Based on observations, interviews, and record review, the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner, and food was prepared and stored in accordance with professional standards for food safety in one out of one facility kitchen and two out of two nourishment rooms. Findings included: An observation was conducted on 12/10/24 at 2:36 p.m. in the north unit nourishment room of: -Cups and trash on the floor under the table. -The shelf above the refrigerator had dirt, dry spilled liquid, and a container with an unknown liquid. -The refrigerator and freezer contained undated, unlabeled food. -There thermometer in the refrigerator was broken and there was no thermometer in the freezer. -The seal around the refrigerator and freezer door was broken and there were icicles hanging from the freezer door and food was spilled on the shelf. -The refrigerator contained an unlabeled container of liquid that had a date of 11/19. -There was a plunger sitting on the floor next to the refrigerator. An observation was conducted on 12/10/24 at 2:45 p.m. in the south unit nourishment room of: -A container of pudding in the refrigerator opened, undated with a rubber band wrapped around it. -The floors in the room were also observed to be dirty and the baseboards were missing. -There was a pitcher of unlabeled and undated liquid in the refrigerator. An observation was conducted on 12/10/24 at 3:35 p.m. during a kitchen tour of: - Gnats in the kitchen and food storage areas. -A container of thickener powder with a cup stored in the powder. -A second container of thickener powder contained a small brown foreign object. -Shelves being used to store food in the dry storage area were rusty and had dust and debris on them. -The walk-in refrigerator had a covered plate of deviled with no date. -The walk-in refrigerator had an unlabeled paper bag on the shelf that contained an unlabeled plastic bag with unidentifiable food and liquid inside. -The walk-in refrigerator had a box of bacon wrapped in plastic. The plastic had been torn open and the bacon was sitting unwrapped. -The walk-in refrigerator had milk crates sitting directly on the floor. -The walk-in refrigerator had a lunch box containing a sandwich sitting on top of a tray eggs. -The walk-in refrigerator contained a rack with spilled mandarin oranges and a pan covered in liquid. -The walk-in freezer contained a blue unlabeled plastic bag tied in a knot. -There was a half empty bottle of green tea sitting on the food preparation table. -There were wires and a piece of insulation in the middle of the kitchen floor under a preparation table. -There was trash and spilled liquids on the floor behind the cart containing the coffee maker. -Two bottles of salad dressing were sitting on the floor being used to prop open the door to the dry food storage room. -The kitchen walls had dirt, grease, and spilled liquid on them. -There was a section of wall by the door in the kitchen that the tile had come off and there was an uncleanable surface. The section of missing tile was sitting on top of a preparation table. -The stainless food preparation tables in the kitchen were corroded and rusting. -There were dead bugs on the table with the coffee maker. -One of the stainless food preparation tables was broken and uneven. -A live roach was observed running across the floor under the three-compartment sink. -A plastic two drawer organizer was sitting on the second shelf of a food preparation area. The organizer was covered in dust, and spilled substances. The top drawer contained cereal and cake mix stored with disposable cups, lids, plastic bags and wrapping paper. The second drawer contained cups and disposable containers along with a stapler, highlighter and pair of eyeglasses. A second plastic storage bin was sitting on the shelf and it was also covered in dust and spilled substances. -Plates were sitting face up on the bottom shelf of the stainless preparation table and stainless bowls were sitting on a shelf with the useable surface face up. -The electrical outlet at the center food preparation area was heavily coated with dust, dirt and a stick substance. On 12/10/2024 at 3:45 p.m. an observation and interview was conducted in the facility's kitchen. Staff A, Dietary Aide was observed in the process of washing dishes with the dishwasher. Staff A demonstrated sanitizer testing. The test strip showed a result of less than 50 PPM (parts per millions). Staff A confirmed the results and stated the results should be between 50-100 PPM. Staff A stated dishes should be run back through. The Certified Dietary Manager (CDM) arrived in the dishwasher area and performed a second test and confirmed the results were less than 50 PPM. The CDC stated, It should be darker. The CDM confirmed the dishwasher was a low temperature/ chemical sanitizer dishwasher. An observation and interview was conducted on 12/10/24 at 3:53 p.m. with the CDM. The CDM was observed leaving her desk from doing paperwork without performing hand hygiene. She walked into the walk-in refrigerator and said the deviled eggs should have been dated/labeled. She looked at the paper bag containing the plastic bag of unidentifiable food and said, That shouldn't be in here. She said it was not labeled and was for a staff party. The CDM said the bacon should be wrapped in plastic and not left uncovered. She said the lunch box belonged to a staff member and should not be in the refrigerator. She then picked up the deviled eggs, lunch box, and paper bag and removed them from the refrigerator. The CDM said the gnats had been a problem in the kitchen since the beginning of October and they were treating them. She also looked in the dry storage room and said the bottles of dressing should not be on the floor propping the door open. She was observed moving the bottles to a shelf. She also said the cup should not have been stored in the thickening powder and she was observed removing it. The CDM had still not performed any hand hygiene. She was observed reaching into the second container of thickening power with her bare hands and taking out the brown foreign object. When asked what she would do with that thickening powder she said they would use it because It wasn't a bug or anything. The CDM reviewed pictures of the nourishment rooms. She said the rooms should be cleaned by housekeeping and cleaning the refrigerators and freezers is a team effort. She said juice should not have been in the refrigerator from 11/19/24 and all food should be labeled/dated. When discussing the broken seals on the refrigerator and freezer she stated Oh that's north unit. That fridge needs to be replaced. The CDM said there should be working thermometers in the refrigerator and freezer and she would replace them. She also said the freezer should not look the way it does and should not be dirty. On 12/11/2024 at 9:17 a.m., an observation and interview was conducted with Staff B, Dietary Aide. Staff B was in the process of washing dishes with the dishwasher. Staff B stated she had washed numerous trays of dishes through the dishwasher and stated she had not tested the dishwasher in the morning. Staff B performed a test strip with results less than 50 PPM. Staff B performed another with results less than 50 PPM and stated, It's getting there. The assistant CDM came to the service area and agreed the test strip was less than 50 PPM as Staff B continued to wash the dishes. The assistant CDM performed four separate tests and on the fourth test the results were at 50 PPM. The assistant CDM stated the dishwasher should be run through several times and tested each time until it reaches the goal of 50-100 PPM. The CDM stated she will have the dishwasher serviced immediately. Staff B was observed putting the previously washed items on a rack with clean dishes to dry. A follow-up observation was conducted on 12/11/24 at 9:27 a.m. in the kitchen of: -The two bottles of salad dressing remained on the floor propping open the dry storage room door. -The shelves in the dry storage room had spilled sugar and small ants crawling on them. -There was a puddle of liquid in the middle of the dry food storage room. -The plastic storage containers continued to be covered in dust and crumbs. -The bacon in the refrigerator remained unwrapped. -The unlabeled blue plastic bag remained in the walk-in freezer. The bag was opened and observed to contain vegetables. -The milk cartons remained sitting directly on the floor in the walk-in refrigerator. -The plastic storage bins under the preparation table continued to have cake mix and cereal stored with disposable cups and lids. -The front of the reach-in refrigerator had dried liquid and food particles on the doors. An observation and interview was conducted on 12/11/24 at 9:27 a.m. in the kitchen. The CDM was sitting at her desk with her office door open five feet from the dry storage room. She walked out of her door and was asked about the two bottles of salad dressing sitting on the floor being used as a door prop. She stated, Oh, they put them back. The CDM said she did not know there were ants in the dry storage room. She observed the ants and said the shelves needed to be cleaned and she would call maintenance to see about getting a treatment. The CDM was asked about the unlabeled blue plastic bag in the walk-in freezer. She was adamant It was ice. The assistant dietary manager opened the bag and confirmed it was vegetables and not ice. The CDM said,It needs to be thrown out. It felt like ice An interview was conducted on 12/11/24 at 10:15 a.m. with the Maintenance Director and Regional Maintenance Director. They observed the wires and insulation in the middle of the kitchen floor and said it should be covered with a box, not exposed. An interview was conducted on 12/11/24 at 10:18 a.m. with the Assistant Dietary Director. She said the milk crates should not be sitting on the floor in the walk-in refrigerator. She looked at the dirty containers in the kitchen and said they should be cleaned daily. She looked inside the drawer of the two drawer storage container and said she did not know why food was in there with nonfood items. She was also observed looking at the food preparation tables and confirmed they have rust and corrosion on them. An interview was conducted on 12/11/24 at 12:30 p.m. with a service representative from the dishwashing chemical company. He reviewed the pictures of the sanitation test strips and confirmed the chemical concentration did not reach 50 PPM. He said they chemicals should have been tested on a plate surface instead of the trough and the concentration would probably be less there. He said the machine should be run 2-3 times then tested to ensure the temperature was up to 120 degrees Fahrenheit and the chemical sanitizer reached 50 PPM prior to washing dishes. A review of the facility's policy titled, Dishwasher Temperature, revised 10/19/2022 showed the following: Policy statement: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperature. A further review of the policy, showed the following explanation and compliance guidelines: 4. For low temperature dishwashers (chemical sanitization) a. The wash temperature shall be 120 degrees Fahrenheit. b. The sanitizing solution shall be 50-100 PPM (parts per million) hypochlorite chlorine on dish surface in final rinse. 5. If needed, run several empty dish racks through dishwasher to obtain the correct temperature and parts per million. 