Based on observations and interviews, the facility failed to maintain the laundry areas in a clean and sanitary manner. The findings include: A tour of the facility was conducted on 12/11/24 at 2:27 PM with the facility's Environmental Services Director. During this tour, the surveyor reviewed the soiled utility and shower rooms on each hallway along with the facility's laundry area. Photographic evidence was obtained of all the following areas of concern. The Infectious Waste room located within the nursing station on the North/Rehab hallway contained a handwashing sink. Closer observation revealed there was no paper towel holder present despite a sign present which stated for staff to wash hands prior to returning to work. Within this room, the surveyor also noted the soiled linen cart had no cover and the linens were not properly bagged. The Soiled Utility room on the North/West hallway contained a specimen refrigerator in which the freezer had a large build-up of ice, requiring defrosting. Upon entering the laundry area, there were 2 washing machines and 2 dryers observed. There was a large build-up of lint in the dryer lint traps of both dryers and a brown melted substance throughout the drums of both dryers. Staff A, Laundry Aide, stated the maintenance staff cleaned the drums and lint areas quarterly but could not recall when it was done last. Staff A further stated the laundry staff should be cleaning the lint traps every hour.

**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 a secure manner for 2 of 20 residents reviewed (Resident #37 and #16). The facility also failed to ensure medications were locked in a secure manner during 2 of 5 medication administration observation times. The facility also failed to properly dispose of medications during 2 of 5 medication observation times. The findings included: Resident #37 During a tour of the facility conducted on 12/10/24 at 8:58 AM, the surveyor observed a tube of Arthritis Cream on the nightstand of Resident #37. (photographic evidence obtained) A review of Resident #37's medical record revealed she was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. A review of Resident #37's physician orders revealed there was no active order for arthritis cream. A review of Resident #37's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #37 had a Brief Interview of Mental Status (BIMS) score of 13, which indicates she was cognitively intact. Further review of the medical record revealed no assessment was found to indicate if Resident #37 was safe to self-administer her medications. Resident #16 During a tour of the facility conducted on 12/10/24 at 9:02 AM, the surveyor observed a bottle of Saline Nasal Spray on the nightstand of Resident #16. (photographic evidence obtained) A review of Resident #16's medical record revealed she was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. A review of Resident #16's physician orders revealed there was no active order for nasal spray. A review of Resident #16's Quarterly MDS, dated [DATE], revealed Resident #16 had a BIMS score of 14, which indicates she was cognitively intact. Further review of the medical record revealed no assessment was found to indicate if Resident #16 was safe to self-administer her medications. An interview was conducted with the facility's Director of Nursing (DON) on 12/10/24 at 9:05 AM. During this interview, the DON stated neither of these residents were assessed as being safe to self-administer their medications. Medication administartion observation Upon approaching Staff B, Registered Nurse (RN), for a medication administration observation on 12/10/24 at 8:09 AM, Staff B was observed with two medication cups present on top of her medication cart, one with tablets and one with crushed medications, while she was actively placing medications into a third medication cup located in her hand. Staff B then walked away from her medication cart, leaving the computer screen on, the medication cart unlocked, and the two medication cups on top of the cart to administer the medications in the cup that was in her hand to Resident #3. Staff B then entered a resident's room to wash her hands, again leaving the computer screen on, the medication cart unlocked, and the two medication cups on top of the cart unattended. Staff B then returned to the medication cart, picked up the medication cup with the crushed medications, mixed pudding into the crushed medications, and walked away from the medication cart, again leaving the computer screen on, the medication cart unlocked, and the remaining medication cup on top of the cart to administer the medications to Resident #6. Staff B then returned to her cart, picked up the final medication cup and walked down the hallway away from the medication cart, again leaving the computer screen on and the medication cart unlocked, to administer the medications to Resident #53. Upon completion of the observation, Staff B was asked why she had medications cups prepared for three separate residents. Staff B responded that she had intended to give Resident #53 his medications first, but that he was not in his room when she entered to administer his medications. She said that, when she returned to her medication cart, Resident #6 then approached her asking for his medications. While she prepared his medications, Resident #3 approached her asking for his medications because he had an appointment. She explained this was why she had medications for three residents prepared at one time. She further stated she knew she should not have pre-poured medications present on top of her cart, but that she did not want to get in trouble by putting the medication cups into the medication cart before she