from signs and symptoms of respiratory distress through the next review. Record review of Minimum Data Set, dated [DATE] revealed in section C: Cognitive patterns, the brief interview of mental status was a 15 suggesting Resident #211 was cognitively intact. In section J: Health conditions, no to shortness of breath. In section O: Special treatments, procedures, and programs No to oxygen therapy. Review of facility's policy titled oxygen administration with revision date of October 2010 documented: The purpose of this procedure is to provide guidelines for safe oxygen administration. In section titled preparation, 1.) verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Class III

Based on observation, record review and interview the facility failed ensure accuracy in the reconciliation in the accounting of all controlled substances for 2 out of 2 residents whose narcotic records were reviewed (Resident#150 and Resident#76). There were 262 residents residing in the facility at the time of survey. The findings included: Observation on 02/21/2024 at 12:30 PM on the second-floor south station, cart 2. During Controlled Substance count with Staff D, Registered Nurse (RN), it was revealed during the counting of the controlled substances sheet for Resident #76's, Medication: Methadone, Dosage: 5 mg (milligram) tablet; indicated on the last line of sheet that the person giving the medication: Staff D, Date: 2/20/2024, Time: 5:00PM, Amount on hand: 22, Amount given: 1, Amount remaining: 21. (see photo evidence). Review of the physical bingo card for the Methadone 5 mg for Resident #76, count was 20. Observation on 02/21/2024 at 12:32 PM on the second-floor south station cart 2. Controlled substances count with Staff D, Registered Nurse (RN) revealed the controlled substances sheet for Resident#150 Lorazepam, Dosage: 1mg tablet. Noted on the Last line of the sheet indicated the Person giving: Staff D, Date: 2/20/2024, Time: 5:00 PM, Amount on hand: 14, Amount given: 1, Amount remaining: 13. (see photo evidence). Review of the physical bingo card for Resident #150 indicated the count was 12. On 02/21/2024 at 12:35 PM Staff D, RN stated she administered the narcotics at 9:00 AM and did not reconcile narcotics because she was busy. She is aware she should sign out narcotics at the time she administers it to the resident. On 02/21/2024 at 4:29 PM the Director of Nursing (DON) stated: Before a nurse administers a narcotic, the nurse verifies the physician order and then reconciles the narcotic administered on the counting-controlled substances sheet. It is not appropriate for a nurse to administer a narcotic at 9:00 AM and sign-out the narcotic at 12:30PM on the counting-controlled substances sheet. I will investigate this situation and complete an in-service with all nursing staff to reinforce the time frame for signing out narcotics. It is important to sign out narcotics at the time of administration because we must make sure we are following doctor's orders to meet the resident's needs and to make a nurse is not diverting medication. Review of the facility's Policy and Procedure entitled Controlled Substances revised April 2019. Policy Statement: The Facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) Name of the resident receiving the medication; (2) Name, strength, and dose of the medication; (3) Time of administration; (4) Method of administration; (5) Quantity of the medication remaining; and (6) Signature of nurse administering medication. (in a timely manner)

Based on record review and interview and the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe, Clean, Comfortable, Homelike Environment, F689 Free of Accident Hazards, Supervision, Devices, F695 Respiratory/Tracheotomy Care and Suctioning. These repeated deficiencies have the potential to affect 266 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 11/18/2022, F584 Safe, Clean, Comfortable, Homelike Environment, F689 Free of Accident Hazards, Supervision, Devices, F695 Respiratory/Tracheotomy Care and Suctioning. were cited. Interview with Administrator and the Director of Nursing on 02/22/2024 at 01:40 PM. The Administrator and DON stated that the QAPI (Quality Assurance and Performance Improvement) meetings are held every month with the attendees are the Risk Manager, Social services, Medical Director, Complaint Officer, Infection Control, MDS coordinator and Activity Director. QAPI review of the plan that was provided by the facility indicated: Vision A Vision statement is sometimes called a picture of your organization in the future; it is your inspiration and the framework for your strategic planning. The vision of the facility is to create an environment where people are loved, valued, and dignified. Mission or Cores Principles are: Superior Quality of Care Exceptional Quality outcomes and Service delivery Caring and top performing staff Outstanding Resident and Family Satisfaction It provides the framework or context within which the company's strategies are formulated. The Facility is each resident's home. We are committed to enhancing quality of life by nurturing individuality and independence. We are growing a value-driven community while leading the way in honoring inherent senior rights and building strong and meaningful relationship with all whose lives we touch. Performance Improvement Projects (PIPs): The QAPI Committee annually prioritizes activities, endorses, or re-endorses policies and procedures, and continually monitor for improvement through the use of QAPI self-assessment. In addition, the QAPI Steering Committee will implement any PIP topics indicated by date analysis. Quality improvement activities are also developed in collaboration with the support of providers, residents, and staff. PIPs are implemented in accordance with CMA protocol for conducting PIP's including: 1. Measurement of performance using objective quality indicator. 2. Implementation of system interventions to achieve improvement in quality. 3. Evaluation of the effectiveness of the interventions 4. Plan and initiation of activities for increasing or sustaining improvement. Implementation of new PIPs or any significant changes proposed to existing PIPs will be subject to approval. As such, reports reflecting new or charging PIPs will be submitted to the corporation and/or the Upper Management. Peer Reviews: The facility monitors provider and facility adherence to quality standards via site visits and ongoing review of complaints, adverse events, and sanctions and limitations on licensure. The purpose of the peer review program is to monitor accessibility, quality, adequacy, and outcomes of services delivered. The facility performs audits of providers to review clinical and administrative policies and procedures, clinical record's against standards, adherence to timely access to care requirements, and administrative practices for the purpose of monitoring compliance with best practice for the purpose of monitoring compliance with the facility and Rehab Center contact, including state and federal requirements.

Based on observations, interviews, and record review the facility failed to ensure the essential patient care equipment was in safe operating condition for three out of three residents who used mechanical lifts for transfer (Residents # 25, #464, and #129). The mechanical lift used to transfer the residents who required total assistance from the bed to the chair was not working. The findings included: Observation on 02/21/2024 at 07:25 AM revealed that on the second floor there were six (6) mechanical lifts working to take care of 91 residents who were totally dependent on the equipment. On the first floor five mechanical lifts worked to take care of 71 residents who were totally dependent on the equipment. In total the facility had five mechanical lifts broken. On 02/20/2024 at 11:20 AM, during an interview with Resident #25 the resident revealed that he needs assistance to be transferred from his bed to the wheelchair and assistance is provided using the mechanical lift. He has to wait for a long time because on the first floor there are only a few mechanical lifts working for all the residents that need them. The other ones had been broken for a long time. Record review of the Quarterly Minimum Data Set (MDS)/ Consolidated Appropriations Act (CAAs) dated 01/29/2024 for Resident #25 revealed in Sections C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) a score of 15 out of 15 indicating Resident # 25 is cognitively intact. Section GG for Functional Abilities and Goals indicated upper and lower extremity impairment on both sides and noted for Wheelchair (manual or electric)-Yes. On 02/21/2024 at 01:47 PM Resident #464 stated that she has been in the facility since February 1, 2024. They take me out every single day but, it takes very long time for them to get me out of the bed. Usually by 12:00 PM is when they get around to get me out of bed. Every single day they don't get me out of bed until 12:00 PM. Record review of the admission Minimum Data Set (MDS)/ Consolidated Appropriations Act (CAAs) dated 02/08/2024 for Resident #464 documented in Sections C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) a score of 12 out of 15 that suggests the resident is moderately impaired. Section GG for Functional Abilities and Goals indicate in ADL (activities of daily living) that the resident is dependent in all areas. On 02/21/2024 at 01:59 PM Resident #129 stated: I have been in this facility for a long time, I like to get out of my bed every day, but they take too long for them to take me out of my bed to my wheelchair. Record review of the Modification of Annual Minimum Data Set (MDS)/ Consolidated Appropriations Act (CAAs) dated 12/22/2023 for Resident #129 revealed in Sections C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 12 out of 15 to suggest the resident is suggests the resident moderately impaired. Section GG for Functional Abilities and Goals indicate functional limitation in range of motion and impaired in both sides, Wheelchair (manual or electric)-Yes. On 02/21/2024 at 08:15 AM during an interview the Maintenance Director stated that at the moment the facility has three mechanical lifts on the second floor working and five on the first floor. The facility has 12 Mechanical Lifts and 3 to stand up, in total 15. On 02/21/2024 at 08:12 AM during an interview with The Administrator revealed that the vendor that fixes the mechanical lifts came on 02/14/2024 to check on them and the facility has 15 of them, out of those 15, only 4 are not working, parts need to be replaced, and two of them need to be complete replaces. The parts were ordered, and they were expecting to receive then in the next few weeks. Record review of the order purchase of equipment revealed that the facility placed the order on 02/21/2024 at 10:06 AM, after it was brought to the administrator attention that there was some equipment not working. Record review of the Assistive Devices and Equipment Policy Statement documented: Our facility maintains and supervises the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. they may include (but not limited to): a) safety devices (grab bars, toilet rises, bedside commodes, etc.); and mobility devices (wheelchairs, walkers, and canes). Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. Device condition - devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired.