6. Chemical solutions shall be maintained at the correct concentration, based on periodic testing at least once per shift , and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 7. Water temperature shall be measured and record prior to each meal and/or after the Dishwasher has been emptied or re-filled for cleaning purposes. 8. Immediate action will be taken if dishwasher temperatures and/or chemical levels are inadequate. A review of the facility's policy titled, Food Safety Requirements, revised on 10/19/2022, showed the following: Policy statement: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. a. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. c. f. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. . b. Dry food storage-keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. d. Refrigerated storage foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. ii. iii. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use -by date, or frozen (where applicable)/ discarded; and v. Keeping foods covered or in tight containers. 6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b. 7. Staff shall adhere to safety hygienic practices to prevent contamination of foods from hands or physical objects a. Staff shall wash hands according to facility procedures. (Photographic evidence obtained).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An observation on 03/18/24 at 9:56 a.m., revealed a name plate on Resident #70's door with the last name spelled incorrectly. The incorrect spelling would cause a different pronunciation of Resident #70's last name. During an interview on 03/18/24 at 9:57 a.m., Resident #70 confirmed the door name plate was the incorrect spelling of her last name. A review of the admission Record showed Resident #70 was initially admitted to the facility on [DATE] with diagnoses included but not limited to unspecified dementia, unspecified severity with other behavior disturbance, brief psychotic disorder, heart failure, major depressive disorder, recurrent unspecified. Review of the Census List page showed Resident #70 had a room change to her current room on 12/14/23. During an interview on 03/20/24 at 12:02 p.m., Staff F, Certified Nursing Assistant (CNA) stated, They left the R out of her name. Staff F, CNA confirmed Resident #70's last name was misspelled on the door name plate. During an interview on 03/20/24 at 12:18 p.m., Staff G Licensed Practical Nurse (LPN), Unit Manager (UM) stated the admission department adds names to the door name plates when residents are admitted . Staff G, LPN, UM stated she would expect the name to be on the door the same day a resident was admitted or changed rooms. Staff G LPN, UM confirmed Resident # 70's last name was misspelled on the door name plate. An observation on 03/18/24 at 11:46 p.m., revealed the name plate on Resident #102's door did not match the resident's name. The name was from a previous resident that was discharged on 03/14/2024. Photographic evidence obtained. During an interview on 03/18/24 at 11:47 p.m., Resident #102 stated his name did not appear on the door name plate. Resident #102 confirmed he had a different last name than the last name revealed on the door name plate. A review of the admission Record showed Resident #120 was admitted to the facility on [DATE] with diagnoses included but not limited to unspecified dementia, unspecified severity without behavior disturbance, type II diabetes, solitary pulmonary nodules and major depressive disorder, recurrent, unspecified. The admission Record also included the Resident #102 full name which was not available on the door name plate during observation. Review of the Census List page showed Resident #102 had a room change to her current room on 10/01/23. During an interview on 03/20/24 at 12:18 p.m., Staff G Licensed Practical Nurse (LPN), Unit Manager (UM) stated the admission department adds names to the door name plates when residents are admitted . Staff G, LPN, UM stated that she would expect the name to be on the door the same day a Resident was admitted or changed rooms. Staff G LPN, UM confirmed Resident #102's name was not on the door name plate. Review of the facility's policy Promoting/Maintaining Dignity dated 09/07/22 showed, It is the practice to protect and promote residents' rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Based on observations, interviews, and record reviews, the facility 1) failed to maintain the dignity of one resident (#80) related to clean clothing out of fifty three residents sampled, 2) failed to ensure the preferred name was utilized for one resident (#169) out of fifty three residents sampled, 3) failed to ensure the name of one resident (#70) was spelled correctly on the resident's door, and 4) failed to ensure the name of one resident (#102) was displayed on the resident's door out of fifty three residents sampled. Findings included: 1. On 3/18/24 at 12:54 p.m. Resident #80 was observed walking in the hallway of the secured memory care unit wearing a pair of plaid Capri pants inside out with spots of a brown substance near the waistband, down the left pant leg, and on the back of the right anklet sock. The resident was observed walking from one end of the unit to the other end with multiple staff in the hallway. Staff K, Certified Nursing Assistant (CNA) watched the resident walk away from them to the other end of hallway and when the resident was coming back to there area, the staff member asked the resident to Come here so I can clean you up, the staff member did not intervene further with the resident. Resident #80 continued to walk in the hallway and at 1:00 p.m., Staff K was observed passing meal trays to other residents in their rooms as Resident #80 was observed wearing the same pants inside out with the same substance attached to them and sock. Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), was observed donning Personal Protective Equipment (PPE) followed by the resident, Staff K entered the room with a meal tray and on 3/18/24 at 1:22 p.m. Resident #80 was observed walking in the hallway with a cleaned plate and fork, when directed by an unknown staff member the resident returned to room, the brown substance was seen on the right sock and multiple spots on back of the left leg and waistband of the inside out pants. An observation was made on 3/18/24 at 1:25 p.m., of Resident #80 speaking with Staff K at the end of the hallway, the resident walked with the staff member to the resident room and at 1:27 p.m., the staff member asked the resident to go check if glasses were in there, the resident went into the room and Staff K left the area, the resident promptly left the room, continuing to wear pants inside out with a brown substance attached to the pants and sock. On 3/18/24 at 1:28 p.m., Resident #80 was observed walking into another resident's room at the end of the unit then back out, continuing to walk in the hallway, standing behind Staff K (who was at a kiosk hanging on the wall on the opposite side of the unit from where the resident's room was located) before continuing on. An observation was made on 3/18/24 at 1:33 p.m. of Staff G handing Resident #80 a facial mask asking the resident to put it on, the resident was observed walking away from the staff member holding the mask in hand. On 3/18/24 at 1:40 p.m., another surveyor reported a member of the Maintenance department stated Someone catch her, she needs to be changed. On 3/18/24 at 1:40 p.m., Staff G responded, directed the resident into resident's room, then left, followed by the resident who was observed walking on the opposite end of the unit. The Activity Director assisted the resident back to the resident's room, the Activities Director entered the room then left, the resident promptly left the room. On 3/18/24 at 1:44 p.m., a paperback word search puzzle book was observed sitting on top of the medication cart assigned to Staff A, Registered Nurse (RN). The staff member tossed the book to the nursing station desk next to the desktop computer and keyboard. Staff A sat down in front of the desktop and picked up a pink inkpen. The staff member looked up, noted this writer, stood up, left the nursing station, and began assisting residents with applying hand sanitizer outside of the unit's dining room. (Photographic evidence was obtained). An observation on 3/18/24 at 1:50 p.m. showed the word search book had been repositioned from the previous position. Staff A was observed assisting Resident #80 back to the room. On 3/18/24 at 1:51 p.m., Staff A was observed encouraging Resident #80 to leave the bathroom of another resident room, and assisting the resident back to her room. Staff A was observed dressing in PPE while Resident #80 remained in her room. An interview was conducted with Staff G on 3/18/24 at 1:58 p.m. The staff member reported noticing the bowel movements areas on Resident #80 About a hour ago, during lunch but was told by staff Resident #80 had refused (to be changed). The staff member stated she had attempted to assist resident but was dressed in PPE so guessed the resident did not know who she was. Staff G did not voice the expectation regarding staff assisting the resident with toileting hygiene. Staff G reported going to ask Staff A to try to assist (Staff A was in the room with the resident). Review of the admission Record showed Resident #80 was admitted on [DATE] and included diagnoses not limited to severe unspecified dementia with other behavioral disturbance, cognitive communication deficit, and need for assistance with personal care. Review of Resident #80's Annual comprehensive assessment showed the resident had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, indicating a severe cognitive impairment, the resident was able to independently maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal, and was frequently incontinent of bowel. Review of Resident #80's care plan showed the resident had a potential for Activities of Daily Living (ADL) self-care performance deficit related to (r/t) severe Dementia with cognitive impairment, chronic encephalopathy (and) currently independent/supervision with all ADL's. The interventions included staff were to encourage the resident to participate to the fullest extent possible with each interaction. Review of the Registered Nurse Job Description, copyrighted 2023, explained the purpose was May provide direct nursing care to the resident's and supervises the day-to-day nursing activities performed by the licensed practical/vocational nurse and certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures. Performs rounds to ensure resident needs are being met and personnel are performing their assigned duties. 