could give them. Staff B was informed that the concern was that the medication cart was left unlocked numerous times, and the medications were left unattended. Upon approaching Staff E, a Licensed Practical Nurse (LPN), for a medication administration observation on 12/10/24 at 3:50 PM, the surveyor observed Staff E return to her medication cart from within a resident room and pull the lock button of the medication cart out with her fingers without using a key, indicating the cart was not locked properly/securely. A medication administration observation was conducted on 12/10/24 at 4:00 PM with Staff E for Resident #45. Staff E retrieved from the medication cart an inhaler and a plastic box which she explained contained Resident #45's glucometer and three insulin pens. Staff E further stated one of the insulin pens was new and not opened yet. Staff E then entered Resident #45's room to perform a blood glucose check, leaving the three insulin syringes and inhaler unattended on top of the medication cart. After returning to the medication cart, Staff E prepared Resident #45's two insulin pens for administration. Upon re-entering Resident #45's room at 4:09 PM, Staff E again left the remaining (third) insulin pen and inhaler unattended on top of the medication cart. Throughout the medication administration observation, each time Staff E returned to the medication cart, she instinctively pulled at the cart drawers, indicating she did not typically lock her cart securely. Upon completion of the observation, Staff E was asked if she should have secured the medications in the medication cart while she was in Resident #45's room obtaining her blood glucose result and administering the insulin. Staff E stated she should have secured the medications in the cart instead of leaving them unattended in the hallway. When asked how she opened her cart initially without the use of a key, Staff E did not respond. Upon approaching Staff F, LPN, for a medication administration observation on 12/10/24 at 3:55 PM, the surveyor observed Staff F return to her medication cart from within a resident room and pull the lock button of the medication cart out with her fingers without using a key, indicating the cart was not locked properly/securely. Further observation revealed Staff F try four separate keys before being able to unlock her cart with the correct key. Throughout the medication administration observation, each time Staff F closed her medication cart, she pushed the lock button in, but it did not make a click sound to indicate it was properly locked. Then, each time Staff F returned to the medication cart, she inserted the key into the lock, which pushed the lock button into the cart all the way, causing the lock to make its click sound. Upon completion of the observation, the surveyor asked Staff F how she opened her cart initially without the use of a key. Staff F did not respond. An interview was conducted with the facility's DON on 12/10/24 at 4:45 PM. During this interview, she stated the staff were instructed to properly lock their medication carts and secure all medications prior to leaving their carts. Review of the facility policy titled Medication Storage, date revised January 2024 revealed all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper security and all drugs and biologicals will be stored in locked compartments (i.e. medication carts). Only authorized personnel will have access to keys to locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Medication disposal A medication administration observation was conducted on 12/10/24 at 8:38 AM with Staff C, LPN, for Resident #67. While preparing Resident #67's medications, a blood thinner medication tablet fell onto the top of the medication cart. Staff C picked up the pill and put it in the sharps container located on the side of the medication cart. Upon completion of the observation, Staff C was asked why she disposed of the tablet in the sharps container. She stated it had fallen onto the medication cart and could not be administered to the resident. When asked if the facility's procedure was to use a pill buster solution as opposed to disposing of medications in the garbage or sharps container, Staff C stated she did not know. A medication administration observation was conducted on 12/10/24 at 8:51 AM with Staff D, LPN, for Resident #40. While preparing Resident #40's medications, Staff D verbalized that Resident #40 preferred for her medications to be crushed and mixed with pudding. After crushing the medications, Staff D disposed of the crushing plastic packet into the open garbage can located on the side of the medication cart. Closer observation revealed a whole medication tablet in a medication cup sitting on the top of the open garbage in the can. When asked, Staff D stated, it was an extra Eliquis (which is a blood thinner medication). Staff D was asked if it was appropriate for the medication to be thrown into the garbage or if they used a pill buster solution. Staff D stated they did have a pill buster solution on each medication cart but that it was only used for narcotics. When asked again if it was appropriate for the blood thinner tablet to be thrown into the garbage, Staff D did not reply. An interview was conducted with the facility's DON on 12/10/24 at 9:05 AM. During this interview, she stated the staff were instructed to use a pill buster solution to dispose of any and all unused medications. Review of the facility policy titled Disposal of Medications and Medication-Related Supplies, date revised January 2018 revealed options to dispose of prescription drugs include-mix the drug with an undesirable substance, put the mixture into a disposable container with a lid.