Based on interview and record review, the facility failed to implement their policy and procedures on abuse for one (Resident #1) out of one sampled resident whose abuse report was reviewed. This facility practice had the potential to have a negative impact on the health and safety of all 263 residents residing in the facility at the time of the survey. The findings included: Review of the facility's Abuse Reporting Timeline Audit revealed an abuse of unknown injury or fracture occurred on 09/25/2023. Review of Immediate Federal Report revealed the Immediate Report was completed and filed on 09/27/2023 at 8:28 PM while the administrator was notified on 09/25/2023 at 10:30 AM. Interview with the Director of Nursing (DON) on 10/05/2023 at 01:55 PM, the DON confirmed that the initial report was filed about 2 days after the alleged abuse first reported. The DON stated, The procedure is to report the incident right away. I had a case where they sent the resident to the hospital without bruises or redness. After they told me there was a fracture, I did the report. It was a teachable moment. The day I received the result that the resident had a fracture, I reported it right away, and I did a QAPI (Quality Assurance and Performance Improvement) to explain my report. We did the PIP (Performance Improvement Plan). The staff sent the resident to the hospital without mentioning it to me. Yes, the alleged abuse was on September 25, 2023 and I filed the report on September 27, 2023, but that's when I received the x-ray report. The DON reported, one of our nurses reported it to the administrator. The administrator then told our charge nurse, but she forgot to tell me. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation Policy and Procedure dated September 2022 revealed: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (Where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. Within two hours of an allegation involving abuse or result in serious bodily injury; or b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist with resident's right to vote for 1 of 1 sampled residents (Resident #225). The findings included: Record review revealed Resident #225 was admitted to the facility on [DATE]. A comprehensive assessment, dated 10/15/22, documented the resident was cognitively intact, and required extensive one-person assist with activities of daily living. An interview was conducted with Resident #225 on 11/15/22 at 12:00 PM. Resident #225 stated he had been trying to get in touch with social services for approximately two months in order to assist in voting. Resident #225 further stated he was not able to vote this past election. Resident #225 stated he was very upset, as he has not ever not voted. Resident #225 stated this needed to be fixed so as it does not happen again. A subsequent interview was conducted with Resident #225 on 11/17/22 at 9:00 AM. Resident #225 stated he had called the receptionist at the front desk several times to request to speak with social services. An interview was conducted with the receptionist on 11/17/22 at 9:15 AM. The receptionist stated residents frequently call her at the front desk in order to get in touch with dietary, a nurse, a nurse aid, or if something was broken. On admission, the residents are told to call the receptionist if they needed anything. They forward the phone call to the appropriate department or take a message. The receptionist stated she was familiar with Resident #225, as he had called before. The receptionist stated she did not recall what Resident #225 had called for. An interview was conducted with the Social Services Director and social services assistant on 11/17/22 at 10:00 AM. The Social Services Director stated the activities department was in charge of assisting residents to vote. The social services assistant stated she was not aware of Resident #225 trying to get in touch with her. The social services assistant provided documentation of last interaction with Resident #225 dated 09/08/22, concerning therapy and dietary needs. An interview was conducted with the Activities Director on 11/17/22 at 10:30 AM. The Activities Director stated she went around and asked residents who were interested in voting. The Activities Director stated the election office usually come to the facility to assist residents in voting, such as, to register, address changes, anything needed for voter registration. The Activities Director stated she called the election office and they said it was too late to come out to the facility. The Activities Director stated she was not aware of the deadline. The only way a resident could vote was by absentee ballot. If residents did not receive an absentee ballot, they weren't able to vote. The Activities Director stated Resident #225 was a resident that had expressed interest in voting. The Activities Director stated she was not aware of which residents received an absentee ballot. The Activities Director stated she assisted one resident who had received an absentee ballot who requested assistance. She did not inquire if any of the residents wanted/needed assistance with absentee ballots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and policy review, the facility failed to provide showers per resident request for 1 of 251 sampled residents screened in the initial pool (Resident #121). The findings included: The facility's policy titled Standards and Guidelines: SG Showers/Bathing issued 03/08/10 and revised 03/27/21 revealed It will be the standard of this facility to assure that showers/bathing are offered to residents at least 2 times weekly or per resident/representative preference unless specifically ordered otherwise by the physician or care planned otherwise. Refusals for showers/bathing should be reported to the licensed nursing staff . On 11/15/22 at 11:29 AM, Resident #121 was interviewed during the initial screening process. Resident #121 was observed in a hospital type gown, lying in bed. The resident stated that he would like to get dressed when he got out of bed. He also stated that he never got a shower. He was given a bed bath but would like a shower ideally everyday. Resident #121 was initially admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes, Hemiplegia, and Cerebral Infarction. His quarterly Minimum Data Set with an assessment reference date of 09/04/22 revealed his Brief Interview for Mental Status was 14 out of 15 which indicated he was cognitively intact. On 11/18/22 at 10:26 AM the resident was again observed in bed in a hospital type gown. He stated he had not had a shower since he was last interviewed and would still like to be showered. On 11/15/22 at 10:35 AM, Staff K, a Certified Nursing Assistant (CNA) was asked about the shower schedule for Resident #121. She stated that he is scheduled for a shower twice a week and she has given him showers. She also stated that if he refused, she would give him a bed bath. On 11/18/22 at 12:25 PM, this surveyor entered the resident's room with Staff H, a Licensed Practical Nurse (LPN). This surveyor asked Resident #121 with Staff H present if he had been given showers. Resident #121 stated that he has not had a shower and would like one everyday if he could. Resident #121 stated that he is fine being in bed with a hospital gown on, but when he is going to an activity he would like to be dressed. Staff H stated that she was unaware that the resident wanted a shower but was not given one. On 11/18/22 at 12:35 PM, during an additional interview, Staff K stated that she did not know that she is supposed to inform the nurse if a resident refuses a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 9 out of 36 sampled residents (Residents #11, #27, #63, #105, #129, #146, #203, #255, #459). Review of the facility's policy titled Work Orders, Maintenance with no date included the following: To establish priority of maintenance service, work orders must be filled out electronically using an online application such as TELS and forward to the Maintenance Director. It shall be the responsibility of the department directors and employees to fill out and submit work orders to the Maintenance Director. Work orders are reviewed daily. Emergency or critical work orders would be called in to the Maintenance Director. Emergency requests will be given priority. On 11/15/22 at 9:54 AM an observation of vent with missing slats coated with dust across from the shower room near the 2 South Nursing Station. On 11/15/22 at 10:15 AM an observation was made in Resident # 203's room of the floor under the air conditioning unit was black and the baseboard next to the air-conditioning unit was pushed in (Photographic Evidence Obtained), ceiling tiles near the window had stains, the main light for the room had a burnt out light bulb, the bathroom had plaster above the sink and 3 areas of mismatched paint on the walls, and part of the linoleum next to the shower was missing and concrete was showing. On 11/15/22 at 10:30 AM an observation was made in the shower room located near the 2 South Nursing Station that had black mold-like substance on the tile on the walls, loose tiles, and a hole near the shower faucet. On 11/15/22 at 10:50 AM an observation was made in Resident #105's room of the air conditioning vent dusty, and dirty with a black mold-like substance (Photographic Evidence Obtained), ceiling tiles in the bathroom stained, and just outside of the room on both sides of the door the bumper guard near the floor was missing the end piece and had sharp edges exposed. On 11/15/22 at 10:53 AM an observation was made in Resident #459's room of mismatched paint/plaster above sink and the light over the sink had no light switch or pull cord. On 11/15/22 at 10:55 AM an observation of Resident #129's room air conditioning vent was dirty and soiled with debris and dust (Photographic Evidence Obtained),baseboard located by the window were coming away from the wall (Photographic Evidence Obtained), multiple areas on the walls had plaster and mismatched paint the areas were as follows: above the head of the bed, across from the foot of the bed, and under the window (Photographic Evidence Obtained), the bathroom had stained ceiling tiles (Photographic Evidence Obtained), the floor next to the tub was missing flooring and appeared to be down to concrete (Photographic Evidence Obtained), and mismatched paint above the sink (Photographic Evidence Obtained) On 11/15/22 at 11:00 AM an observation was made in Resident #146's room of an overwhelming pungent musty mildew-like smell upon entering the room, the air conditioning vent was dirty with a black mold-like substance (Photographic Evidence Obtained), and ceiling tiles in the corner by the window were stained. On 11/15/22 at 11:35 AM an observation was made of Resident #63's bathroom with the tile around the tub having a yellow mold-like substance. On 11/15/22 at 2:08 PM an observation of ceiling vent covered with dust and debris in the hallway next to room [ROOM NUMBER]. On 11/15/22 at 4:57 PM an observation of Resident #225's room with a large gap between the air conditioning vent and the wall. On 11/16/22 at 9:00 Am an observation at 1 South Nursing Station of missing corner paneling on desk. On 11/16/22 at 11:40 AM an observation of dripping ceiling air conditioning vent by 1 South Nursing Station. On 11/16/22 at 11:45 AM an observation of broken floor near the exit door located by room [ROOM NUMBER]. On 11/16/22 at 12:00 PM an observation of dirty door that leads to the smoking patio near 1 South Nursing Station. On 11/16/22 at 1:20 PM an observation of broken door molding across from the Admissions Office near the 1 North Nursing Station. On 11/17/22 at 8:30 AM an observation was made in Resident #11's room of a missing ceiling tile behind the entrance door (Photographic Evidence Obtained), and caution tape across the shower entrance into the shower and the ceiling above the shower has a hole around a possible old light fixture with capped wires coming out (Photographic Evidence Obtained). On 11/17/22 at 8:50 AM an observation was made in Resident #27's room of a greenish-gray mold-like substance on the wall by the window (Photographic Evidence Obtained), air conditioning vent has black mold-like inside the vent (Photographic Evidence Obtained), and 2 stuffed animals on top of overbed light. During an interview conducted on 11/15/22 at 10:20 AM with Staff S Certified Nursing