2. Review of Resident #169's medical record revealed he was admitted to the facility on [DATE] with diagnosis that included Fusion of spine, and Torticollis. Review of the residents Brief Interview For Mental Status (BIMS), dated 3/1/24, revealed a score of 13 (Cognitively intact). Observation on 03/18/24 at 11:17 AM of Resident #169's name posting located on the wall outside of his room door revealed a name normally referred to a female. Observation of the resident at this time revealed the resident had facial hair consisting of a beard and goatee. Interview with Resident #169 at this time revealed that they identify as he/him/they and prefers to be referred to as an alternate name he had provided to staff. The resident reported he prefers to have his provided name posted outside of his room. Interview on 03/20/24 at 09:31 AM with Staff U, Certified Nursing Assistant (CNA) revealed she had worked with Resident #169 before. During the interview Staff U continuously referred to Resident #169 as his given name and she and was continuously corrected by this surveyor. Staff U reported she could not help how she referred to the resident and she had to get use to it, but that she is trying. Interview with Staff V, Licensed Practical Nurse (LPN), Unit Manager on 03/20/24 at 09:42 AM revealed she was very aware of Resident #169's preference and staff are all aware and are trained and honor the resident's preference. Interview on 03/20/24 at 01:24 PM with the Social Service Director revealed she has addressed the resident's preference of how he identifies. She reported she does nothing with the resident's name tag on the door, and the residents given name is official and must reflect the residents legal name on the door. Interview on 03/20/24 at 02:22 PM with the Nursing Home Administrator (NHA) revealed the residents rights are honored related to his preference of how he wants to be identified. She reported the resident's name tag on his door was an oversight and will be changed right away and all staff have been trained. Review of the facility policy titled Resident Rights with a review/revised date of 6/2023 revealed the following: 10. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to refer three residents (Residents #5, #54 and #70) of fifteen residents reviewed for Level I Pre-admission Screening and Resident Review (PASRR), for a newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II PASARR resident review upon a significant change in status assessment. Findings included: A review of the admission Record showed Resident #5 had an original admission date of 10/06/18 with diagnoses included but limited to anxiety disorder, unspecified, hyperthyroidism, chronic obstructive pulmonary disease and unspecified convulsions. Resident #5 was later identified with new diagnoses that included: -Other specified anxiety disorders on 08/02/22 -Other specified Depressive Episodes on 08/02/22 -Unspecified dementia, unspecified severity, with other behavioral disturbance on 10/01/22 -Major depressive disorder, recurrent, unspecified on 10/10/23 -Schizoaffective Disorder-Bipolar type on 02/15/21 Review of Resident #5's quarterly Minimal Data Set (MDS) assessment, dated 02/22/24, revealed under Section C-Cognitive Patterns, Resident #5 had a Brief Interview for Mental Status (BIMS) of 02 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #5 had diagnoses of Non-Alzheimer's Dementia, Anxiety disorder, Depression, and Schizophrenia. A review of Resident #5's Level I PASRR assessment, dated 08/08/15 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections schizoaffective disorder was not checked. A review of the admission Record showed Resident #70 had an original admission date of 11/03/23 with diagnoses included but limited to unspecified dementia, unspecified severity, with other behavioral disturbance, brief psychotic disorder, heart failure, and essential primary hypertension. Resident #70 was later identified with new diagnoses that included: -Major depressive disorder, recurrent, unspecified on 12/05/23 Review of Resident #70's quarterly (MDS assessment, dated 02/06/24, revealed under Section C-Cognitive Patterns, Resident #70 had a BIMS of 04 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #70 had diagnoses of Non-Alzheimer's Dementia, Depression (other than bipolar) and Psychotic disorder. A review of Resident #70's Level I PASRR assessment, dated 10/24/23 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections depressive disorder was not checked. During an interview on 03/21/24 at 11:51 a.m., the Director of Nursing (DON) confirmed residents who are diagnosed with new mental health diagnoses should have their PASRRs updated and resubmitted to reflect those changes. The DON stated Resident #5 should have had an updated PASRR that reflected the new mental health diagnosis of schizophrenia and Resident #70 should have had an updated PASRR that reflected the new mental health diagnosis of depressive disorder. Review of the facility's policy Resident Assessment-Coordination with PASARR Program dated 09/07/22 showed, .9. Any resident who exhibits a newly evident or possible serious mental illness, intellectual disability, or a related condition will be referred to the state mental health or intellectual disability authority for a level II resident review. 3. On 3/18/24 at 9:54 a.m. Resident #54 was observed ambulating in the hallway of the secured memory care unit pushing an empty wheelchair. On 3/18/24 at 10:45 a.m., Resident #54 was observed sitting in the unit's dining room with other residents and the television was playing. Review of Resident #54's admission Record showed the resident had been admitted on [DATE] and included the diagnoses of cognitive communication deficit(onset 7/5/23) unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 7/5/23), brief psychotic disorder (onset 7/14/23), and unspecified persistent mood (affective) disorder (onset 7/14/23). Review of Resident #54's Preadmission Screening and Resident Review (PASRR), dated 7/5/23, did not reveal the resident had a mental illness (MI), suspected MI (SMI), or Intellectual Disability (ID). The PASRR did not reveal the resident had a primary diagnosis of dementia or related neurocognitive disorder. The review showed question 7 had been answered Yes the resident had validating documentation to support the dementia or related neurocognitive disorder, Medical history. Section IV revealed the resident did not have a diagnosis or suspicion of SMI or ID and a Level II PASRR was not required. Review of Resident #54's PASRR revealed in Section II A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis or dementia or related neurocognitive disorder, and a suspicion or an Serious Mental Illness, Intellectual Disability, or both. During an interview on 3/21/24 at 12:00 p.m., the Director of Nursing stated Resident #54's PASRR should have fixed this one. The DON reported the facility had recognized an issue with PASRR's and had initiated a Performance Improvement Plan (PIP). Review of the facility PIP - PASRR Completion, 2/1/2024, showed the status of the Quality review for all current residents PASRR's was completed to ensure accuracy and prompt completion. was complete. The policy - Resident Assessment - Coordination with PASARR Program, implemented 9/7/22, showed This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The guidelines directed: - 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. - 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability has determined as appropriate for admission. - 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop a comprehensive care plan for 2 of 2 (#98, #100) residents reviewed for vision and dental services. Findings included: Review of the facility policy titled Comprehensive Care Plans with an implemented date of 9/7/22 revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident #98's medical record revealed she was admitted to the facility on [DATE] with diagnosis that included Type 2 Diabetes Mellitus foot ulcer, Peripheral Vascular Disease, and Basal Cell Carcinoma of skin. Review of the record revealed a Brief Interview for Mental Status (BIMS) dated 2/8/24 with a score of 14 (Cognitively intact). Interview on 03/18/24 at 11:33 AM with Resident #98 revealed she has been in the facility since November 2023, had dental and vision concerns but has not been seen by the dentist or the optometrist. The resident reported she only has 1 tooth. Interview on 03/20/24 at 10:01 AM with Resident #98 revealed she still has not had an appointment for dental or vision. Review of Resident #98's record revealed there was no care plan in the record that reflected the residents needs related to dental and vision. Review of the resident records revealed an admission Evaluation dated 12/14/23 which indicated the following: -ORAL/NUTRITION Resident teeth are broken and/or have carious. -SENSORY Eyesight is impaired resident wears glasses. Hearing adequate. Review of the residents 5-day Minimum Data Set (MDS) dated [DATE] revealed the following: -Vision-Impaired -Dental indicates no dentures or mouth pain or difficulty chewing Review of the residents physician order dated 12/15/23 revealed the following: -May have Dental, Dermatology, Ophthalmic, Podiatry, Wound, Psychology and Psychiatry consults as needed to eval and treat Review of the record revealed no indication that appointments related to vision and dental had been completed. Interview on 03/20/24 at 03:10 PM with the Social Serviced Director (SSD) revealed anyone who needs dental or vision is on the list to be seen unless they have a private vendor or the family says no to services, or if they can't afford it. Interview on 03/21/24 at 10:22 AM with Resident #98 revealed she only has 1 tooth and gums her food. She reported she would like to be seen by the dentist to evaluate the need to remove the one tooth or not. She reported she had old glasses that were for seeing near and far and she also has a newer pair of glasses for reading but neither of them work. Review of Resident #100's medical record revealed she was admitted to the facility on [DATE] with diagnosis that included Dementia/Alzheimer's with behaviors. Review of the record revealed that the resident was alert with confusion at times. Interview on 03/18/24 at 11:33 AM with Resident #100's family member and Health care proxy revealed the resident has been in the facility since October 2023, had dental and vision concerns but had not been seen by the dentist or the optometrist. The residents family member reported the resident only had a few teeth. Interview on 03/20/24 at 10:01 AM with Resident #100's family member revealed the resident still has not had an appointment for dental or vision. Review of Resident #100's record revealed there was no care plan in the record that reflected the residents needs related to dental and vision. Review of Resident #100's records revealed an admission Evaluation dated 10/26/23 which indicated the following: -ORAL/NUTRITION Resident teeth are broken and/or have carious. -SENSORY Eyesight is adequate. Review of Residents #100's Quarterly MDS dated [DATE] revealed the following: -Vision-Adequate with no corrective lenses -Dental indicates no dentures or mouth pain or difficulty chewing Review of the resident's physician order dated 10/26/23 revealed the following: -Ophthalmology/Podiatry//Psych Services as needed Review of the record revealed no indication that appointments related to vision and dental had been completed. Interview on 03/20/24 at 03:10 PM with the Social Serviced Director (SSD) revealed anyone who needs dental or vision is on the list to be seen unless they have a private vendor or the family says no to services, or if they can't afford it. Interview on 03/21/24 at 10:22 AM with Resident #100's family member revealed Resident #100 only has 7 teeth which all need to come out. She reported her family member is not in any pain at this time but was seen by an oral surgeon when residing in another city who said they