Based on observations, interviews, and policy review the facility failed to ensure infection control standards were maintained during 2 of 5 medication administration observations. The findings include: A medication administration observation was conducted on 12/10/24 at 4:00 PM with Staff E, Licensed Practical Nurse (LPN) for Resident #45. Staff E stated Resident #45 was due to receive two insulin shots. After appropriately obtaining Resident #45's blood glucose result, Staff E prepared the insulin pens for administration. Upon entering Resident #45's room, Staff E washed her hands, then approached Resident #45, cleaned the right and left upper quadrants of Resident #45's abdomen, and proceeded to administer the two types of insulin without first donning gloves. Upon completion of the observation, Staff E was asked if she should have donned gloves prior to administering the insulin doses. Staff E confirmed she should have donned gloves. Medication administration observations were conducted on 12/10/24 at 8:09 AM with Staff B, Registered Nurse (RN). Staff B was observed administering medications to Resident #6 in the hallway and then return to her medication cart and prepare medications for Resident #53 without washing her hands in between the residents. Staff B then administered medications to Resident #53 and then returned to her medication cart to prepare medications for Resident #76 without washing her hands. Staff B then took the blood pressure cuff from on top of her medication cart and entered Resident #76's room to attain her blood pressure prior to administering her medications. Upon returning to the medication cart, she placed the used blood pressure cuff back on top of her medication cart and proceeded to finish preparing Resident #76's medications. After administering Resident #76's medications, Staff B returned to her medication cart without washing her hands. Staff B did not clean the blood pressure cuff. Upon completion of the observation, Staff B was asked if she should have washed her hands and cleaned her blood pressure cuff between residents. Staff B confirmed she should have washed her hands and cleaned her blood pressure cuff. Interviews were conducted with the facility's Director of Nursing, Corporate Nurse Consultant, and Administrator on 12/10/24 following the medication administration observations. They all confirmed the nurses should have washed their hands and equipment between residents and that Staff E should have donned gloves prior to injecting the insulin. Review of the facility policy titled Insulin Pen, date revised January 2024 revealed the proper procedure for administration of insulin included the staff member donning gloves prior to the injection.

Based on observations, interview, and policy review, the facility failed to maintain oxygen tubing and humidifiers in safe operating condition for 1 of 1 sampled resident (#11). The findings included: On 1/17/24 at approximately 9:48 AM, an observation and interview was conducted with Resident #11. The resident's room was under droplet precautions to prevent transmission of COVID-19 (Coronavirus Disease 2019). Resident #11 had an oxygen concentrator at his bedside. His oxygen tubing was on the floor. The humidifier attached to the concentrator had a piece of tape with a date of 12/21/23 written on it. The oxygen tubing storage bag hanging on the concentrator had a different name written next to patient name. The room number written on the storage bag was not Resident #11's room. The storage bag was dated 12/28/23. (Photographic evidence obtained) Resident #11 was asked if he utilized this oxygen concentrator. The resident reported that he used the concentrator sometimes. On 1/17/24 at approximately 1:00 PM, an interview was conducted with Nurse F, a Licensed Practical Nurse (LPN), in resident #11's room. She was shown the humidifier that had the date 12/21/23, the oxygen tubing that was on the floor, the oxygen tubing storage bag hanging on the concentrator that had a name other than Resident #11, the incorrect room number written on the storage bag, and the date of 12/28/23 written on the bag. She was asked if the tubing should have already been changed. LPN F agreed that the tubing and humidifier should have been changed and that the tubing should not be on the floor. She explained that night shift nurses are supposed to change oxygen tubing and humidifiers once a week on Wednesday nights. LPN F explained that she would get new supplies and immediately removed the tubing, the humidifier, and the bag from the concentrator. On 1/17/24, a review of Resident #11's medical record and care plan was conducted. The care plan noted that he tested positive for COVID on 1/8/24. The care plan does not mention treatment with oxygen anywhere. A review of physician orders for Resident #11 was conducted. He