Assistant (CNA) when asked how long the walls have been with plaster and mismatched paint in Resident #203's room he said they were working on it this weekend. During an interview conducted on 11/15/22 at 10:23 AM with Staff W Environmental Services Housekeeper, when asked how often each room is cleaned, she stated 3-4 times a day sometimes more. When asked how often the floors are mopped, she replied at least once a day. When asked how long the linoleum has been missing from the floor in the bathroom next to the shower in Resident #203's bathroom, she said about 3 or 4 months ago when they replaced the tub with a shower. During an interview conducted on 11/17/22 at 9:00 AM with Resident #27 when asked how long the wall under the window has been discolored, she stated it started about a month ago and gets worse every time it rains. During an interview conducted on 11/17/22 at 11:05 AM with the Director of Maintenance, when asked how long he has been with the facility, he replied, he has been with the facility for 3.5 years. The maintenance department consists of himself, 2 painters and 3 maintenance staff members. He stated that all routine maintenance issues/concerns go through the TELS system (computerized reporting for maintenance issues), and all staff have access to the TELS system. They have had the TELS system since before he started working with the facility. The facility does not keep records or have access to a work order history, it will only show what issues are open. They Keep a schedule of refurbishing program for the entire facility including what has been completed each room and what needs to be done for each room. During a tour of the facility conducted on 11/18/22 at 9:00 AM with the Director of Maintenance he stated that some of the issues identified, he was not aware of. He explained that he was checking on one of his painters and discovered that they were painting rooms with mismatched paint and told the painter to stop until they had the correct color of paint to match the existing paint on the walls. During an interview conducted on 11/18/22 at 9:45 AM with the Director of Maintenance, he stated they have a restoration refurbishing program that has been in progress for 1 year, they started with the more common areas first and this included changing out the ceiling lights, ceiling tiles and painting, the rehab gym. He estimates that approximately 45-50 rooms are completed including changing tubs to flat showers, but the floors next to the new showers are not completely restored. In the process of covering the walls in the dining rooms with a paneling (FRP boards a type of paneling). He may have an issue with a maintenance staff member that needs to be a little more detailed. He stated he thinks he may need additional staff beside the 2 they just hired recently. He is the only maintenance staff that goes into the TELS system, he will assign the various issues/concerns to specific maintenance staff and prints out sheets for each individual maintenance staff member. The staff member hands this into the Director of Maintenance daily so he can keep track of what is completed and what is still outstanding. He said some staff are not computer literate and will hand him slips of paper with identified maintenance issues/concerns, he then enters them into the TELS system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to provide fingernail grooming (Resident #10 and Resident #94) to assist with dining (Resident #94) and failed to provide care and services to prevent a decline in the range of motion (Resident #117, Resident #231, and Resident #225) for 5 of 5 sampled residents for Activities of Daily Livings (ADLs). The findings included: A review of the facility's policy titled ADL Care and Assistance, revised on 03/27/21, showed that the following: each Resident will be assessed/evaluated upon admission or shortly after for their level of resident ability/function and staff assistance required to perform ADLS safely. The Minimum Data Set (MDS) assessment is an example of an assessment/evaluation of the level of resident ability/function and staff assistance required to perform ADLs. Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the Resident while ensuring the needs and desired goals. ADL assistance needs should be reflected in the person-centered plan of care. 1. In an observation conducted on 11/15/22 at 9:30 AM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. In an observation conducted on 11/15/22 at 2:00 PM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 2:00 PM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 4:00 PM, Resident #10 was noted in bed. Closer observation showed jagged, long uneven fingernails with an unidentified brown matter underneath the fingernails. Resident #10 was admitted to the facility on [DATE] with diagnoses of hyperlipidemia, depression, and mild protein-calorie malnutrition. The MDS assessment dated [DATE] showed that Resident #10 had a Brief Interview of Mental Status (BIMS) score of 03, which is severely cognitively impaired. Section G for eating showed that Resident #10 needed total assistance and one person's assist. The care plan showed that Resident #10 has a self-care deficit with dressing, grooming, and bathing, as evidenced by the need for assistance with personal care tasks and mobility skills. Cognitive deficit related to dementia, impaired mobility, and generalized weakness. The Resident participates with ADLs with cues from staff. It further showed to provide hands-on assistance with dressing, grooming, and bathing as needed. 2. In an observation conducted on 11/15/22 at 1:07 PM, the lunch tray arrived for Resident #94 and was placed on her side table. Staff left the tray at the bedside and walked out to help pass other lunch trays. At 1:15 PM, Resident #94's tray was about 5% consumed, and no staff was noted in the room assisting her with the lunch meal. Continued observation at 1:29 PM showed that Resident #94's tray was left 95% untouched. In an observation conducted on 11/15/22 at 1:07 PM, Resident #94 was noted in her room. Closer observation showed long-jagged fingernails with unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 9:40 AM, Resident #94 was noted in her room. Closer observation showed long-jagged fingernails with unidentified brown matter underneath the fingernails. In an observation conducted on 11/17/22 at 9:10 AM, Resident #94 was noted in her room. Closer observation showed long-jagged fingernails with unidentified brown matter underneath the fingernails. In an observation conducted on 11/16/22 at 9:40 AM, Resident #94 was noted in her room with the breakfast tray in front of her. She was observed eating one tablespoon of the eggs, but everything else on the tray was untouched. The closer observation did not show any staff in the room assisting her with her breakfast meal. At 9:50 AM, the tray was taken out of her room. In an observation conducted on 11/17/22 at 9:10 AM, Resident #94 was noted in her room with the breakfast tray on the side table, and the Resident was noted asleep. At 9:30 AM, Resident #94 was awake, but the breakfast tray was untouched. A review of the chart showed that #94 was readmitted on [DATE] with diagnoses of acute respiratory failure, type 2 diabetes, and dementia. A review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #94 is cognitively severely impaired. Under section G for eating, it showed that Resident #94 is for supervision with set up only. The care plan showed that Resident #94 has a self-care deficit with dressing, grooming, and bathing, as evidenced by the need for assistance with personal care tasks and mobility skills. Cognitive deficit related to impaired mobility, generalized weakness, and limited endurance. It further showed to assist with nail shaping, keep nails short and clean and provide hands-on assistance with dressing, grooming, and bathing as needed. In an interview conducted on 11/17/22 at 11:43 AM, Staff F, a Licensed Practical Nurse (LPN), stated that the fingernail grooming is done by the Certified Nurse Assistance that is assigned to the Resident. It is usually done during daily care or as needed. In an interview on 11/17/22 at 11:46 AM, Staff G, a Certified Nursing Assistant, stated that activities usually involve fingernail grooming. If the Resident stays in bed and does not attend activities, she will do the fingernail grooming as needed as part of her daily care. In this interview, the surveyor asked Staff G to accompany her to Resident #94's room. Staff G was asked if she thinks Resident #94's fingernails needed grooming and cleaning, and Staff G said yes. When asked why it was not done, Staff G stated that Resident #94 does not like her fingernails trimmed. When asked if it is documented in the electronic charting or in the daily care notes, Staff G said no. Staff G then stated, let me do it now and see if Resident #94 will let me trim and clean her fingernails. Continued observation showed that with some encouragement, Resident #94 allowed Staff G to trim and cut her fingernails. 3. A review of the facility's policy Standards and Guidelines: Restorative Nursing Program, dated 12/01/16, and revised 03/27/21, documented: It will be the standard of this facility to provide restorative nursing services to residents that require them to attempt to maintain or improve function or as ordered by the physician. Restorative Programs include Range of motion (active and passive), splint or brace assistance, bed mobility, transfers, walking, dressing and/or grooming, communication, amputation/prosthesis care, or eating and/or swallowing. Record review revealed Resident #225 was admitted to the facility on [DATE]. A comprehensive assessment, dated 10/15/22, documented the resident was cognitively intact, and required extensive one-person assist with bed mobility. The assessment further documented transfers out of bed did not occur. Resident #225 was care planned for participating in restorative nursing program. Interventions included to provide restorative programs/interventions as ordered/indicated and refer to therapy as necessary. Resident #225 was further care planned for at risk for falls related to weakness, immobility, and generalized muscle weakness and impaired balance related to muscle wasting. Interventions included staff to assist with transfers, and to utilize mechanical lift with assist of 2 for transfers. A review of Resident #225's orders revealed an order dated 07/08/22; May participate in restorative program as needed and as tolerated. An interview was conducted with Resident #225 on 11/17/22 at 9:00 AM. Resident #225 stated he does not get therapy. Resident #225 further stated he does not get out of bed. He was told he could not get out of bed due to the wounds on his buttocks. A review of Resident #225's records did not reveal any documentation of the resident need to stay in bed. A review of the resident's wound care notes documented the resident up to chair with cushion. An interview was conducted with Staff T, a Registered Nurse, on 11/17/22 at 1:00 PM. Staff T stated she was not aware Resident #225 did not get out of bed. Staff T further stated the resident's wounds were improved. A side-by-side interview was conducted with Resident #225 by Staff T and surveyor on 11/17/22 at 1:30 PM. Resident #225 stated he had not been out of bed to a chair since admission to the facility. Resident #225 further stated he was going out of his mind just lying there. An interview was conducted with the Director of Rehabilitation on 11/18/22 at 9:00 AM. The Director stated Resident #225 had received occupational therapy from 09/14/22-10/12/22, working on bed mobility. The Director stated he was told verbally by wound care not to get Resident #225 up to chair. The Director acknowledged no documentation for the resident to not get up to chair. The Director further acknowledged the weekly wound care notes for Resident #225 documented up to chair with cushion. An interview was conducted with Staff E, Restorative Aid, on 11/18/22 at 10:00 AM with the Director of Rehabilitation present. Staff E stated Resident #225 refused restorative therapy. Staff E acknowledged there was no documentation of resident #225 refusing restorative care. An interview was conducted with Resident #225 on 11/18/22 at 10:30 AM with the Director of Rehabilitation and Staff E. Resident #225 again stated he had