need to come out but then the resident ended up in facility. Resident #100 opened his mouth and showed the 7 teeth remaining in his mouth. Resident #100's family member reported Resident #100 does not have glasses but needs glasses to read because he can't see the print. Interview on 03/21/24 at 10:32 AM with Staff W, Social Service revealed he was not aware of Residents #98 and #100 vision and dental status. He reported he had to call the dental and vision vendors. He indicated he was able to find a email from the vision vendor who accepted the residents as patients and that they were requesting additional information. He was unable to verbalize if the documentation had been provided to the vendor or if the resident had been seen. Interview on 03/21/24 at 10:39 AM with Staff X, Licensed Practical Nurse (LPN), MDS Coordinator revealed she completes the appropriate sections of the MDS and does a screen which includes a full physical observation of the resident to include vision and oral. She reported if there is a need or concern then she develops a care plan and then informs social services so they can schedule needed services. She reported she was not aware of the need for dental or vision for Residents #98 and #100 and is not sure why there was no dental or vision care plan developed for the two residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to consistently provide a packaged meal for one resident (#87) out of four residents receiving dialysis. Findings included Review of Resident #87's medical record revealed that she was admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, End Stage Renal Disease. The record revealed the resident receives dialysis from a local vendor on Monday, Wednesday and Friday. The record included a Brief Interview for Mental Status (BIMS) dated 2/14/24 with a score of 14 (Cognitively intact). Interview on 03/20/24 at 09:06 AM with Resident #87 revealed her lunch has not been brought up to her yet for her 10:00 AM pick up for dialysis. She reported usually the packaged lunch comes up at 6:00 AM but sometimes they forget so her (family member) is bringing her a lunch before she leaves. Observations on 03/20/24 at 09:56 AM of Resident #87 in her room revealed her (family member) was present and that they were waiting for transportation. Interview with the resident at this time revealed she was told that her lunch would be up but that it hasn't come up yet. Resident #87 reported that she was anxious about the timeliness of her pick-up and reported that although her pick-up time is 10:00 AM the transportation usually comes by 9:50 AM to get her to dialysis. Observations on 03/20/24 at 10:04 AM transportation for Resident #87 arrives. It was noted at this time there is still no lunch present for the resident. Staff U, Certified Nursing Assistant (CNA) verbalized to herself she had to go to the kitchen to get the residents lunch and walked down the hallway. Observations on 03/20/24 at 10:11 AM Resident #87's transportation was leaving the residents room with resident and (family member) walking behind. It was noted there was still no lunch present for the resident to take to dialysis. Observations on 03/20/24 at 10:13 AM while exiting the facility the transportation personnel was noted to ask the receptionist if she could get a lunch for the resident. At this time the resident verbalized she did not want to wait for the lunch because it was late. The transportation team exited the building with the resident and loaded the resident into the transportation van. After resident was loaded into the transportation a kitchen aide noted to run out of the facility and hand a bagged lunch to the transport personnel for the resident. Inspection of the bagged lunch revealed it consisted of a peanut butter and jelly sandwich, graham crackers, and soda. The resident's (family member) verbalized at this time that the resident goes without a lunch at least 1 time a week, but he comes to the facility daily and is here before she leaves for dialysis and is at the facility when she returns so if it appears that there will be no packed meal he will bring something for her. Review of the resident's physician order dated 2/13/24 revealed the following: Dialysis Days: Monday, Wednesday, Friday. Chair time: 11AM Transport Pick up Time: 10AM Review of Resident #87's care plan revealed the resident is at risk for complications r/t receives dialysis with an Initiated date of 05/15/2023 and a revision date of 08/01/2023. Continued review of the residents care plan related to dialysis revealed interventions that included Send snack with resident on dialysis days with an Initiated date of 05/15/2023. Review of Resident #87's progress notes revealed no entries of the resident refusing any of her meals for dialysis. Interview on 03/20/24 at 10:26 AM with the Certified Dietary Manager (CDM) revealed dialysis residents always gets a packed meal when going to dialysis. She reported if the resident has an early appointment the lunch is prepped from the night before. For later dialysis appointments bagged lunches are made fresh for the resident. She reported usually the lunches are ready and prepped before the resident has to leave, but today they were behind because of the dish machine. This surveyor shared with the CDM a report that dialysis packed lunch is not provided every time the resident has dialysis. The CDM reported that I don't know that I can contest to that because there are a lot of moving parts in the kitchen. The CDM stated, I cannot confirm that she gets a meal each time she goes to dialysis. The CDM reported that as an alert the kitchen gets a sheet listing the dialysis patients which indicates the days and time of pick-up and that We try to have target times to mitigate problems, but there are a lot of moving parts so things come up. Interview on 03/20/24 at 11:46 AM with the Nursing Home Administrator (NHA) revealed the kitchen usually provides a meal for residents who go out of the facility for dialysis. She reported sometimes residents refuse to take a lunch and that this information is documented in the residents record. The NHA reported she is not aware of anything going on in the kitchen that would cause the kitchen to fall behind. Review of the facility policy titled Hemodialysis with an implemented date of 8/25/22 revealed the following: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure one (South #2) of four medication carts was locked while unattended, medications were secured, medications were stored per manufacturer guidelines, one (South) of two treatment carts were locked while unattended, and medications were not stored with cleaning materials. Findings included: On 3/18/24 at 9:41 a.m. while standing at an unlocked medication cart, Staff A, Registered Nurse (RN) offered to obtain a face mask for writer. The staff member left the nursing station, leaving the cart unlocked, went into the room opposite the station, returning a moment later with a box of face masks. A housekeeper was in the nursing station mopping while the cart was unlocked and unattended. The South #2 medication cart was parked in the nursing station; however the cart was parked against a half wall and within reach of residents on a memory care unit. Staff A confirmed the cart was reachable and had been unlocked. On 3/18/24 at 12:10 p.m., an observation was made of a blue oval tablet on the floor in the doorway of room [ROOM NUMBER]. Staff Z, Interim Staff Educator, observed the blue tablet, picked it up (using a glove) and said it looked like a thyroid pill. On 3/20/24 at 9:48 a.m., an observation was conducted with Staff R, Licensed Practical Nurse (LPN) of the South #2 medication cart. The observation revealed an unopened bottle of Latanoprost Ophthalmic solution. The pharmacy bag containing the bottle was labeled Refrigerate. The observation revealed 2 containers of pudding sitting on top of the insulin containers. On 3/20/24 at 10:23 a.m., an observation was conducted with Staff P, RN of the South #1 medication cart. The observation revealed an opened undated bottle of Latanoprost Ophthalmic solution, a vial of insulin dated 2/14/24, with a pharmacy label showing to discard after 28 days (3/13/24 - 7 days prior to the observation), an undated, unopened Insulin Lispro pen labeled with a sticker to discard after 28 days and contained within a pharmacy bag revealed 2/4/24 opened. (3/3/24 - 17 days prior to the observation), and an undated opened Breo Ellipta 100 microgram/25 microgram (Fluticasone furoate/vilanterol) inhaler, contained within a pharmacy bag revealing an open date of 1/10/24. The inhaler label showed an area to date when the tray was opened and to discard 6 weeks (2/21/24 - 28 days prior to the observation). On 3/20/24 at 3:59 p.m., an observation was made of an unlocked unattended treatment cart on the memory care unit, parked outside of the nursing station. The cart contained medicated ointments and creams. Staff P and Staff R reported Staff G, Unit Manager, had been the last one in it. Staff G confirmed, at 4:02 p.m. on 3/20/24, she was the last one in it and had left it unlocked. On 3/20/24 at 4:27 p.m. an observation was conducted with Staff Q, LPN of one medication cart on the North unit. The observation showed a container of [vendor name] Disinfectant wipes lying on its side with a wipe sticking out of the container. The wet wipe was lying against extra medications stored in the bottom drawer and a wet spot was observed on the packaging of a full card of the medications. The staff member confirmed the findings. The policy - Medication Storage, implemented 8/25/22, revealed It is the policy of this facility to ensure 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 sanitation, temperature, light, ventilation, moisture control, segregation, and security. The compliance guidelines included the following: - 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments (see attached listing). c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. - 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications. - 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacy for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