had a diagnosis of chronic obstructive pulmonary disease. An order to place Resident #11 on Isolation Droplet Precautions due to rule out COVID-19 for 10 days was written on 1/8/24. Resident #11 had an order dated 1/9/24 to receive oxygen at 2 liters per minute via a nasal cannula as needed (prn) for shortness of breath or oxygen saturation levels less than 92%. A review of the Medication Administration Record (MAR) was conducted and revealed no orders for the oxygen tubing or the humidifier to be changed. On 1/17/24 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON). A copy of the policy regarding maintenance of respiratory therapy equipment was requested. The DON explained that there is not a policy for that. The DON was asked if there was anywhere that nurses were required to sign and document that oxygen tubing and humidifier have been changed. The DON indicated that there was not an area in the medical record for staff to document humidifier or oxygen tubing changes. She explained there was a note on each medication cart instructing night shift (11:00 pm-7:00 am shift) to change the tubing every Wednesday night. A review of the Night Shift Nurse Duty dated 1/23/23 and posted on each medication cart was conducted. It was noted that the form stated Oxygen tubing and nebulizers are to be bagged and labeled every Wednesday. The list did not mention changing the tubing or humidifiers. (Photographic evidence obtained) On 1/17/24, a review of the oxygen administration policy dated 11/2020 was conducted. The policy recommended changing the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Humidifier bottles should be changed when empty and every 72 hours or as recommended by the manufacturer. Delivery devices are to be stored in a plastic bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with residents and staff, and review of immunization records, the facility failed to offer provide education and offer COVID 19 vaccines in a timely manner for 5 of 5 sampled residents. (Residents #9, #10, #11, #12, and #13) The findings included: On 1/16/24 at approximately 10:15 AM, the Director of Nursing (DON) explained that there had been an outbreak of COVID infections at the facility. Since 1/6/24, 32 of the 88 residents in the facility had tested positive for COVID. As of today (1/16/24), 31 of the 88 residents were still under droplet isolation precautions. On 1/16/23. a review of records for the sample residents was conducted. The record of Resident #9 revealed that he was admitted to the facility on [DATE]. His record did not contain proof that the resident had ever received a COVID vaccine. A declination form was provided indicating that Resident #9 verbally declined the vaccine on 3/23/23. There was no further documentation that the resident had been offered or provided education regarding a booster covid vaccine since 3/23/23. Resident #10 was admitted on [DATE]. The pharmacy record and immunization record for Resident #10 revealed that he received dose 1 of the COVID vaccine on 6/13/22. A declination form was provided indicating that Resident #10 verbally declined the vaccine on 3/23/23. There was no further documentation that the resident had been offered or provided education regarding a booster covid vaccine since 3/23/23. Resident #11 was admitted to the facility on [DATE]. There was a form that indicated Resident #11 consented to receive the COVID vaccine on 3/23/23. Review of the immunization record of Resident #11 revealed that he received a COVID vaccine on 3/31/23. There was no further documentation that the resident had been offered or provided education regarding a booster COVID vaccine since 3/31/23. On 1/8/24, Resident #11 tested positive for COVID-19. Resident #12 had been admitted to the facility on [DATE]. The record of Resident #12 had a form indicating the resident verbally consented to receive the COVID vaccine on 3/23/23. A review of the immunization record of Resident #11 revealed that he received the COVID vaccine on 3/31/23. There was no further documentation that the resident had been offered or provided education regarding a booster vaccine since 3/31/23. Resident #13 was admitted to the facility on [DATE]. His record had a COVID vaccine card that indicated he received the Moderna COVID vaccine on 1/15/21 and 2/12/21. According to the pharmacy record and immunization record for Resident #13, the last COVID vaccine was administered on 11/12/21. A declination form was provided indicating that Resident #13 verbally declined the covid vaccine on 3/23/23. There was no further documentation that the resident had been offered or provided education regarding a booster vaccine since 3/31/23. On 1/17/23 at approximately 2:00 PM, an interview was conducted with Resident #9. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:10 PM, an interview was conducted with Resident #10. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:15 PM, an interview was conducted with Resident #11. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:20 PM, an interview was conducted with Resident #12. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:30 PM, an interview was conducted with Resident #13. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 3:00 PM, an interview was conducted with the Director of Nursing (DON) regarding the last date residents at the facility were educated and offered a COVID vaccine booster. She explained that some residents received the bivalent booster at the facility last year. She said the updated COVID vaccine with the new antigens that came out in September of 2023 has not yet been offered at the facility. The DON mentioned that staff at the health department came out to help with the COVID outbreak at the facility last week. They offered to help provide resident education. She explained that the facility did provide Flu and Pneumococcal vaccines in October of 2023 but no COVID vaccines were provided at that time. The DON said that the residents at the facility declined the COVID vaccine in October but she did not provide any declamation statements for the COVID vaccine or proof that education was provided in October. The Director of Nursing did provide emails dated 12/27/23 and 1/4/24 from a Center for Medicare and Medicaid Services (CMS) contractor quality advisor regarding COVID vaccine compliance. The email dated 12/27/23 stated that the nursing home was 0% up to date with the updated COVID vaccine as was reported in National Healthcare Safety Network (NHSN). The email noted that the nursing home with a 0% vaccination rate have also had increased rates of COVID 19 cases. The email dated 1/4/24 offered resources to increase vaccine compliance with the updated COVID vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review the facility failed to provide sufficient nursing staff to ensure residents received required assistance in a timely manner during an outbreak when 32 of the 88 residents at the facility had been placed on isolation precautions after testing positive for COVID-19 (Coronavirus Disease 2019). The findings include: Observations On 1/16/24 at approximately 10:15 AM, upon entrance to the facility, the Director of Nursing (DON) explained that there had been an outbreak of COVID-19 infections at the facility. Since 1/6/24, 32 of the 88 residents in the facility had tested positive. Upon entering the facility, 31 of the 88 residents were still under droplet isolation precautions. During the initial interview, multiple call lights could be heard going off continuously in the background. The initial tour of the facility was conducted at 11:00 AM on 1/16/24. During the tour, multiple call lights could be heard going off. There were no staff available at the nurse's station. The phone at the nurse's station was ringing continuously. There were few staff observed in the hallways. At approximately 11:20 AM, the call light in room [ROOM NUMBER] was going off. The room was on droplet isolation precautions due to COVID-19. After a few minutes, Resident #14 opened the door to the room. She was seated in a wheelchair as she waited in the door way for about 10 minutes with no mask on. Nurse B, a Licensed Practical Nurse (LPN), was at the medication cart nearby. She left the medication cart to respond to Resident #14 and explained that the door must be shut as she went into the room to assist the resident. The surveyor observed the call light from room [ROOM NUMBER] going off continuously from approximately 11:30 AM until 12:00 PM. The call light in room [ROOM NUMBER] was also going off from approximately 11:35 AM-12:10 PM. The call light in room [ROOM NUMBER] was going off as well during that time. Rooms 100-1,100-2, 101-2, 102-2, 106-1, 106-2, 110-1,111-2, 121-1, 123-1, 123-2, 130-1, 130-2, 134-1,134-2, 135-1, 135-2, 137-1, 137-2,137-3,138-1,138-2, 142-1, 142-2, 144-1, 144-2, 145-1,145-2, 151-2, and 152-2 were all observed to have been placed on droplet isolation precautions due to testing positive for COVID. Rooms 101-1,102-1, 111-1,121-2, 134-3, 135-3 were additionally on droplet precautions due to exposure to a roommate with a positive COVID test. The resident in room [ROOM NUMBER]-2 was under continuous 1:1 supervision. On 1/17/24, the call light to room [ROOM NUMBER] was going off continuously from 4:05 PM-4:34 PM. Resident interviews On 1/16/24 at approximately 11:50 AM, an interview was conducted with Resident #2. She reported that the she often must wait long periods of time to receive any response when she calls for assistance. Resident #2 said she frequently waits up to an hour or two to get assistance. She explained that response time has been worse over the past few days and also at night