not received any kind of therapy and was just wasting away in bed. The Director of Rehabilitation stated they would get Resident #225 out of bed to a chair and would evaluate for therapy services. An observation of Resident #225 was conducted on 11/18/22 at 12:00 PM. Resident #225 was observed sitting up in a high back chair in his room. Resident #225 looked at surveyor and said: Thank you, thank you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess for safety of smoking for 1 of 2 sampled residents (Resident #217). The findings included: A review of the facility's policy Safe Smoking, dated 10/01/2004, and revised 03/27/21, documented: Electronic vapor cigarettes will be addressed and accommodated per the same guidelines as for actual cigarettes. A safe Smoking Screen is performed on admission for a resident who wishes to smoke. Resident #217 was admitted to the facility on [DATE]. An admission comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required limited to extensive one to two-person assist with activities of daily living. The assessment further documented the resident did not use tobacco. Record review revealed a care plan dated 11/15/22, documented Resident #217 desires to smoke. Resident has been assessed as able to smoke independently. A review of a Smoking Evaluation form dated 11/14/22 revealed the document was not completed/blank for Resident #217. An interview was conducted with Resident #217 on 11/18/22 at 9:00 AM. The resident stated will go out to smoke around 11:00 AM. An interview was conducted with the Unit Manager (UM) on 11/18/22 at 9;30 AM. Surveyor questioned the UM if Resident #217 was evaluated for safe smoking. The UM stated he would get back to me. On 11/18/22 at 12:00 PM, the UM approached surveyor and stated Resident #217 did not smoke. Surveyor, accompanied by the UM went to the patio. Resident #217 was observed smoking an electronic cigarette.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to assess for removal of indwelling urinary catheter when clinical condition demonstrates that catheterization is not necessary for 1 of 2 sampled resident for indwelling urinary catheter (Resident #212 and #194). The findings included: Review of the facility's policy titled, Standards and Guidelines: SG (Standards and Guidelines) Indwelling Catheters, with a revised date of 03/27/21, included the following: It will be the standard of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Under Guidelines included: 1. Indication for Indwelling Catheter use: Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible. Contamination of Stage III or IV pressure ulcers (or greater) with urine which has impeded healing. Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain. 2. Information of the indication of use should be supported in the clinical record for use of indwelling catheters exceeding 14 days. 3. An indwelling catheter that does not fall into one of the supporting categories above should be discontinued and removed. 14. Use of the indwelling catheter should be reflected in the resident-centered plan of care. Review of the facility's policy titled, Standards and Guidelines: Prevention of Catheter Associated Urinary Tract Infections (CAUTIs), with a revised date of 03/27/21, included the following: It is the policy of this facility that indwelling catheters are only utilized with written rationale for the use, consistent with evidence-based guidelines (e.g., acute urinary retention, bladder outlet obstruction, neurogenic bladder or terminally ill for comfort measures). Under Guidelines included: 1. Catheters are removed as soon as possible and are not used for the convenience of resident care personnel. 2. Intermittent catheterization should be used rather than indwelling catheter whenever possible. Under Catheter Insertion and Care included: 9. Recognize and assess for complications and their causes. Maintain a record of any catheter-related problems. 10. Attempt to remove the catheter as soon as possible when no indications exist for its continuing use. On 11/15/22 at 1:50 PM an observation was made of Resident #212 having an indwelling catheter in a privacy bag hanging on the side of the bed. Record review for Resident #212 revealed the resident was admitted to the facility on [DATE] and included the following diagnoses: Encounter for Attention to Tracheostomy, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Morbid (Severe) Obesity, Epilepsy, Other Acute Kidney Failure, and Personal History of Other Malignant Neoplasm of Bronchus and Lung. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #212 had a Brief Interview for Mental Status of 15, which indicated that she had an intact cognitive response. Review of Section G of the MDS dated [DATE] revealed that Resident #212 had a bed mobility, dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of 1-person physical assistance, transfer self-performance of activity did not occur with support of ADL (Activity of Daily Living) activity itself did not occur. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 for catheter care q shift (every shift) with an end date of 09/13/22. . Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 to change catheter drainage bag as needed for leaking or cloudiness with an end date of 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 to change indwelling catheter for leakage or blockage with an end date of 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 to insert/maintain indwelling catheter (16 French) with an end date of 08/17/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/17/22 to insert/maintain indwelling catheter (16 French) for Dx (Diagnosis) Sacrum Ulcer Stage 4 with an end date 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 09/13/22 to insert/maintain indwelling catheter (20 French) for Dx Retention of Urine with end date of 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 11/16/22 to D/C (Discontinue) [] catheter and monitor for voiding one time a day for no criteria for use. Review of the Comprehensive Nursing Evaluation for Resident #212 dated 08/16/22 revealed under Section 9. Skin Integrity included the following: Sacrum scars, Left thigh (rear) redness, Abdomen surgical scars, other discoloration of the legs, Other fragile skin. Under Section 12. Genitourinary/ Gastrointestinal/ Reproductive included the following: Urinary Device Use: [indwelling urinary catheter]. Review of the Daily Skilled Note for Resident #212 dated 08/17/22 revealed under Systems - Genitourinary urinary device in use [] left unchecked. Under Systems - Resident response to treatments and Additional Comments included [] catheter in place no s/s (signs and/or symptoms) of bleeding or infection. Review of the Skin & Wound - Total Body Skin Assessment for Resident #212 dated 08/17/22 revealed the number of new wounds was 0. Record review of nursing documentation for Resident #212 08/17/22 to 08/30/22 does not reveal any documentation of the resident having an indwelling urinary catheter, or an indwelling urinary catheter removal, insertion, assessment, or catheter care provided. Review of the Daily Genitourinary Skilled Note for Resident #212 dated 08/31/22 revealed under Systems - Genitourinary included the following: Urinary device in use: Has [] catheter. Nursing interventions: Irrigated catheter per orders. Catheter care provided. Incontinence care provided. Review of the Narrative Nurses note for Resident #212 dated 09/13/22 with an effective date of 09/12/2022 included: Noticed [] catheter came out from patient. Called the doctor to notify him of the status of the catheter. The doctor advised to reinsert the catheter. Verified the catheter size and proceed to reinsert a new catheter. At this time there is no leakage and catheter placement has been verified. Review of the Daily Skilled Note for Resident #212 dated 09/13/22 revealed under Systems - Genitourinary Urinary device in use: has a [] catheter, urinary device is patent and draining; free from complications. Review of the Daily Skilled Note for Resident #212 dated 09/14/22 revealed under Systems - Genitourinary Urinary device in use: has a [] catheter. Complications related to urinary device included: Urinary device is patent and draining free from complications and Complications with urinary device observed (but not further described). Interventions included: Catheter care provided. Incontinence care provided. Review of the Care Plan for Resident #212 with initial date of 08/30/22 and a most recent revised date of 11/17/22 that had a focus on The resident has an alteration in elimination AEB (As Evidenced By): is incontinent of bowel and bladder; impaired mobility r/t (related to) Diagnoses (Dx): Morbid Obesity, and Kidney Failure, requires staff assist with toileting/incontinence care needs, is at risk for constipation r/t impaired mobility. Goals included: Resident will be clean, dry, and odor free daily thru the next review date. Resident will have adequate bladder function thru catheter and will remain free from complications r/t use of device thru the next review date. Resident will remain free from sx/sx (signs and symptoms) of UTI (Urinary Tract Infection) thru the next review date. Resident will have a regular bowel movement at least q (every) 3 days thru the next review date. The interventions included: Administer medications as ordered; observe for effectiveness and for SEs (side effects). Check resident upon arising, and at HS (hour of sleep) for incontinence; perform incontinence care prn (as needed). Observe for sx/sx of UTI; report to physician if noted. Observe for the presence of stool, amount of stool, color and consistency that might indicate constipation/infection. Labs as ordered, report results to physician. Schedule urology appointments as needed. Observe for changes in bowel/bladder function; update physician if noted. During an interview conducted on 11/17/22 at 8:10 AM with Staff X Registered Nurse Unit Manager, when asked what time is good to schedule observation of catheter care for Resident #212, she stated that the catheter had been discontinued and removed last night (11/16/22). Staff X went on to say that when a resident was admitted with an indwelling catheter; they verify if the resident meets criteria and if not, they get an order to have the catheter removed, the resident does not meet criteria at this time, so it was removed. During an interview conducted on 11/17/22 at 8:20 AM with the Director of Nursing (DON), she approached surveyor to inform that when a resident is admitted with an indwelling catheter they check to see if the resident meets criteria to have an indwelling catheter (i.e., Stage IV sacral wound). During an interview conducted on 11/17/22 at 4:50 PM, Staff U Registered Nurse (RN) was asked about Resident #212's indwelling urinary catheter, Staff U revealed that the indwelling urinary catheter was discontinued yesterday (11/16/22). She added that she took it out in the morning, and she documented it in the progress notes. During an interview conducted on 11/17/22 at 4:55 PM with Staff V float Certified Nursing Assistant (CNA) when asked when she last took care of Resident #212, she stated about 2 weeks ago. When asked if she remembered if the resident had an indwelling urinary catheter, she said yes. During an interview conducted on 11/18/22 at 9:00 AM with Staff X Registered Nurse Unit Manager, regarding the indwelling urinary catheter for Resident #212, she stated that she had misunderstood about the discontinued date for the indwelling urinary catheter for Resident #212, and it was discontinued on 08/16/22 not 11/16/22. Surveyor informed Staff X Registered Nurse Unit Manager that an indwelling urinary catheter had been observed by the surveyor on 11/15/22 and during an interview with Staff U Registered Nurse (RN) she had stated that she removed the indwelling urinary catheter for Resident #212 on 11/16/22. Staff X Registered Nurse Unit Manager insisted that Resident #212 did not have an indwelling urinary catheter and has not had one since it was discontinued/removed on 08/16/22. During an interview conducted on 11/18/22 at 10:30 AM with the Director of Nursing (DON), she stated that Resident #212 was admitted to the facility on [DATE] with an indwelling urinary catheter. When a resident is admitted with an indwelling catheter and there is no reason for the catheter, it is removed per facility protocol/policy. No physician order is needed to remove the indwelling urinary catheter since this is their protocol/policy. The DON stated that on 08/17/22 the indwelling urinary catheter for Resident #212 was removed. She acknowledged that the nurse removing the indwelling urinary catheter should document that the indwelling urinary catheter was removed and there was no documentation that the indwelling urinary catheter was removed for Resident #212. The DON stated that on 09/13/22 staff entered an order to insert indwelling urinary catheter for Resident #212, and then entered an order to discontinue the indwelling urinary catheter the same day (09/13/22). The DON then changed her statement and said that the indwelling urinary catheter that Resident #212 was admitted with (on 08/16/22) was never removed as it should have been as per their facility protocol on 08/17/22. She also stated that there was an order dated 08/17/22 to discontinue the indwelling urinary catheter and again stated that the indwelling urinary catheter was not removed from the resident per physician order and their protocol. The DON stated that on 09/12/22 the indwelling urinary catheter came out of Resident #212 per nursing documentation and the nurse documented that she obtained an order to reinsert the indwelling urinary catheter on 09/13/22. 