4. On 3/19/2024 at 9:51am Staff B, Dietary Aide was observed in the kitchen working at the food prep station with parfaits dishes. Staff B was observed wrapping parfait dishes with plastic wrap with bare hands. She then removed what appeared to be electronic phone ear bud devices from her ears with bare hands. She then placed the earbuds into her pocket and continued wrapping parfait cups with plastic wrap with bare hands. Once the parfait containers were wrapped and placed on a silver tray, Staff B wrapped the entire tray of parfaits, wrote a date on the top of wrapped parfait tray and placed them into the cooler. Staff B was then observed putting on gloves and placing bread directly onto the service station table. Staff B did not perform hand hygiene during the observation. During an interview with Staff B on 03/21/2024 at 11:50a.m., she stated she should wash her hands before and after food preparation. She also stated that she is only to use her ear buds while operating the dish machine. She then stated that she should not touch her face or skin while preparing food without washing her hands and the prep stations are wiped down once an hour. Review of the facilities Food and Safety Requirement Procedure states: Dated Reviewed: 10/19/2022 Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions: Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Food Distribution means the process involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. Food Service means the process involved in actively serving food to the resident. When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor). Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Foodborne illness refers to an illness caused by the ingestion of contaminated food or beverages. Policy Explanation and Compliance Guidelines: 1. Food safety practices hall be followed through the facility's entire food handling process. This process begins when food is received from the vendor and ends with deliver of the food to the resident. Elements of the process include the following: D. Distribution and service of food to the resident, including transportation, set up, and assistance. F. Employee hygienic practices 2. The Director of food and Nutrition service shall order food from approved sources and maintain invoices from food vendors that show the source of food acquisition and the date of delivery. 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. 5. Food and Beverages d. washing hands between contact with residents and after collecting soiled plates and food waste. e. Use of gloves when touching and assisting with ready-to-eat foods. f. Timely distribution of all meals/snacks. 6. All equipment used in the handling of the food shall be cleaned and sanitized, and handled in a manner to prevent Contamination. c. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. staff shall wash hands according to facility procedures. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. e. Hairnets should be worn when cooking, preparing, or assembling food, such as stiffing pots or assembling the ingredients of a salad. However, staff do not need to wear hairnets when distributing food to residents at the dining table(s) or when assisting residents to dine. h. Gloves will be worn when directly touching ready-to-eat foods and when serving residents who are on transmission-based precautions. However, staff do not need to ear gloves when distributing food to residents at the dining table(s) or when assisting residents to dine unless touching ready-to-eat food. 8. Additional strategies to prevent foodborne illness include, but are not limited to: a. preventing cross-contamination of foods. 3. An observation on 03/18/24 at 12:20 p.m., revealed fifteen residents seated in the Secured Unit dayroom. An observation on 03/18/24 at 12:35 p.m., revealed the lunch cart being delivered to the Secure Unit. Staff was observed immediately passing out the lunch trays to all fifteen residents. One resident (#83) was observed eating beef stroganoff with her hands. The lunch observation revealed no hand hygiene practices by staff. During an immediate interview on 01/18/24 at 12:35 p.m., Staff F Certified Nursing Assistant (CNA) stated the facility protocol was to provide every resident a hand sanitizing wipe for hand hygiene prior to meals but stated today, it just did not happen and was not sure why. Staff F, CNA stated the hand sanitizer and sanitizing wipes were in the locked storage unit in the dayroom. During an interview on 03/20/24 at 10:52 a.m., the Administrator stated she expected the staff to ensure residents were provided hand hygiene in the form of either hand sanitizer or sanitizer wipes prior to being served each meal. Based on observations, interviews, and record reviews, the facility failed to implement an appropriate infection control program related to ensuring staff were aware precaution measures for one (#80) of one residents with precautions, provide a cleanable mattress for one (#95) out of 52 residents, and to ensure adequate hand hygiene was performed for staff and residents. Findings included: 1. An interview on 3/18/24 at 9:37 a.m. was conducted with an unknown Certified Nursing Assistant (CNA) on the memory care unit. The CNA stated there was no COVID infection on the unit and Staff A, Registered Nurse (RN) confirmed this information. On 3/18/24 at 9:47 a.m., an observation was made of Resident #80's room, hanging from the door was a Personal Protective Equipment (PPE) caddy and a sign showing Droplet precautions. The caddy held gowns, N95 masks, faceshields, and gloves. During the observation, Resident #80 was observed walking out of the room. On 3/18/24 at 12:54 p.m., Resident #80 was observed walking independently in the hallway of the unit, not wearing any personal protective equipment (PPE). On 3/18/24 at 1:03 p.m., an observation was made of Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM) asking Resident #80 who was ambulating in the unit, to go back to room to eat. The staff member dressed in gown, gloves, mask, and face shield, stating Resident #80 had tested positive for COVID a week ago Friday, and comes off precautions on the 22nd, the 10th day (after testing positive). Staff G directed the resident into the room. On 3/18/24 at 1:06 p.m. Staff K, CNA, walked into Resident 80's room to the window side of the room and handed a meal tray to Staff G. The room continued to be posted for Droplet precautions as Staff K entered the room without any PPE. On 3/18/24 at 1:20 p.m., Staff K walked into Resident #80's room, putting gloves on and calling for Resident #80. Staff G called to the staff member from a room across the hall and the staff member left the area. On 3/18/24 at 1:33 p.m. Staff G handed Resident #80 a face mask as the resident ambulated past the nursing station, asking the resident to put it on. The resident held the mask in hand walking away from staff. 2. On 3/18/24 at 9:35 a.m., an observation was made of Resident #95's mattress on the memory care unit. The mattress' plastic/vinyl covering was missing, the top of the mattress was whitish-light blue in color. The room was designated (by sign on door) to be scheduled for Deep Clean. On 3/18/24 at 12:48 p.m., an observation continued of Resident #95's mattress. The mattress was torn in an area approximately the size of a dinner plate, revealing an interior of green foam. Review of the policy - Cleaning and Disinfection of Resident-Care Equipment, implemented/revised on 9/6/22, revealed Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current Center for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection. Cleaning is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymic products. Disinfection refers to the thermal or chemical destruction of pathogenic and other types of microorganisms. Reusable single-resident items are items that may be used multiple times, but for one resident only. Examples include bed pans, urinals, and disposable blood pressure cuffs/stethoscopes. 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: c. Direct care staff are responsible for cleaning single resident equipment when visibly soiled, and according to routine schedule parentheses where apical parentheses. e. Most equipment may be cleaned/ disinfected in the areas in which the equipment is used. Review of the policy - Infection Prevention and Control Program, implemented 8/25/22 and revised 7/13/23, revealed This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. e. Environmental Cleaning and disinfection shall be performed according to the facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside their scope to the appropriate department. 5. Isolation protocol (Transmission-Based Precautions- contact, droplet, neutropenic): a. A resident with infection or communicable disease shall be placed on transmission based precautions. b. Residents will be placed on the list of restrictive transmission based precaution for the shortest duration possible under the circumstances. 9. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the handrail in one (South - Memory Care) of two units was secure and did not cause a safety issue regarding the presence of broken and/or missing components. Findings included: 1. An observation on 03/18/24 at 12:23 p.m. revealed three decorative fence posts pulled from the wall outside room [ROOM NUMBER]. The hallway handrail attached to the wall through the decorative fence post was loose and wobbly when touched. Photographic evidence obtained. An observation on 03/19/24 at 10:24 a.m. revealed three decorative fence posts pulled away from the wall outside room [ROOM NUMBER]. The hallway handrail attached to the wall through the decorative fence post was now unsecured from the wall. Photographic evidence obtained. During an interview on 03/19/24 at 10:26 a.m., Staff J, Director of Maintenance (DOM) stated, I did not know this was like this. Staff F, DOM stated the unsecured hallway handrail was certainly a safety concern and he would have expected the staff to have informed the maintenance department so the handrail could have been fixed. Review of the Maintenance Log from 02/29/24-03/19/24 revealed no entries for loose or broken hallway handrails. During an interview on 03/21/24 at 1:29 p.m., the Director of Nursing (DON) stated anything that is visibly broken or needs fixed should be put in the maintenance log and reported. The DON stated, I heard about the hallway handrails and would have expected the rails to have been reported and fixed. Review of the facility's policy Accidents and Supervision dated 09/07/2022 showed, Policy: The resident environment will remain as free of accident hazards as possible. 1. Identification of Hazard and Risks- a. All staff (professional, administrative, maintenance) are to be involved in observing and identifying potential hazards in the environment. 2. On 3/18/24 at 10:32 a.m. an observation was made of two broken handrail brackets between room [ROOM NUMBER] and nursing station on the South-Memory Care unit. On 3/18/24 at 12:33 p.m. an observation showed a metal bracket attached to one side of the underneath of a handrail between room [ROOM NUMBER] and the nursing station. The bracket was not attached to the other side and a space between the bracket and handrail was approximately 1/2 inch. On 3/18/24 at 12:36 p.m. an observation was made of a missing handrail cap near room [ROOM NUMBER]. On 3/18/24 at 12:48 p.m. an observation was made of a missing handrail cap near room [ROOM NUMBER]. On 3/19/24 at 10:35 a.m. an observation was conducted of the handrails on the South-Memory Care Unit, which revealed: - a missing end cap near room [ROOM NUMBER] - a missing end cap and a broken handrail bracket near room [ROOM NUMBER] - a broken handrail bracket between rooms [ROOM NUMBERS] - a broken handrail bracket near room [ROOM NUMBER] - a missing end cap near room [ROOM NUMBER] - a broken handrail bracket near room [ROOM NUMBER] - a loose end cap next to room [ROOM NUMBER] On 3/20/24 at 11:39 a.m. Resident #23 was observed grasping the handrail to propel self in wheelchair from the patio to the nursing station. An interview and observation of the South-Memory Care unit handrails was conducted with the Maintenance Director on 3/20/24 at 12:12 p.m. The director stated the expectation was for staff to notify him of any issues but he also should have noticed them. He stated he did have end caps and had fixed many. The Maintenance Director asked this writer to observe one handrail that had been fixed. We went into the North unit and the director explained he had tightened