and on the weekends. She explained that she uses a walker and receives assistance with bathing due to issues with balance and falls. She reported that a staff member became frustrated when she asked for help with bathing a few weeks ago and told her she did not have time to assist her in the shower. Resident #2 said, I am not the only one who lives here who has problems getting help. Sometimes they tell you I am too busy to help you. On 1/16/24 at approximately 12:30 PM, an interview was conducted with Resident #8. When she was asked how she liked living at the facility, she responded by explaining that she does not like living at the facility. She stated it takes a long time to get help. She explained that she wears briefs and utilizes a walker but does not get assistance in a timely manner when she calls for help. She explained that sometimes she has to soil her brief because the wait is too long. On 1/16/24 at approximately 12:40 PM, an interview was conducted with Resident #7. She explained that staff tries to get it all done but many times the response is really slow with getting help when needed. On 1/16/24 at approximately 1:00 PM, Resident #1 explained that the staff is very slow answering call lights and it has been worse recently. Sometimes the staff are somewhat rude and frustrated. She stated that she thinks they need more staff to help. She said recently a nurse was in a rush and almost mixed up her and her roommate recently and gave the wrong medication. Her roommate realized it was not her medicine so the error did not occur. She reported that she wears briefs and receives assistance with peri care and showering. She explained that staff often rushes when assisting her with care. She said she has had problems with urinary tract infections and she thinks staff rushing through care might be a contributing factor. In addition to the slow response, staff does not take the time to provide proper care and privacy while providing care. On 1/16/24 at approximately 1:20 PM, Resident #4 said the food is often cold by the time they get it. She tries not to call much because she knows how busy they are. She explained that her roommate helps her quite a bit. She mentioned again that it always takes a long time to get help. Her roommate is going to be discharged soon and she worries how it will be when she has to rely on staff to assist her. On 1/17/24 at approximately 9:48 AM, an observation and interview was conducted in room [ROOM NUMBER]-1 with Resident #11. room [ROOM NUMBER] was under droplet precautions to prevent transmission of COVID 19. Resident #11 said sometimes it takes 10-15 minutes for someone to respond, sometimes much longer. On 1/17/24 at approximately 10:00 AM, Resident #13 was interviewed about care and services. He indicated that he is blind and needs extra help. The resident explained that once in a while it takes a very long time to get help and that is the main problem. Staff interviews On 1/15/24 at approximately 4:00 PM, an interview was conducted with Staff C, a Certified Nursing Assistant (CNA). CNA C explained that she often works the evening and overnight shift. She was asked about her normal assignment. She explained that she often has 18 residents to care for. She explained if a CNA has 18 residents, then 12 of those residents might need complete assistance with care. Some residents require more than one staff member to assist them. She went on to explain that 18 residents is a lot to manage. Staff C said it has been consistently short staffed for the year that she has worked at the facility. On 1/17/24 at approximately 9:00 AM, an interview was conducted with Nurse F, a Licensed Practical Nurse (LPN). LPN F explained that they have enough nurses but they need more direct care staff, especially with the recent outbreak of COVID residents being sick and on isolation. They have also had an increase in staff members missing work as well. She explained that the evening and overnight shifts really could use extra staff. Staff struggles to get everything done. When they can't get everything done, they usually pass on what is not completed to the next shift. She explained that the nurses try to help keep up with answering call lights and assist with direct care when they can. On 1/17/24 at approximately 11:15 AM, a follow-up interview was conducted with LPN F. LPN F reported that she has 29 residents today and this is a usual assignment. Most of the time she gets her work completed. The unit managers help and she stays late to complete her work if she needs to. She reported that one resident is currently under 1:1 supervision due to exit seeking behavior which takes up more direct care resources. She reported that there is often call ins and the facility has to make arrangements to cover. On 1/17/24 at approximately 12:20 PM, an interview was conducted