2. Resident #194 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required supervision with set-up help only for activities of daily living. The resident was always continent of bladder. Record review revealed Resident #194 was transferred out to the hospital on [DATE] for a fall with injury. Resident was readmitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident required extensive two-person assist for bed mobility and had an indwelling catheter (urinary catheter). Resident #194 was care planned for alteration in elimination, requires staff assist with toileting, continent of bladder due to [brand] indwelling urinary catheter, dated 10/29/22. Reason was documented as urinary retention. A review of Resident #194's orders revealed an order dated 11/14/22 to insert/maintain indwelling catheter for a diagnosis of BPH (enlarged Prostate). An interview was conducted with Staff T, Unit Manager, on 11/17/22 at 1:20 PM. Staff T stated Resident #194 had an indwelling urinary catheter due to urinary retention from the hospital. Staff T acknowledged Resident #194 did not require an indwelling urinary catheter prior to hospitalization. Staff T further acknowledged there was no urologist consult for Resident #194 or attempts to discontinue the indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's policy titled Standards and Guidelines: Weighing/Weight Loss Protocol, revision date 03/05/21 revealed the following: New admits and readmissions will be weighed upon within the first ten days, monthly and/or as ordered by the physician. Monthly weights will be completed by the nursing department. Weekly and daily weights may be obtained per RD [registered dietitian] or physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention. An interview was conducted on 11/16/22 at 4:35 PM with Staff P, Registered Dietitian and Staff O, Corporate Dietitian. Staff P stated she documents the assessments on all of the high-risk residents and the admissions; she clarified that a high-risk resident is any resident on dialysis or tube feeding. Staff P said Staff C, Registered Dietitian works part time and documents the quarterly assessments on any resident who is not considered to be high-risk. When asked how quickly she must do her initial assessment on newly admitted residents, Staff P stated, it depends on how long it takes for the CNAs to do the weights; but that she has a maximum of seven days to document her initial assessment. Staff O stated it takes an average of three to four days for the Certified Nursing Assistants (CNAs) to obtain a resident's initial weight after admission and that it could take longer if a resident is admitted over a weekend. An interview was conducted on 11/16/22 at 4:54 PM with the facility's DON. She stated there is a Restorative CNA who is responsible for obtaining resident's weights. When asked who documents the resident's weights in the computerized chart, she stated the weights are documented by either herself or her assistant. She said when a resident is readmitted to the facility, the resident is weighed per facility policy-an initial weight is obtained, then weekly weights for three weeks, then the resident is changed to monthly weights if there are no concerns. 2) During the initial tour of the facility conducted on 11/15/22 at 11:36 AM by a fellow surveyor, it was noted that Resident #40 had suffered weight loss. Resident #40 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #40 had a medical history significant for a brain injury, falls, high blood pressure, Schizophrenia, and psychosis. A Quarterly Minimum Data Set (MDS) was completed on 10/09/22. This MDS documented Resident #40 had a Brief Interview of Mental Status (BIMS) score of 6, which indicates Resident #40 had moderate cognitive impairment. Resident #40 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no admission weight obtained until 01/19/22. Review of Resident #40's physician orders revealed there was an order written on 11/22/21 for Obtain weight upon admission then weigh weekly x 4 and then weigh monthly. An admission Dietary Profile was documented on 11/23/21. Under the section titled Dietary Narrative Note, the dietitian wrote, last weight obtained was 227.6 pounds on 10/13/21. This indicated the dietitian used a weight that was more than one month old for her initial assessment when Resident #40 was readmitted to the facility. 3) During the initial tour of the facility conducted on 11/15/22 at 10:25 AM by a fellow surveyor, it was noted that Resident #128 appeared thin. Resident #128 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #128 had a medical history significant for Alzheimer's, falls, depression, and a swallowing disorder. An admission Minimum Data Set (MDS) was done 09/05/22. This MDS documented Resident #128 had a Brief Interview of Mental Status (BIMS) score of 99, which indicates Resident #128 had severe cognitive impairment. Resident #128 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no admission weight obtained until 09/12/22. Review of Resident #128's physician orders revealed there was an order written 08/29/22 for Obtain weight upon admission then weigh weekly x 4 and then weigh monthly. An admission Dietary Profile was documented on 09/08/22. Under the section titled Weight, the dietitian wrote, 98.6 pounds (07/15/22). This indicated the dietitian used a weight that was more than one month old for her initial assessment when Resident #128 was readmitted to the facility. 4) During the initial tour of the facility on 11/15/22 at 10:30 AM conducted by a fellow surveyor, it was noted that Resident #54 appeared thin. Resident #54 was admitted to the facility on [DATE]. Resident #54 had a medical history significant for a stroke, a swallowing disorder, respiratory failure, seizures, high blood pressure, and muscle weakness. A Quarterly Minimum Data Set (MDS) was completed on 10/28/22. This MDS documented Resident #54 had a Brief Interview of Mental Status (BIMS) score of 99, which indicates Resident #54 had severe cognitive impairment. During the initial record review, it was noted by the surveyor that Resident #54 was admitted from the hospital on [DATE], but no admission weight was obtained until 08/01/22. An Initial Nutrition Risk Evaluation was documented on 07/26/22. Under the section titled Comments, the dietitian wrote, Weight record from [NAME] 05/03/22: 128 pounds. This indicated the dietitian used a hospital weight from more than two months prior to the documented initial assessment. Further review of Resident #54's record revealed there were no Dietary Profiles documented after the Initial evaluation on 07/26/22. An interview was conducted with Staff C, Registered Dietitian on 11/17/22 at 12:52 PM. Staff C independently reviewed Resident #54's chart and agreed that a Quarterly Assessment should have been documented in October. Based on interviews, observations, and record review, the facility failed to provide nutritional assessments in a timely manner and failed to ensure the accuracy of admission/monthly weights for 4 of 8 residents reviewed for nutrition (Resident #94, Resident #40, Resident #128, and Resident #54). The findings included: 1. In an observation conducted on 11/15/22 at 1:07 PM, the lunch tray arrived for Resident #94 and was placed on her side table. Staff left the tray at the bedside and walked out to help pass other lunch trays. At 1:15 PM, Resident #94's tray was about 5% consumed, and no staff was noted in the room assisting her with the lunch meal. Continued observation at 1:29 PM showed that Resident #94's tray was left 95% untouched. In an observation conducted on 11/16/22 at 9:40 AM, Resident #94 was noted in her room with the breakfast tray in front of her. She was observed eating one tablespoon of the eggs, but everything else on the tray was untouched. The closer observation did not show any staff in the room assisting her with her breakfast meal. At 9:50 AM, the tray was taken out of her room. In an observation conducted on 11/17/22 at 9:10 AM, Resident #94 was noted in her room with the breakfast tray on the side table, and Resident #94 was noted asleep. At 9:30 AM, Resident #94 was awake, but the breakfast tray was untouched. A review of the chart showed that Resident #94 was readmitted on [DATE] with diagnoses of acute respiratory failure, type 2 diabetes, and dementia. A review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #94 is cognitively severely impaired. Under section G for eating, it showed that Resident #94 is for supervision with set up only. The care plan showed that Resident #94 is at risk for an alteration in nutrition and hydration related to muscle wasting/atrophy, eating disorder, heart failure, dysphagia, cognitive communication deficit, and a history of being underweight. She requires a mechanically altered diet and requires assistance to complete meals at times. A dietary progress note dated 08/04/22 showed that Resident #94 would receive a house supplement three times a day to increase the nutritional density of intake. A review of Resident #94's weights showed the following: a weight of 106.7 pounds on 09/12/22, a weight of 110 pounds on 10/10/22, and a weight of 108.4 pounds on 11/16/22. A Dietary profile dated 10/20/22 showed the following: Resident #94 is on a Pureed diet with a good intake of meals. Her weight was documented at 110 pounds. It further showed that Resident #94 is eating 75% to 100% of her meals and is at risk for unintended weight loss. Resident #94 needs total assistance with eating. The Certified Nursing Assistants' intake of meals showed that on 11/16/22, Resident #94 ate 75-100% of her breakfast meal and not the 10% or less she ate during the Surveyor's observation. (Photographic evidence obtained). It was also documented that for lunch on 11/16/22. She ate 75-100% of her breakfast meal and not the 10% or less she ate during the Surveyor's observation. (Photographic evidence obtained). In an observation conducted on 11/17/22 at 11:20 AM, Staff D and Staff E, Restorative Certified Nursing Assistants, were asked by surveyor to take a new weight recording on Resident #94. Using a mechanical lift, the first recorded weight showed that Resident #94 was at 100.2 pounds, and the second recorded weight showed that Resident #94 was at 99.8. This showed a significant discrepancy in weight from 108.2 pounds on 11/16/22 to 99.8 pounds a day after. This showed that Resident #94 had a weight loss of about 10 pounds in one month. Staff E stated that he was taught how to use the mechanical lift but was still determining if it was the correct way to obtain accurate weight on residents. A review of the mechanical lift direction of use showed that the method that Staff E and Staff D used to take the weights on Resident #94 in the past before 11/17/22 was incorrect and did not follow the recommended instructions for use. In an interview conducted on 11/17/22 at 12:00 PM with Staff C, the Registered Dietitian stated that she questioned some weight discrepancies in the past but was unsure why. Staff C further acknowledged all findings.