screws to one section of the handrail. The interview continued on 3/20/24 at 12:58 p.m. with the Maintenance Director. The director provided a handrail audit completed on 3/18/24 by a Maintenance Assistant. Review of the handwritten audit (provided by Maintenance Director) of the handrails in the facility was completed. The audit revealed the section of the South-Memory Care unit between rooms 152 to 160 was ok, the section of handrail between room [ROOM NUMBER] to nursing station fail, and a section by South nursing station fixed. The audit did not show any other section of handrail was determined to be ok or fail on the South unit. The audit showed the majority of the handrail evaluations were completed on North unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a clean and homelike environment for one resident unit (Secured Unit) out of two resident units in the facility. Finding included: 1. An observation on 03/18/24 at 10:27 a.m., revealed the secured unit dayroom had ceiling tiles that were pushed up and not flush with the ceiling. The blinds that hung in the window of the dayroom were broken and pulled apart. The walls in the secured unit dayroom were scratched and a piece of the wall near the locked storage closet was cracked. The main door of the dayroom was scratched and was missing paint. During an interview on 03/20/24 at 11:30 a.m., Staff F, Director of Maintenance (DOM) stated Staff I, Maintenance Worker (MW) just changed the blinds in the window this morning. Staff J, DOM stated staff saw Surveyor taking pictures of the blinds. Staff J, DOM was interviewed and shown the piece of wall near the locked storage closet that was cracked. Staff J, DOM stated he had extra pieces to this wall and could get that fixed today. Staff J, DOM recognized the two ceiling tiles that were pushed up from the ceiling exposing the roof area and stated, Yes, I just fixed a tile like that in the kitchen today. Staff J, DOM pointed out a third tile in the ceiling that had a hole in it and stated it would need to be fixed as well. Staff J, DOM was then directed to the main door of the secured unit dayroom. Staff J, DOM confirmed the door was scratched and was missing paint and stated it would look so much better with a new coat of paint on it. Staff J, DOM stated I got some paint last week, I could have that painted in about 45 minutes. Staff J, DOM stated these concerns were not in the maintenance log or brought to maintenance attention. Staff J, DOM stated he expected staff to report environmental concerns to maintenance when items in the facility were damage or needed to be repaired. During an interview on 03/20/24 at 11:37 a.m., Staff I, MW confirmed he was just instructed to replace the blinds in the secure unit dayroom this morning because they were broke and in poor repair. Review of the facility's policy Safe and Homelike Environment dated 07/24/23 showed, Orderly is defined as an uncluttered physical environment that is neat and well-kept. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 2. On 3/18/24 at 9:43 a.m. an observation was made of two lumps of a brown substance on the floor of a small alcove next to the patio entrance in the memory care unit, and a white powdery substance was observed on an over-bed table located in the alcove. On 3/18/24 at 10:01 a.m. an observation was of an uncovered dusty ceiling vent in the bathroom of room [ROOM NUMBER]. On 3/18/24 at 10:24 a.m. an observation revealed a brown substance was smeared on the wall of the alcove near the patio entrance on the memory care unit. Two dressers were observed in the alcove, one contained personal belongings and the other contained an incontinent device, the outside of both dressers were stained with an unknown substance. On 3/18/24 at 10:35 a.m., an observation was made in the bathroom of room [ROOM NUMBER] of a hole in the wall and missing floor tiles under the sink. On 3/18/24 at 12:03 p.m. an observation was made of a missing transition between the bathroom and room in room [ROOM NUMBER]. Photographic evidence was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 03/18/2024, 03/19/2024, 03/20/2024 Resident #53 was observed either in her room and in bed, in her room and seated in a wheel chair, or seated in therapy doing exercises, or hanging out in the front lobby area. Resident #53 had been dressed for the day and was not presenting with any behaviors, pain or discomfort. The room was clean and free from foul odors. Review of Resident #53's medical record, revealed she was admitted to the facility on [DATE]. Review of the advance directives section of the chart revealed Resident #53 had a responsible party to make her medical and financial decisions. Review of the admission diagnosis sheet revealed the following diagnoses; Adjustment Disorder with mixed Anxiety and Depressed Mood (11/29/2023); Pseudobular Affect (11/07/2023) Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 01/29/2024 revealed; (Cognition/Brief Interview Mental Status or BIMS score - 07 of 15, which indicated Resident #53 would not be interview able.) Review of the medical record revealed one Level 1 Pre admission Screening Resident Review (PASRR) tools/assessments. The following PASRR revealed; Level 1 PASSR completed by an Completed by RN at an outside facility on 08/16/2023. Under section I (a) of the PASRR screen, which asks what type of Suspected Mental Illness (SMI) the resident had; revealed it was not checked for any diagnosis. Section I (b) was not checked for any Intellectual Disability (ID). Section II (1, 2, 3, and 4) were not checked with yes, which would indicate a Level 2 PASRR would need to be completed. It was determined Resident #53 was not in need for a Level 2 PASRR to be completed. During Resident #53's admission she had developed diagnoses to include Adjustment Disorder with mixed Anxiety and Depressed Mood with an onset date of 11/29/2023. Neither of the current Level 1 PASRR screens identified Resident #53 of having Adjustment Disorder with mixed Anxiety and Depressed Mood in Section I (b). There was no other Level 1 PASRR screens in the electronic record that reflected Resident #53 with a diagnosis of Adjustment Disorder with mixed Anxiety and Depressed Mood. The facility failed to update the Level 1 PASSRR Screening to reflect the current diagnosis for Resident #53. On 3/21/2024 at 1:00 p.m. the Director of Nursing confirmed Resident #53 had a diagnosis of Adjustment Disorder with mixed Anxiety and Depressed Mood and the current Level 1 PASRR in the chart reflected this diagnosis. 4. On 3/20/2024 at 9:20 AM Resident # 170 was observed sitting on the side of his bed. Resident stated he had open heart surgery on 12/8/2023 which left him with no use of his right hand, a tracheostomy, and a feeding tube. The feeding tube had been removed and healed and the tracheostomy had been removed and he still had a small area to heal. He has had his colostomy since 2018 post surgery for a bowel obstruction. He stated he lost both of his sons but did not elaborate. The resident uses oxygen at three liters via nasal cannula continuously. Review of admission record, dated 3/20/2024, revealed Resident #170 was admitted on [DATE]. with diagnoses of: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Type two Diabetes Mellitus, Morbid (severe) Obesity, Colostomy, Pneumonitis due to inhalation of food and vomit. Review of medical certification for Medicaid long-term care services and patient transfer form (AHCA Form 5000-3008) for Resident #170, dated 3/7/2024, revealed: primary diagnosis - pneumonia, chronic obstruction pulmonary disease exacerbation, patient wears glasses, is on insulin, anticoagulants, has methicillin-resistant staphylococcus aureus (MRSA0 in his nasal area, no attached reports, incontinent, colostomy left lower abdomen, ambulates with an assistive device - wheelchair, requires assistance of one, skin care with a stage two on right buttock. Review of the Level I Preadmission Screening and Resident Review for Resident #170 dated 2/20/24 revealed: Level I Section 1 A Bipolar Disorder, B finding based on documented history, no level II PASRR required. No attached identifying documentation Review of the Level Preadmission Screening and Resident Review for Resident #170 dated 3/13/2024 revealed: Level I Section I B finding based on documented history no Level II PASRR required. No attached identifying documentation Review of Minimum Data Set (MDS) Resident assessment and Care Screening dated 3/11/2023 for Resident #170 revealed: Section C - Cognitive Patterns - Brief Interview for Mental Status (BIMS) Summary Score 15, indicating the resident was cognitively intact. An interview was conducted with the Director of Nursing (DON) on 3/21/2024 at 1:30 PM. The DON stated that when a resident has a psychiatric or psychotherapy evaluation the nursing department is responsible to review the evaluation and update the PASRR if needed and the person in nursing that is accountable is the DON. Based on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents (#7, #13, #14, #20, #50, #53, #65, #80, #88 and #170) of fifteen residents sampled for PASRR review. Findings included: 1. A review of the admission Record showed Resident #65 had an original admission date of 01/19/21 with diagnoses including repeated falls, essential hypertension, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #65's annual Minimal Data Set (MDS) assessment, dated 12/31/23, revealed under Section C-Cognitive Patterns, Resident #65 had a Brief Interview for Mental Status (BIMS) of 00 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #65 had diagnoses of Non-Alzheimer's Dementia and Psychotic disorder. A review of Resident #65's Level I PASRR assessment, dated 01/19/21 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections psychotic disorder was not checked. During an interview on 03/21/24 at 11:51 a.m., the Director of Nursing (DON) confirmed Resident #65's PASRR was inaccurate at admission and should have reflected the diagnosis of Psychotic Disorder. The DON stated because Resident #65's PASRR was inaccurate a new PASRR should have been re-submitted to reflect Resident #65's admitting diagnosis. 