with Staff Member K, medical records personnel. She reported she has worked at the facility for more than 10 years. She reports that she works more on the administrative side but helps with feeding and passing trays. She said PBJ (Payroll Based Journal) hours are met but she does not think resident requirements are met. She explained that 90 percent of the time, the work cannot be accomplished. She explained that, due to lack of staff, residents have not been getting showers at times. She voiced concerns with prevention of pressure sores and residents experiencing weight loss. She explained that it is overwhelming and staff is burned out and morale is low. She explained she does pick up shifts as needed. She stated evening and overnight shifts need the most help. She reported that there has been a high turnover in staff due to the workload and other factors. Staff Member K explained that she has been feeling anxious because residents are not getting the care that they need. On 1/17/24 at approximately 12:30 PM, an interview was conducted with Nurse I, another LPN, regarding care and services at the facility. LPN I explained that sometimes medication pass runs over allotted time frame. She feels like they could use one more nurse on day shift. She explained that all the work can be accomplished on good days. Evening and overnight shifts often need extra help. On 1/17/24 at approximately 12:45 PM, an interview was conducted with Staff M, another CNA, who explained that recently they have had less CNA staff working. There have been staff calling in frequently. There has been a lot of turnover in staff recently. CNA M stated that when there are 7 CNAs working on day shift, they can usually get everything done, but today there are only 6 CNAs. She explained that this is the worst she has seen it in the more than 10 years she has worked full time at the facility. She also explained there is too much to do to get everything done. She stated if she is not able to finish her work, she worries about retaliation from management. On 1/17/24 at approximately 1:00 PM, an interview was conducted with CNA L. She works at the facility as needed. She works 16-hour shifts. She explained that she believes the facility is mostly short staffed. If she is not able to complete her work, she lets the nurse know and they pass whatever is left on to the next shift. If they will not help, she will stay and finish whatever needs to be completed. On 1/17/24 at approximately 1:30 PM, an interview was conducted with CNA H . She reported that CNA assignments often range between 15-18 residents at a time. CNA H stated at times it is hard to for them to complete the work. She explained that there are not enough CNA's employed at the facility. She was asked if the facility increased available staff due to all of the residents on isolation and sick with COVID-19. She said they actually had less staff today. On 1/17/24 at approximately 11:13 AM, an interview was conducted with Staff G, the facility's Scheduler. She stated that, in addition to doing the scheduling, she was also working at the desk to assist with answering phones and watching out for call lights. She was asked if there were staff out today. She explained that two CNA's had called in. They got one covered but she was still looking for coverage for the other. She was asked to describe staffing the last two days. Normally she schedules 8 CNA's for day shift, but that there were 6 CNA's today and 7 yesterday on day shift. The scheduler did not indicate that extra staff were provided to care for the increased needs for all of the residents who were COVID positive. No information was provided that the facility considered increasing available staff to cover for extra needs with so many residents on isolation precautions for COVID.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure that oxygen administration was completed with the order of a physician for 1 of 3 residents sampled for oxygen use. (Resident #1) The findings include: On 4/4/23 at approximately 3:00 PM, Resident #1 was observed receiving oxygen via nasal cannula at 2 liters a minute. A review of Resident #1's clinical record was conducted. A review of physician's orders revealed no order for oxygen. A review of the Medication Administration Record (MAR) revealed no record of oxygen being administered to Resident #1. On 4/5/23 at 3:26 PM, an interview with the Director of Nursing (DON) was conducted. The DON reviewed Resident #1's orders with the surveyor and confirmed there was no order for oxygen. The DON further confirmed that the resident has been receiving oxygen since re-admission on [DATE]. Review of facility policy for Oxygen Administration dated January 2021 (revised January 2023) revealed, Oxygen is administered under orders of a physician, except in the case of an emergency.