Based on record review, observations and interviews, the facility failed to provide proper tracheostomy care for 1 of 1 resident reviewed for tracheostomy care, Resident #212. The findings included: Review of the facility's written procedure titled Trach Care Competency Check List, undated, revealed the following: Apply sterile gloves. The dominant hand will remain sterile. With non-dominant hand, remove oxygen source. Then unlock and remove inner cannula. Place tracheostomy collar over outer cannula. Quickly clean the inside and outside of the inner cannula with brush. With sterile gloved hand, replace inner cannula and lock in place. Replace tracheostomy collar. Observation of tracheostomy care on 11/18/22 at 10:10 AM for Resident #212. The surveyor obtained consent from the resident prior to the start of tracheostomy care. The staff members involved in Resident #212's tracheostomy care were Staff L, Respiratory Therapist, Staff M, Respiratory Therapist, and Staff N, Respiratory Nurse. The surveyor asked Staff L who normally performs tracheostomy care and respiratory medication treatments for the residents. Staff L stated it is always the respiratory therapists who perform these tasks, not the nursing staff. Prior to entering the room, Staff L, Staff M, and Staff N donned isolation gowns; they each already had masks and shields on their faces. Upon entering the room, the surveyor noted there were tracheostomy care supplies present on a bedside table inside the room, wrapped in a bag. Staff L stated they had gathered these supplies. The surveyor asked Staff L to list the supplies on the table. Staff L stated there was a package of gauze, a split gauze (a special gauze pad which is manufactured with a cut down the middle so it can safely fit around the tracheostomy without obstructing the resident's ability to breath properly), inner cannula (which fits inside the tracheostomy tube), normal saline solution, and a new tracheostomy collar (a fabric device which holds the tracheostomy in place in the resident's neck). Staff L and Staff M washed their hands and donned gloves. Staff L then cleaned his stethoscope with an alcohol swab and Staff M cleaned a pulse oximeter(to check Resident #212's oxygen level) with an alcohol swab. Staff L wrapped the end of his stethoscope in a surgical (non-sterile) glove and listened to the resident's lung sounds. Staff M checked Resident #212's oxygen level-it was 95% at 10:30 AM. Staff L then washed his hands and changed his gloves, donning surgical gloves. Staff L then removed the old gauze from under Resident #212's tracheostomy at 10:32 AM. Staff L said Resident #212 needed to be suctioned but noted he did not have a suction catheter kit available in the room. Staff N left the room and obtained a suction catheter kit at 10:33 AM. Staff L washed his hands and changed his gloves, donning 1 surgical glove and 1 sterile glove, and removed the tracheostomy mask (the device that delivers oxygen into the tracheostomy). Staff L then suctioned Resident #212's tracheostomy one time at 10:36 AM. The tracheostomy mask was left off at this time. Staff M washed her hands and donned new gloves. Staff M poured normal saline solution into a sterile container so Staff L could flush the suction tubing. The tracheostomy mask was placed back on the tracheostomy site at 10:40 AM. Staff L and Staff M washed their hands and donned new surgical gloves. Staff L removed the tracheostomy mask from the tracheostomy site and removed the old inner cannula at 10:42 AM. The tracheostomy mask was left off at this time. Staff L washed his hands and donned new surgical gloves. Staff L then removed the new sterile inner cannula from its packaging and told the surveyor that, since he would not be touching the sterile end of the inner cannula that he did not need to wear sterile gloves for this part of the procedure. Staff L then placed the new inner cannula with the non-sterile gloves at 10:45 AM. The tracheostomy mask was placed back on the tracheostomy site at this time. Staff L washed his hands and donned surgical gloves. Staff L then opened a kit containing sterile gauze and sterile gloves. Staff M washed her hands and donned surgical gloves. Staff L dumped the contents of the kit onto a sterile cloth and Staff M poured normal saline solution into a sterile box. Staff L soaked gauze in the normal saline solution and used this to clean the skin around the tracheostomy site at 10:50 AM. Staff L and Staff M removed the old tracheostomy collar and placed a new tracheostomy collar at 10:52 AM. Staff L placed a new split gauze under the tracheostomy site at 10:57 AM and then placed extra gauze around the site to keep Resident #212's clothes clean from secretions. The surveyor found the use of surgical (non-sterile) gloves during the changing of the tracheostomy inner cannula to be an issue during this observation of tracheostomy care. There were also two instances lasting three to four minutes each where Resident #212's oxygen was left off during the tracheostomy care. Both issues go against the facility's procedure for tracheostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow infection control guidelines as per Centers for Disease Control and Prevention (CDC) recommendations during the disconnection of dialysis treatment for 1 of 1 Resident Observed during dialysis (Resident #8). The findings included: A review of the Centers for Disease Control and Prevention (CDC) recommendations, titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, Showed the following: Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. https://www.cdc.gov/hicpac/recommendations/core-practices.html#anchor_1556561902. A record review showed that Resident #8 was admitted on [DATE] with a heart failure end-stage renal disease diagnosis and is dependent on renal dialysis. Further review showed an order for In House Dialysis on Monday, Wednesday, and Friday dated 11/08/22. In an observation conducted on 11/16/22 at 12:16 PM in the dialysis treatment room, Resident #8 was getting ready to be disconnected from her dialysis treatment via Central Venous Catheter (CVC). Staff A, a Registered Nurse (RN), was observed with clean gloves touching the dialysis machine and then touching Resident # 8's bloodlines with the same gloves. She touched the dialysis machine again, removed her gloves, and practiced hand hygiene before placing on a new pair of gloves. Staff A touched the dialysis machine again and then handled Resident #8's bloodlines with the same dirty gloves. Staff A removed her dirty gloves, picked a new pair of gloves, placed them down on the glove box, practiced hand sanitation, and lifted the same pain of gloves again. She continued touching Resident #8's bloodlines. She repeated that same routine, touching the cleaned glove, placing them down, sanitizing her hands, and putting the same clean gloved back on before touching Resident #8's bloodlines. In an interview conducted on 11/16/22 at 12:40 PM, Staff B, Registered Nurse Dialysis Supervisor, stated that she noticed that Staff A removed her dirty gloves, picked a new pair of gloves, placed them down on the glove box, practiced hand sanitation, and lifted the same pain of gloves again before touching Resident #8's bloodlines. She said that she would have to reeducate Staff A on this infection control practice to ensure she did not repeat the same mistake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to secure unattended medications in the medication refrigerator for 1 out of 8 nursing stations, the facility failed to properly secure medication and treatment carts for 2 out of 16 carts, the facility failed to ensure proper disposal of medications during 1 medication administration observation. The findings included: Review of the facility's policy titled Standards and Guidelines: Medication Storage, revised 10/24/22, revealed the following: The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals. Compartments containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view. Medications will be destroyed following FDA, State and Local requirements. Review of the facility's policy titled Standards and Guidelines: Medication Documentation, revised 03/03/21, revealed the following: For routine disposition, facility is required to utilize a chemical dissolution drug disposal system which is safe and minimizes environmental impact. Facility should adhere to the use and container disposal instructions provided with the disposal system. 1) An observation was made on 11/17/22 at 8:20 AM with Staff F during a medication administration observation. The resident had refused her Iron Sulfate tablet during the medication administration. Staff F left the medication in a medication cup and took it back to the medication cart. Once at the cart, she poured five milliliters of water into the cup that contained the Iron tablet. She stated the water was to help soften the pill. After two minutes, Staff F then poured the water into the trash can and disposed the tablet into the sharp's container on the side of the medication cart. 2) An observation was made on 11/16/22 at 10:55 AM while entering room [ROOM NUMBER], the surveyor noted a medication cart outside the room was unlocked. The surveyor turned to obtain photographic evidence of the unlocked cart, but a passing staff member locked the cart before a picture could be taken. 3) An observation was made on 11/18/22 at 7:06 AM while entering the facility, the surveyor noted an unlocked treatment cart next to the 2 North nurse's station. A second observation was made at 7:27 AM of this treatment cart in the same location, still unlocked. The surveyor alerted Staff Z, who was in the nurse's station and confirmed that it was her treatment cart. Staff Z promptly locked the cart after the surveyor intervened. 4) On 11/15/22 at 10:00 AM an observation was made of a locked medication refrigerator located at the 2 South Nursing Station. Staff T Registered Nurse (RN) Nurse Manager unlocked the medication refrigerator for surveyor to review for any expired medications. Staff T Registered Nurse (RN) Nurse Manager then walked away, completely out of the sight of the surveyor and the unlocked medication refrigerator. During an interview conducted on 11/15/22 at 10:05 AM with Staff T Registered Nurse (RN) Nurse Manager when asked why she walked away from the unlocked medication refrigerator, she said I was just putting something away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to honor the residents food preferences, and food intolerances for 3 of 3 residents reviewed for foods (Resident #189, Resident #192, and Resident #100). The findings included: In an observation conducted on 11/15/22 at 9:00 AM, Resident #189 was in the room when his breakfast tray arrived. The tray was noted with over easy-cooked eggs, sausage patty, and a large piece of bread approximately 3 inches long. Closer observation showed a Regular carton of 2% milk and 8 ounces of juice. The meal ticket on the tray showed that Resident #189 was lactose intolerant and liked Sunnyside-up eggs. In this observation, Resident #189 stated that he did not like how they cooked his eggs and wanted his eggs sunny side up. He pointed to the Regular milk and said that he was lactose intolerant and that they always make a mistake and bring him Regular milk. He then picked up the large piece of bread on his tray and said, see, it is hard as a rock. In an observation conducted on 11/16/22 at 9:25 AM, Resident #189 was eating his breakfast. Closer observation showed that his tray had Regular 2% milk, scrambled eggs, and a biscuit. The meal ticket on the tray showed to provide lactose intolerance milk when available. In an observation conducted on 11/18/22 at 1:00 PM, Resident #189 was in his room with a lunch tray that had another resident's meal ticket. In this observation, Resident #189 stated that they gave him the wrong tray and proceeded to call staff to let them know. A chart review showed that Resident #189 was admitted on [DATE] with diagnoses of type 2 diabetes and sleep apnea. An order was noted for a Regular texture diet dated 08/11/21. The Minimum Data Set (MDS) dated [DATE] showed that Resident #189 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. In an interview conducted on 11/15/22 at 11:00 AM with Resident #192, he stated that he asked in the past to be placed on a low-diet meal, but they keep bringing him the same food choices that his roommate gets. He further said that the kitchen always sends foods that he likes and that they never honor his food preferences. Resident #192 said that there are fruit flies in his room daily and that he told them about it, but nothing has been done. A chart review showed that Resident #192 was admitted on [DATE] with diagnoses of diabetes, morbid obesity, and kidney failure. The order was noted on 12/21/21 for a No Added Salt, Controlled Carbohydrate diet. The MDS dated [DATE] showed that Resident #192 had a BIMS score of 15 out of 15, which is cognitively intact. In an interview conducted on 11/15/22 at 10:10 AM with Resident #100, he stated that the facility's food is not good and that it is always cold. They never honor his food choices and that they make mistakes on his tray all the time. A review of the MDS dated [DATE] showed that Resident #100 had a BIMS score of 15 out of 15, which is cognitively intact. An interview conducted on 11/18/22 at 10:03 AM with the facility's Food Service Director stated that she recently made changes to the menu selection and that they are in the process of making changes. She further stated that they have been short staff in the kitchen for some time and have many new staff members who are still learning the process. Therefore, she is on the tray line herself daily. According to her, one person on the tray line is assigned to ensure that the food on the tray is the same as the prescribed diet and food preferences.

Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety, which included: failure to maintain sanitary conditions in the main kitchen, failure to date and label all food items, and failure to dispose of expired foods, in the central kitchen. The findings included: In a tour conducted on 11/15/22 at 8:30 AM in the main kitchen, the following was noted: In the dry storage area, 12 bottles that were 46 ounces each of Cranberry juice had a used-by date of 08/16/22, which expired over three months (photographic evidence obtained). In the dry storage area, five large, dented cans were 6.56 pounds each (photographic evidence obtained). The dry storage area's floor was noted with debris and dirt. One large garbage can was pointed out with the lid wholly opened and empty food boxes near it (photographic evidence obtained). A large Thickener bin was noted with the scoop inside (photographic evidence obtained). The food production area was noted with raw food that was placed on a cardboard box near a dirty hand mixer. The food mixer was noted with debris and rust around the edges (photographic evidence obtained). The reach in refrigerator was noted with food items that were noted dated or labeled edges (photographic evidence obtained). The food production area was noted with cleaning supplies, broom, and dustpan. One large skillet was noted with debris and unidentified matter that was oily to the touch. Three large pots were noted with debris and unidentified matter that was oily to the touch. An interview conducted on 11/18/22 at 10:03 AM with the facility's Food Service Director stated that she recently made changes to the menu selection and that they are in the process of making changes. She further said that they have been short-staff in the kitchen for some time and have many new staff members who are still learning the process. In an interview conducted on 11/18/22 at 2:30 PM, the facility's Administrator was told of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to maintain a medical record that is complete and accurate for 1 out of 2 sampled residents with an indwelling urinary catheter. (Resident #212). The findings included: Review of the facility's policy titled, Standards and Guidelines: SG (Standards and Guidelines) Indwelling Catheters, with a revised date of 03/27/21, included the following: It will be the standard of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Under Guidelines included: 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site. 13. Pertinent information regarding care and changes in condition related to the indwelling catheter should be documented in the clinical record. 14. Use of the indwelling catheter should be reflected in the resident-centered plan of care. Record review for Resident #212 revealed the resident was admitted to the facility on [DATE] and included the following diagnoses: Encounter for Attention to Tracheostomy, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Morbid (Severe) Obesity, Epilepsy, Other Acute Kidney Failure, and Personal History of Other Malignant Neoplasm of Bronchus and Lung. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #212 had a Brief Interview for Mental Status of 15, which indicated that she had an intact cognitive response. Review of Section G of the MDS dated [DATE] revealed that Resident #212 had a bed mobility, dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of 1-person physical assistance, transfer self-performance of activity did not occur with support of ADL (Activity of Daily Living) activity itself did not occur. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 for catheter care q shift (every shift) with an end date of 09/13/22 . Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 to change catheter drainage bag as needed for leaking or cloudiness with an end date of 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 to change indwelling catheter for leakage or blockage with an end date of 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/16/22 to insert/maintain indwelling catheter (16 French) with an end date of 08/17/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 08/17/22 to insert/maintain indwelling catheter (16 French) for Dx (Diagnosis) Sacrum Ulcer Stage 4 with an end date 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 09/13/22 to insert/maintain indwelling catheter (20 French) for Dx Retention of Urine with end date of 09/13/22. Review of the Physician's Orders revealed that Resident #212 had an order dated 11/16/22 to D/C (Discontinue) [indwelling urinary catheter] and monitor for voiding one time a day. There were no criteria for use. Review of the Comprehensive Nursing Evaluation for Resident #212 dated 08/16/22 revealed under Section 9. Skin Integrity included the following: Sacrum scars, Left thigh (rear) redness, Abdomen surgical scars, other discoloration of the legs, Other fragile skin. Under Section 12. Genitourinary/ Gastrointestinal/ Reproductive included the following: Urinary Device Use: [] catheter. Review of the Daily Skilled Note for Resident #212 dated 08/17/22 revealed under Systems - Genitourinary urinary device in use (indwelling urinary catheter) left unchecked. Under Systems - Resident response to treatments and Additional Comments included indwelling urinary catheter in place no s/s (signs and/or symptoms) of bleeding or infection. Review of the Skin & Wound - Total Body Skin Assessment for Resident #212 dated 08/17/22 revealed the number of new wounds was 0. Record review of nursing documentation for Resident #212 08/17/22 to 08/30/22 does not reveal any documentation of the resident having an indwelling urinary catheter, or an indwelling urinary catheter removal, insertion, assessment, or catheter care provided. Review of the Daily Genitourinary Skilled Note for Resident #212 dated 08/31/22 revealed under Systems - Genitourinary included the following: Urinary device in use: Has catheter. Nursing interventions: Irrigated catheter per orders. Catheter care provided. Incontinence care provided. Review of the Narrative Nurses note for Resident #212 dated 09/13/22 with an effective date of 09/12/2022 included: Noticed [indwelling urinary catheter] came out from patient. Called the doctor to notify him of the status of the catheter. The doctor advised to reinsert the catheter. Verified the catheter size and proceed to reinsert a new catheter. At this time there is no leakage and catheter placement has been verified. Review of the Daily Skilled Note for Resident #212 dated 09/13/22 revealed under Systems - Genitourinary Urinary device in use: has a [indwelling urinary catheter], urinary device is patent and draining; free from complications. Review of the Daily Skilled Note for Resident #212 dated 09/14/22 revealed under Systems - Genitourinary Urinary device in use: has a [indwelling urinary catheter]. Complications related to urinary device included: Urinary device is patent and draining free from complications and Complications with urinary device observed (but not further described). Interventions included: Catheter care provided. Incontinence care provided. Review of the Treatment Administration Records (TARS) for Resident #212 from 08/16/22 to 11/16/22 revealed catheter care was provided every shift from 08/16/22 to 08/31/22. Review of the Care Plan for Resident #212 with initial date of 08/30/22 and a most recent revised date of 11/17/22 that had a focus on The resident has an alteration in elimination AEB (As Evidenced By): is incontinent of bowel and bladder; impaired mobility r/t (related to) Diagnoses (Dx): Morbid Obesity, and Kidney Failure, requires staff assist with toileting/incontinence care needs, is at risk for constipation r/t impaired mobility. Goals included: Resident will be clean, dry, and odor free daily thru the next review date. Resident will have adequate bladder function thru catheter and will remain free from complications r/t use of device thru the next review date. Resident will remain free from sx/sx (signs and symptoms) of UTI (Urinary Tract Infection) thru the next review date. Resident will have a regular bowel movement at least q (every) 3 days thru the next review date. The interventions included: Administer medications as ordered; observe for effectiveness and for SEs (side effects). Check resident upon arising, and at HS (hour of sleep) for incontinence; perform incontinence care prn (as needed). Observe for sx/sx of UTI; report to physician if noted. Observe for the presence of stool, amount of stool, color and consistency that might indicate constipation/infection. Labs as ordered, report results to physician. Schedule urology appointments as needed. Observe for changes in bowel/bladder function; update physician if noted On 11/15/22 at 1:50 PM an observation was made of Resident #212 having an indwelling urinary catheter in a privacy bag hanging on the side of the bed. During an interview conducted on 11/17/22 at 8:10 AM with Staff X Registered Nurse Unit Manager, when asked what time is good to schedule observation of catheter care for Resident #212, she stated that the catheter had been discontinued and removed last night (11/16/22). She went on to say that when a resident was admitted with an indwelling catheter. She stated that they verify if the resident meets criteria and if not, they get an order to have the catheter removed, the resident does not meet criteria at this time, so it was removed. On 11/17/22 at 8:20 AM, the Director of Nursing (DON) approached the surveyor to inform that when a resident is admitted with an indwelling catheter they check to see if the resident meets criteria to have an indwelling catheter (i.e., Stage IV sacral wound). During an interview conducted on 11/17/22 at 4:50 PM with Staff U Registered Nurse (RN) when asked about Resident #212's indwelling urinary catheter, she stated the indwelling urinary catheter was discontinued yesterday (11/16/22). She added that she took it out in the morning, and she documented it in the progress notes. During an interview conducted on 11/17/22 at 4:55 PM with Staff V float Certified Nursing Assistant (CNA) when asked when she last took care of Resident #212, she stated about 2 weeks ago. When asked if she remembered if the resident had an indwelling urinary catheter, she said yes, the resident had a [indwelling urinary catheter]. During an interview conducted on 11/18/22 at 9:00 AM with Staff X Registered Nurse Unit Manager, regarding the indwelling urinary catheter for Resident #212, she stated that she had misunderstood about the discontinued date for the indwelling urinary catheter for Resident #212, it was discontinued on 08/16/22 not 11/16/22. Surveyor informed Staff X Registered Nurse Unit Manager that an indwelling urinary catheter had been observed by the surveyor on 11/15/22 and during an interview with Staff U Registered Nurse (RN) she had stated that she removed the indwelling urinary catheter for Resident #212 on 11/16/22. Staff X Registered Nurse Unit Manager insisted that Resident #212 did not have an indwelling urinary catheter and has not had one since it was discontinued/removed on 08/16/22. During an interview conducted on 11/18/22 at 10:30 AM with the Director of Nursing (DON), she stated that Resident #212 was admitted to the facility on [DATE] with an indwelling urinary catheter. She revealed that when a resident is admitted with an indwelling urinary catheter and there is no reason for the indwelling urinary catheter, it is removed per facility protocol/policy. No physician order is needed to remove the indwelling urinary catheter since this is their protocol/policy. She stated that on 08/17/22 the indwelling urinary catheter for Resident #212 was removed. She acknowledged that the nurse removing the indwelling urinary catheter should document that the indwelling urinary catheter was removed and there was no documentation that the indwelling urinary catheter was removed for Resident #212. The DON stated that on 09/13/22 staff entered an order to insert indwelling urinary catheter for Resident #212, and then entered an order to discontinue the indwelling urinary catheter the same day (09/13/22). The DON then changed her statement and stated that the indwelling urinary catheter that Resident #212 was admitted with (on 08/16/22) was never removed as it should have been as per their facility protocol on 08/17/22. She also stated that there was an order dated 08/17/22 to discontinue the indwelling urinary catheter and again stated that the catheter was not removed from the resident per physician order and their protocol. The DON stated that on 09/12/22 the indwelling catheter came out of Resident #212 per nursing documentation and the nurse documented that she obtained an order to reinsert the indwelling urinary catheter on 09/13/22. The DON stated that there were no orders for catheter care after 09/13/22. When the DON was asked what catheter care consists of, she stated it is checking for kinks, making sure it the tubing is patent, make sure it is covered with a privacy bag, and that the indwelling urinary catheter is still inserted, and free from complications. She also stated that the catheter care only needs to be done once a day and if it is not documented on the Treatment Administration Record, then catheter care would be documented in the Daily Skilled Notes. When asked if the daily catheter care would include cleaning the resident's body and the catheter at the site of the indwelling catheter insertion site, she stated no, the daily catheter care does not include cleaning the catheter at insertion site. The DON stated the indwelling urinary catheter that was reinserted on 09/13/22 had daily catheter care provided and that it was documented daily in the Daily Skilled Notes. She admitted that there may be a couple of Daily Skilled Notes that were not done. The DON had Staff Y MDS (Minimum Data Set) Coordinator, and Staff Z MDS (Minimum Data Set) Coordinator PRN (as needed) to assist her with locating documentation for catheter care being provided to Resident #212. Staff Y MDS (Minimum Data Set) Coordinator, and Staff Z MDS (Minimum Data Set) Coordinator PRN verified that from 09/17/22 to 11/16/22 there were 20 days with no documentation for catheter care on the TAR, Daily Skilled Notes, or Progress Notes for Resident #212 (indicating 20 out of 61 days or 33% there was no documentation for catheter care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure an effective call light system for 2 South (24 rooms). The findings included: On 11/15/22 at 11:40 AM this surveyor entered the room of Resident #244. The resident stated that she felt wet and needed to be changed. At 11:47 AM this surveyor asked her to press her call light so staff will be aware of her needs. At 11:54 AM no staff had come yet to answer the light. This surveyor looked out in the hallway and the light above the door to the room was on. This surveyor then walked to the nurse's desk where Staff H, a Licensed Practical Nurse (LPN) was present at the desk. She was asked if she realized that a call light was on and she stated that she did not hear it ringing so the call light in that room must not be working. She then notified the Director of Maintenance. On 11/15/22 at 1:30 PM another surveyor went into room [ROOM NUMBER] and room [ROOM NUMBER] and pressed the call lights. Observed Staff H at the desk with the call bell system behind her not looking at the call bell system when the surveyor pressed the lights in rooms [ROOM NUMBERS] . The lights went on the board but there was no tone and Staff H did not look up to see if a call light was lit. The facility became aware of the lack of sound with the call lights after surveyor intervention. The Administrator was made aware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to equip corridors with firmly secured an unbroken handrail. The findings included: Review of the facility's policy titled Work Orders, Maintenance with no date included the following: To establish priority of maintenance service, work orders must be filled out electronically using an online application such as TELS and forward to the Maintenance Director. On 11/15/22 at 1:25 PM an observation of a loose handrail next to room [ROOM NUMBER]. On 11/15/22 at 10:20 AM an observation was made on the second floor across from the elevator of corner handrail broken with sharp edges exposed. On 11/15/22 at 10:20 AM an observation was made on the first floor across from the elevator of corner handrail broken with sharp edges exposed. During a tour of the facility conducted on 11/18/22 at 9:00 AM with the Director of Maintenance he stated that some of the issues identified, he was not aware of. During an interview conducted on 11/18/22 at 9:45 AM with the Director of Maintenance, he stated he will start working on fixing or replacing the handrails immediately.