Based on record review, staff interviews and facility policy review, the facility failed to ensure the timely submission of an allegation of abuse and failed to ensure a 5-day report was submitted in a timely manner for 1 of 2 incidents reviewed. The findings include: A review of the facility's submission history into the Incident Reporting System revealed an incident occurred on 10/03/2022 at 1:40 PM. The facility submitted the Immediate Report over 26 hours later on 10/04/2022 at 4:06 PM and the 5 Day Report was submitted 10 days after the occurrence on 10/13/2022 at 3:35 PM. On 11/16/2022 at 1:44 PM, an interview was conducted with Administrator. He stated the 5 Day Report was not submitted until 10/13/2922 because he did not have access to the reporting system. A review of the User Registration Agreement signed by Administrator was dated 10/10/2022. On 11/17/22 at 12:19 PM, an interview was conducted with Staff B, Social Work Assistant (SSA). Staff B stated Staff A, a Licensed Practical Nurse (LPN) made her aware of the incident on the morning of 10/04/2022. Staff B, SSA stated the incident should have been reported by Staff A, LPN on 10/03/2022 within 2 hours. A review of the Facility Policy Abuse, Neglect and Exploitation dated 11/2020, revised 10/1/2022 was conducted. Policy stated, The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Policy further stated An immediate investigation is warranted when suspicious of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion, for 6 of 19 residents reviewed for Resident Assessment, (residents #1, #2, #3, #6, #7 and #8). The findings include: A review of facility's MDS records were compared with CMS' electronic records and revealed the following residents did not have the MDS transmitted: Resident # 2's QuarterlyMDS assessment dated [DATE] was not transmitted. Resident # 6's Quarterly MDS assessment dated [DATE] was not transmitted. Resident # 8's Discharge return anticipated MDS assessment dated [DATE] was not transmitted. Resident # 3's Quarterly MDS assessment dated [DATE] and discharge return anticipated MDS assessment dated [DATE] were not transmitted. Resident # 1's Quarterly MDS assessment dated [DATE] and Discharge return anticipated MDS assessment dated [DATE] were not transmitted. Resident # 7's Annual MDS assessment dated [DATE] was not transmitted. On 04/01/22 at approximately 09:06 AM, an interview was conducted with [NAME] President of Clinical Reimbursement Services via telephone who verified that residents #1, #2, #3, #6, #7 and #8's MDS assessments were not transmitted at the required timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician orders, review of resident's Minimum Dataset (MDS) assessments and staff interviews, the facility failed to accurately code assessments for 2 of 19 residents (#7 and #44). The findings include: A review of medication orders was conducted for resident # 7 which revealed a physician order for tube feeding during the lookback period of the assessment. A review of MDS was conducted for Resident # 7. The Annual MDS assessment dated [DATE] and the Quarterly MDS assessment dated [DATE] did not document tube feeding. A review of medication orders was conducted for resident #44 which revealed a physician's order for dialysis services during the lookback period of the assessment. A review of MDS was conducted for Resident #44. The most recent MDS assessment dated [DATE] did not document dialysis services. On 03/30/22 at approximately 03:28 PM, an interview was conducted with the MDS coordinator. MDS coordinator pulled up the most recent completed MDS assessments for resident #7 dated 02/15/2022 and 11/18/21 and verified that assessments did not document tube feeding. MDS coordinator further verified that resident #7 was receiving tube feeding services during the look back period and stated the assessments were incorrect. MDS coordinator also pulled up the most recent completed MDS assessment for resident #44 dated 12/09/21 and verified that assessment did not document dialysis. MDS coordinator verified that resident # 44 was receiving dialysis services during the look back period and stated the assessment was incorrect.

Based on record review and staff interview the facility failed to refer a resident with a diagnosis of a serious mental disorder for a PASARR (pre-admission screening and resident review) level II for 1 off 3 residents reviewed for PASARR. (Resident #85) The findings include: A record review was conducted for Resident #85 which revealed that the resident had diagnoses of Bipolar Disorder, Obsessive Compulsive Disorder (OCD), and Post Traumatic Stress Disorder (PTSD) dated 10/7/19. A review of the PASARR level I, dated 11/2/21, revealed the form stated that no level II review was required. On 3/31/22 at approximately 10:15 AM, an interview was conducted with the Social Worker, who stated that the Director of Nursing (DON) oversaw any level II PASARR reviews. On 3/31/22 at approximately 10:35 AM, an interview was conducted with the DON, who stated that she was not aware of any level II PASARR occurring. At this time the Level I PASARR for Resident #85 was reviewed with the DON. The DON confirmed that a level II PASARR was not completed.