Based on observations, interviews, and record review, the facility failed to provide the correct food consistencies for the Mechanical Soft Diets for 2 of 2 residents during dining observations (Resident #10 and Resident #167). This has the potential to affect 38 residents on the Mechanical Soft diet. The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular diet consistency had honey-glazed ham, red cabbage, and seasoned roasted potatoes. The Mechanical soft diet had ground honey-glazed ham, red cabbage, and mashed potatoes. The Diet Type Report provided by the facility showed that 38 residents are on a Mechanical soft consistency diet. In an observation conducted on 11/15/22 at 8:45 AM, Resident #10 was noted in the room with her breakfast tray in front of her. Closer observation showed a breakfast meal with a large piece of bread approximately 3 inches long that was untoasted and hard to the touch. It also had a ground sausage patty and scrambled eggs. The meal ticket on the tray showed that Resident #10 was on a Mechanical soft diet. In an observation conducted on 11/15/22 at 1:30 PM, Resident #10 was noted eating her lunch in her room. Closer observation showed a tray that had the following: ground glazed ham, purple cabbage, and roasted potatoes that were about 2 inches in size and hard to the touch. The meal ticket on the tray showed that Resident #10 was on a Mechanical soft diet. In an observation conducted on 11/15/22 at 9:10 AM, Resident #167 was noted in his room waiting on the breakfast meal. The tray arrived with the following foods: a large piece of bread approximately 3 inches long that was untoasted and hard to the touch. It also had a ground sausage patty and scrambled eggs. In an interview conducted on 11/17/22 at 9:28 AM with Staff Y, the Speech Therapist stated that a Mechanical soft diet consistency needs to have ground meat and maybe a smooth texture like mashed potatoes. If any vegetables are served, they need to be cut and chopped and soft to the touch. She also said that if potatoes are served on a Mechanical diet, they need to be soft to the touch and cut easily through with a fork. When asked about the large piece of bread that was observed on some of the trays, she stated that the bread needs to be soft and easy to chew. Staff Y further reported that they only have one type of Mechanical soft diet in this facility. When asked if she participated in the menu selection for the different diet consistencies, she said no. During an interview conducted on 11/18/22 at 10:03 AM, the facility's Food Service Director stated that she recently made changes to the menu selection and that they are in the process of making changes. the facility's Food Service Director also reported that the Speech Therapist must tell them which level of mechanical soft they need to give certain residents and that any special modifications will be put under the note section of the meal ticket. When asked why all residents on the Mechanical soft diet on 11/15/22 received roast potatoes with honey glazed ham and not the mashed potatoes specified under the Mechanical soft diet, the facility's Food Service Director revealed that she did not know. She further acknowledged that she did not know that mashed potatoes was noted under the Mechanical soft diet section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to follow the resident's approved menu for the Regular diets (Resident #189 and Resident #92). This could affect all residents receiving Regular, consistency diets (145 residents). The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular Diet consistency had 3 ounces of honey-glazed ham,4 ounces of red cabbage, and 4 ounces of seasoned roasted potatoes. The Diet Type Report provided by the facility showed that 145 residents are on a Regular diet consistency. In an observation conducted on 11/15/22 at 1:40 PM, Resident #189 was noted in his room with the lunch tray at his bedside. Closer observation showed a lunch meal that had the following: a slice of glazed ham, purple cabbage, and roasted potatoes. In this observation, Resident #189 stated that the ham is so small that he is not sure that it weighs 3 ounces. A chart review showed that Resident #189 was admitted on [DATE] with type 2 diabetes and sleep apnea diagnoses. An order was noted for a Regular texture diet dated 08/11/21. The Minimum Data Set (MDS) dated [DATE] showed that Resident #189 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. A chart review showed that Resident #92 had an order for a Regular texture diet dated 11/09/21. In an observation conducted on 11/15/22 at 1:50 PM, Resident #92's lunch tray was observed with the following: a piece of glazed ham with a slice of pineapple on top, purple cabbage, and roasted potatoes. Closer observation showed a small thin slice of the glazed ham that did not look like it was 3 ounces in size. Surveyor then asked to take the weight of the sliced ham using the facility's food scale. The facility's Food Service Director asked Surveyor if she could put the sliced pineapple with the ham before taking the weight. Surveyor explained that pineapple is not considered a protein food. The Food Service Director placed the sliced ham on the scale, which showed a weight of 1 ounce. In this observation, she was asked if the glazed ham that was served for lunch today was sliced and measured before serving to ensure that it was 3 ounces per slice; she said no. she stated that she did not take the weight of each sliced glazed ham before placing them on the tray line. The Food Service Director stated that she used the food slicer to cut the glazed ham, and it was set at number 3 for three ounces. She was under the impression that the number 3 was used for a 3-ounce measuring size. The Food Service Director reported that all the sliced ham that was served for lunch on 11/15/22 was sliced using the number 3 on the slicer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure resident's rooms are designed and equipped for adequate nursing care, comfort, and privacy of residents in a safe manner. Semi-private resident rooms measured under the required 80 square feet per resident and multiple residents complained to the surveyors of their rooms being cramped and cluttered. The findings included: Review of a Memo provided to the surveyors by the facility's Administrator revealed the following: 81 rooms in the facility are semi-private rooms. Of these, 58 measure 157 square feet-which equates to less than the required 80 square feet per resident. These measurements do not include the bathroom or closet storage space in the rooms. During a tour of the facility conducted on 11/16/22 at 11:00 AM, it was noted by the surveyors that a number of the facility's semi-private rooms appeared to be small. It was noted in room [ROOM NUMBER] that a wheelchair between the beds was touching the side rails of each bed, indicating the space between the beds was minimal. On 11/16/22 at 11:23 AM, after obtaining consent from the Resident, the surveyors measured room [ROOM NUMBER]. The surveyors measured the room to be 153 inches long by 144 inches deep. There were 2 bedside tables present in the room which measured 19 inches by 19 inches. Taking into account the size of the bedside tables, the surveyors calculated 150.5 square feet for the room space. On 11/16/22 at 11:30 AM, the surveyors measured room [ROOM NUMBER] with the AHCA Life Safety Surveyor. The surveyors measured the room to be 12 feet by 12 feet. Taking into account the size of the bedside tables, the surveyors calculated 141.5 square feet for the room space. On 11/16/22 at 11:35 AM, the surveyors measured room [ROOM NUMBER] with the AHCA Life Safety Surveyor, the facility's Maintenance Director and the facility's Administrator. The measurements taken were 155 inches by 145 inches. Taking into account the size of the bedside tables, the surveyors calculated 154.5 square feet for the room space. All parties involved agreed these measurements do not equate to the required 80 square feet of space for each resident in a double-occupancy room. The Life Safety Surveyor explained to the Maintenance Director and the Administrator that the rooms being cluttered with belongings and wheelchairs is hazardous for the residents and the staff. When asked how many rooms in the facility have the same layout as room [ROOM NUMBER], the Maintenance Director stated all 19 rooms on the wing (152-172) have this layout, but that there may be more in the facility. Of the 19 rooms on the wing (152-172), the surveyor noted that 2 of the rooms (164 and 166) are single occupancy rooms. The surveyors asked for a map of the facility to count how many rooms have this layout throughout the facility. An interview was conducted on 11/16/22 at 11:25 AM with Resident #100. Resident #100 stated he did feel that his room was cramped and cluttered. (Photographic evidence obtained). Resident #100 stated he had a medical history of paraplegia for which he required the use of a wheelchair. Review of a Quarterly Minimum Data Set (MDS) completed 09/30/22 revealed Resident #100 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates he was mentally intact. For functional status, he required extensive assistance for bed mobility, dressing, toilet use, personal hygiene; total dependence of 2 staff for transfers. An interview was conducted on 11/16/22 at 12:03 PM with Resident #152. Resident #152 stated she did feel that her room was cramped and cluttered. ( Photographic evidence obtained). Resident #152 had a medical history of morbid obesity and a tracheostomy for which she required the use of oxygen equipment. She also required the use of a wheeled walker for ambulation. A Quarterly MDS done 11/09/22 showed Resident #152 had a BIMS score of 15, which indicates she was mentally intact. For functional status, she required supervision assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. An interview was conducted on 11/16/22 at 12:09 PM with Resident #157. Resident #157 stated he did feel that his room is cramped and cluttered. ( Photographic evidence obtained). Resident #157 had a history of a traumatic brain injury, quadriplegia, seizures. A Quarterly MDS done on 09/29/22 showed Resident #157 had a BIMS score of 3, which indicates severe cognitive impairment. However, Resident #157 was able to answer all the surveyor's questions without difficulty. For functional status, he required total dependence of 2 staff for bed mobility, transfers, toilet use; total dependence of 1 staff for dressing, eating, personal hygiene.