5. Review of Resident #14's admission Record showed the resident was admitted on [DATE] with the diagnoses of Pseudobulbar affect (PBA), unspecified mood (affective) disorder, unspecified anxiety disorder, moderate recurrent major depressive disorder (MDD), cognitive communication deficit, and unspecified severity unspecified dementia with other behavioral disturbance. Review of Resident #14's Preadmission Screening and Resident Review (PASRR), dated 3/4/19, showed the resident had Mental Illness (MI) diagnoses of anxiety and depressive disorders. The PASRR did not reveal the resident had a secondary diagnosis of dementia and a Level II evaluation was required and did not include the resident's diagnosis of PBA. During an interview on 3/21/24 at 12:02 p.m. the Director of Nursing (DON) stated Resident #14's PASRR should have been redone. Review of Resident #80's admission Record showed the resident was admitted on [DATE] with secondary diagnoses of severe unspecified dementia with other behavioral disturbance, and cognitive communication deficit. The record included other diagnoses of unspecified recurrent major depressive disorder (onset 10/10/23) and unspecified persistent mood (affective) disorder (onset 6/13/23). Review of Resident #80's PASRR, dated 2/6/23, showed the resident did not have any Mental Illness (MI) or suspected MI (SMI), or Intellectual Disability (ID). The PASRR showed the resident had a disorder resulting in functional limitations of major life activities, had serious difficulty in concentration, persistence, and pace, and had a serious difficulty of adaption to change. The PASRR revealed the resident's primary diagnosis was dementia. The PASRR revealed Resident #80 was admitted under a 30-day Hospital Discharge Exemption and if the resident's stay was anticipated to exceed 30 days the Nursing Facility (NF) must notify the Level I screener on the 25 th day of stay and the Level II evaluation must be completed no later than the 40 th day of admission. The evaluation showed a Level II PASRR was not required. During an interview on 3/21/24 at 11:57 a.m., the Director of Nursing stated Resident #80's PASRR was a definitely resubmit. Review of Resident #13's admission Record showed the resident was admitted on [DATE]. The record revealed the primary diagnosis of the resident was depressive-type schizoaffective disorder (onset 2/16/21), and other diagnoses of moderate recurrent major depressive disorder (onset 8/2/22), unspecified mood disorder due to known physiological condition (onset 6/9/22), unspecified anxiety disorder (onset 6/9/22), other specified eating disorder (onset 6/9/22), and tertiary diagnosis of unspecified recurrent major depressive disorder. Review of Resident #13's Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview of Mental Status (BIMS) score was 6 out of 15, indicating a severe cognitive impairment. Review of Resident #13's PASRR, dated 9/12/13, revealed the resident had a Serious Mental Illness of Schizophrenia with a serious difficulty of concentration, persistance, and pace and had experienced an episode of significant disruption resulting in an intervention by housing or law enforcement officials. The evaluation revealed the resident was being admitted from a hospital after receiving acute inpatient care and required Nursing Facility services fro the condition received in the hospital. A Level II was determined to be required prior to the facility admission. Review of Resident #13's Level II Determination report showed the resident had a mental health diagnosis of Undifferentiated type Schizophrenia with an unknown onset date. The evaluation revealed a Brief Interview of Mental Status was conducted and indicated a score of 13 which suggests intact cognitive status. Review of Resident #13's Level I and Level II PASRR evaluations did not included the diagnoses of schizoaffective disorder, moderate recurrent major depressive disorder, unspecified mood disorder due to known physiological condition, unspecified anxiety disorder, and other specified eating disorder was not included in the evaluations. (The resident's care plan showed a diagnosis of Pica). During an interview on 3/21/24 at 12:02 p.m., the Director of Nursing stated Resident #13's PASRR and Level II should have been redone. Review of Resident #88's admission Record revealed the resident was admitted on [DATE] with a primary diagnosis of unspecified Alzheimer's disease. The record included additional diagnoses of severe vascular dementia with other behavioral disturbance (onset 11/29/22) and generalized anxiety disorder (onset 6/13/23). Review of Resident #88's PASRR, dated 6/6/22, did not reveal the resident had any Mental Illness or Intellectual Disability, and did not have a primary diagnosis of a related neurocognitive disorder (Alzheimer's disease). The PASRR revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. The PASRR showed a Level II evaluation was not required. During an interview on 3/21/24 at 12:06 p.m., the Director of Nursing reviewed Resident #88's PASRR and stated it should have been redone. The DON stated when a resident gets a new diagnosis, the PASRR should be redone. Review of Resident #50's admission Record revealed the resident was admitted on [DATE] and a readmission on [DATE]. The record showed the resident was admitted with a primary diagnosis of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The record included diagnoses of unspecified anxiety disorder (onset 8/7/23), and unspecified recurrent major depressive disorder (onset 8/31/20). Review of Resident #50's PASRR, dated 8/12/20, revealed in Section I a diagnosis of depressive disorder and was receiving services for mental illness (MI). The evaluation showed in Section II the indicators for decision-making showed the resident had a disorder resulting in functional limitations, serious difficulty with interpersonal functioning, concentration, persistence, and pace, and a serious difficulty with adaption to change. The PASRR revealed the resident had received treatment for MI with psychiatric treatment more intensive than outpatient care and an episode of significant disruption to normal living situation. The PASRR revealed a Level II PASRR evaluation must be completed prior to admission if any box in Section I.A. or I.B. is checked and there is a yes checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. The PASRR showed the resident did have a primary diagnosis of dementia with validating documentation. A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion of diagnosis of an Serious Mental Illness, Intellectual Disability, or both. The evaluation showed the resident may not be admitted to the Nursing Facility as a Level II was needed and telephone consent for a Level II was obtained. The resident's electronic record did not include a Level II evaluation for Resident #50 nor did the facilty provide one. The PASRR did not include the resident's diagnosis of anxiety disorder. During an interview on 3/21/24 at 11:51 a.m., the Director of Nursing (DON) reported having to look at the Past Medical History (PMH) to be considered a Serious Mental Illness (SMI) and schizophrenia would trigger a Level II, so if there were hospitalizations or receiving mental health services would trigger a Level II or a ID, if dementia, might not only if there is mental health also. The DON reported a Performance Improvement Plan (PIP) was started a month ago, the Social Service Director (SSD) would audit the PASRR's and if something was noted, the DON was notified and it was addressed. Review of the PASRR Completion PIP, dated 2/1/24, showed the Quality review for all current residents PASRR's was completed to ensure accuracy and prompt completion, the status of this action step was documented as complete. The policy - Resident Assessment - Coordination with PASARR Program, implemented 9/7/22, showed This facilty coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The guidelines directed: - 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. - 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability has determined as appropriate for admission. - 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. 2. On 3/18/24 at 10:00 a.m., 3/19/24 at 1:00 p.m., and on 3/20/2024 at 7:30 a.m. Resident #7 was observed in his room and either seated in his wheelchair or was lying in bed. Each time observed, Resident #7 was observed dressed for the day and not presenting with any behaviors, pain, or discomfort. Resident #7 was pleasant to speak with and was able to speak related to his medical care and services. Resident #7 confirmed he had been routinely seen and assisted by a psychologist and felt the services helped him. Review of Resident #7's medical record, revealed he was admitted to the facility on [DATE]. Review of the advance directives section of the chart revealed Resident #7 was his own responsible party but had family as emergency contacts only. Review of the admission diagnosis sheet revealed the following but not limited to diagnoses; BiPolar disorder (onset date 10/11/2016); Epilepsy (onset date 12/15/2020); Major Depression (onset date 7/5/2022); Anxiety (onset date 7/5/2022) and (onset date 1/10/2023). Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 2/1/2024 revealed; (Cognition/Brief Interview Mental Status or BIMS score - 13 of 15, which indicated Resident #7 would be able to answer questions related to his care and service.) Review of the medical record revealed two Level 1 Pre admission Screening Resident Review (PASRR) tools/assessments. The following PASRRs revealed; -Level 1 PASSR completed by an Assistant Registered Nurse Practitioner (ARNP) from a outside agency on 9/23/2016. Under section I (a) of the PASRR screen, which asks what type of Suspected Mental Illness (SMI) the resident had; revealed it was only checked for Other diagnosis - TBI. Section I (b) was not checked for any Intellectual Disability (ID). Section II (1, 2, 3, and 4) were not checked with yes, which would indicate a Level 2 PASRR would need to be completed. It was determined Resident #7 was not in the need for a Level 2 PASRR to be completed. It was determined upon admission Resident #7 had a diagnosis of BiPolar disorder with an onset date of 10/11/2026. This diagnosis was not identified on the 9/23/2016 Level 1 PASRR. -Level 1 PASRR screen on 10/12/2016, competed by a Registered Nurse from the current facility. Review of Section I (a) of the PASRR screen, which asks what type of SMI the resident had; revealed diagnoses to include Bipolar disorder, and Depression disorder. There was nothing checked in Section I (b). Also, Section II (1, 2, 3, and 4) were not checked with yes, which would indicate a Level 2 PASRR would need to be completed. It was determined Resident #7 was not in the need for a Level 2 PASRR to be completed. During Resident #7's admission he had developed diagnoses to include Epilepsy with an onset date of 12/15/2020. Neither of the current Level 1 PASRR screens identified Resident #7 of having Epilepsy in Section I (b). There was no other Level 1 PASRR screens in the electronic record that reflected Resident #7 with a diagnosis of Epilepsy. On 3/21/2024 at 1:00 p.m. the Director of Nursing revealed the above mentioned Level 1 PASRR screens were conducted well before his employment at the facility, but did confirm when a resident develops any SMI or ID diagnosis, a new and revised Level 1 PASRR should be completed. He confirmed Resident #7 had a diagnosis of Epilepsy and neither of the current Level 1 PASRR in the chart reflected this diagnosis. On 3/18/24 at 10:15 a.m. and on 3/19/24 at 7:45 a.m. Resident #20 was observed in her room and was either lying in bed or was noted in a wheelchair at bedside. An attempted interview revealed she did not speak when she was spoken with. She appeared to just want to be in her room and left alone. Resident #20 had been observed dressed for the day and well groomed. She was not otherwise presenting with any behaviors, pain or discomfort. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #20 had a guardian in place to make her medical and financial decisions. Review of the admission diagnosis sheet revealed diagnoses to include: Cerebral Palsy (onset date 10/19/2015); Schizoaffective Disorder (onset date 2/9/2021), Bipolar Disorder (onset 10/19/2015), Schizophrenia (onset date 10/19/2015.) The record revealed an incapacity statement signed and dated by the Medical Doctor on 1/23/2013. Review of the medical record revealed a Level 1 PASRR screen dated 12/15/2010, and was completed by a Registered Nurse at a Hospital. The Level 1 PASRR screen revealed primary diagnosis to include: Scoliosis, Cerebral Palsy; and with a secondary diagnosis of Schizophrenia. It was determined at Resident #20's admission, she also had a diagnoses to include Bipolar disorder with an onset date of 10/19/2015. The PASRR dated 12/15/2010 did not identify Resident #20 of having BiPolar disorder, nor were there any other Level 1 revised or new Level 1 PASRR in the chart that identified Resident #20 having a SMI diagnosis. On 3/21/2024 at 1:00 p.m. the Director of Nursing confirmed Resident #20 had a diagnosis of BiPolar and it should have been identified in the SMI diagnosis section with a more current and revised PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to have activities available and provide adequate space for activities for 52 residents residing on one of one memory care units. Findings included: The initial tour of the memory care unit was conducted on 3/18/24, the observation of the unit and resident rooms did not reveal any posted activity calendar. On 3/18/24 at approximately 10:00 a.m., Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), took approximately 6-7 memory care residents outside to a patio to play with a football. On 3/18/24 at 10:04 a.m., an observation was made of 12 residents sitting, either in a dining chair or wheelchair, in the day room on the memory care unit. The television was playing a sitcom. Staff M, Patient Care Assistant (PCA) was sitting in the corner of the room without any verbal or physical interaction with the residents. Staff K, Certified Nursing Assistant (CNA) directed an ambulatory male resident into the room then left the area. The male resident leaned up against the wall, Staff M stood up, pushed wheelchairs out of the way (from middle of room) and directed the resident to a dining chair. A continued observation of the memory care's day room revealed 12 residents in the room, without a staff member and the sitcom continued. The residents were in sitting at tables along walls or in wheelchairs in different positions throughout the room. The area did not reveal any other activities were ongoing. The approximated dimensions of the memory care units dining room was 14 feet (ft) x 16 ft and a section 8 ft x 6 ft for approximate square footage of 272 sq ft, five 3 ft x 3 ft (approximate) tables were in the room (45 square ft), 272 sq ft - 45 sq ft = 227 sq ft. 227 sq ft divided by 12 residents and one staff member = 17.46 sq ft per person, approximately a 4.2 ft square per person in the dining room. On 3/18/24 at 9:54 a.m. Resident #54 was observed ambulating in the hallway of the memory care unit pushing a wheelchair. On 3/18/24 at 10:45 a.m., Resident #54 was observed sitting in the day room with 11 other residents with the television playing. The resident was sitting in the middle of the room in between tables lining the walls with others residents sitting in wheelchairs. Staff M was sitting in the corner of the room without any interaction with residents. On 3/21/24 at 9:41 a.m. Resident #54 was observed sitting in hallway across from nursing station with other residents when Staff G asked if the resident wanted to go for coffee (off unit). On 3/18/24 at 10:00 a.m., Resident #23 was observed sitting on side of bed, yelling about getting self up. On 3/18/24 at 10:52 a.m., Resident #23 was observed sitting in hallway across from the nursing station with other residents. The observation revealed no activity was occurring. On 3/18/24 at 10:52 a.m., Resident #23 was observed sitting in hallway across from nursing station, no activity was occurring in the area. On 3/20/24 at 11:00 a.m., Resident #23 was observed coming from outside patio, grasping handrail with left hand, utilizing the handrail to propel self in wheelchair. On 3/18/24 at 10:51 a.m., Resident #50 was observed sitting in wheelchair outside the door of the memory care's dining room, across from nursing station. The observation revealed no activities were ongoing other than a television playing in the dining room. On 3/21/24 at 9:43 a.m. Resident #50 was observed in the unit's dining room with seven (7) other residents with movie playing on the television. The observation revealed one of the seven residents was facing the hallway, one was facing out the window, one resident was in the corner adjacent to the television, and one was sitting under the television with head bowed down. Staff A began encouraging residents to use hand sanitizer and handed a bottle to a staff member sitting in the corner. Resident #50 was taken from the dining room to the resident room. On 3/18/24 at 11:48 a.m., 13 residents were observed in the dining area of the memory care unit. Unknown staff member brought a male resident into the room, having to move a female resident away from a table where she sat to place the male resident in the room. On 3/18/24 at 1:40 p.m., Staff A, Registered Nurse (RN) came out of the nursing station and asked residents (who were sitting around the station) if they wanted hand sanitizer then the staff member started up music. On 3/18/24 at 2:33 p.m., an observation of the memory care unit did not reveal any ongoing activities for the residents who were sitting around the nursing station. On 03/19/24 4:01p.m., an observation was made of nine (9) residents sitting in wheelchairs and dining chairs around the memory care nursing station. At the same time nine (9) residents were observed in the dining room with 4 residents facing the television, two with eyes open and five residents not facing the television. No other activity was occurring. An interview was conducted with the Recreation Director on 3/20/24 at 9:14 a.m. The staff member stated activities in the memory care unit have to do more with calming, do a lot of music, and do a lot outside. She reported a previous aide (who used to work at facility) came back to assist with activities today and tomorrow. She stated the more high functioning residents were taken to the main Dining Room for activities, coffee, games, parties, church, and bible studies when the unit was not on isolation. (Memory care unit has been on isolation for COVID+ resident (#80)). The director reported unit activities included a lot of crafts, having markers and papers printed off computer, life reminiscing about past and things, and coffee at 10:00 a.m. She pointed to a bright yellow and pink rolled up material and small ball on desk, saying she saw Staff G with parachute and ball. The director pointed to a closed door beside the patio entrance and reported it was the activity room and had a posted Activity calendar, however, the room needed to be deep cleaned, it had a smell. An observation of the room with the Recreation Director and Staff G was made, revealing a room with a sewer-type smell and multiple totes of activity materials and a large Activity calendar was posted on the wall. (photo of calendar obtained) The Director reported not having any documentation regarding which resident did what activity or who had attended any of the activities, probably should, will start. The Director reported not having an assistant for approximately one month, relies on staff to assist with activities. The calendar posted in the closed Activity room of the memory care unit revealed on 3/18 the following activities had been scheduled with times: - 9:00 a.m. Stretch - 10:00 Coffee Social - 11:00 Sunshine stroll - 1:30-3:30 Quiet time - 2:00 Snacks and Drinks - 2:00 Bible Study with [NAME] - 3:15 Music Therapy - 4:00 Sunshine Time On 3/20/24 at 9:32 a.m., the Recreation Director stated Resident #80 enjoyed music and coffee, likes to walk so the resident will go outside and walk, loves music and snacks. The staff member reported snacks are provided on the unit at 10 a.m. and 2 p.m. The Director stated the activity room had been closed for a week and games and puzzles were kept in there. An observation was made on 3/20/24 at 9:43 a.m. of Staff G reporting to the Recreations Director residents were going to be taken outside and informing the director residents could be taken off the unit for coffee. The Director took 4 residents, including Resident #80 off unit for coffee. An observation on 3/20/24 at 9:46 a.m. showed seven (7) residents in the dining room with television playing. Five of the seven residents were not watching the movie, heads were bent down, and no interaction was occurring between Staff M (sitting in corner) and an unknown female aide standing in the doorway facing the television. An observation on 3/21/24 at 11:27 a.m. revealed 11 residents sitting in the unit's dining room with Staff Y, CNA, sitting in corner. The staff member reported only interacting with residents if they talk to her. One of the eleven residents in the room appears to be watching the movie, no other activity occurring in the room. The staff member stated residents could pick the movie if they wanted to. An observation on 3/21/24 at 11:33 a.m. revealed Staff G had 14 residents on the patio listening to music and playing with parachute. An interview was conducted with Staff L, CNA, at 3/21/24 at 11:37 a.m. The staff member reported staff do not document specific activities but do document when a resident participates in an activity. Review of Resident #54's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified persistent mood (affective) disorder, and cognitive communication deficit. Review of Resident #54's admission Minimum Data Set (MDS), dated [DATE], showed listening to music was somewhat important to the resident. Review of Resident #23's care plan revealed the resident required assistance with activity participation, identified as Catholic, always enjoys exercising/walking, being outdoors, TV/movies, coffee and music, and needed verbal invites, encouragement, and escort. The goal was the resident would attend/participate in/with activities of preference at least 3-5 times (x) weekly as tolerated/as will allow thru Next Review Date (NRD). Review of Resident #54's Quarterly/Comprehensive Participation Review, dated 1/8/24, revealed the resident resided on the memory care unit, attended and participated in/with activities of preference mostly on unit but was verbally invited and escorted to parties and music off unit. Progress toward the resident's goal was met. Review of Resident #54's March CNA Task documentation did not reveal any documentation of activities the resident had participated in or had refused. Review of Resident #23's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to bipolar-type schizoaffective disorder, unspecified intellectual disabilities, and Parkinson's disease without dyskinesia without mention of fluctuations. Review of Resident #23's Quarterly MDS, dated [DATE] revealed a Brief Interview of Mental Status score of 5 out of 15 indicating a severe cognitive impairment. The Annual MDS, 10/27/23, revealed listening to music participating in favorite activities, and going outside was somewhat important to the resident. Review of Resident #23's care plan revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs, enjoyed TV/movies & soap opera's, basketball, coloring/painting, coffee/snacks (junk food), Diet MT. Dew, music = country and R&R and needed verbal invites/encouragement, reminders and escort. The goal of the residents activity was to attend/participate in/with activities of preference at least 3-5x. weekly, as tolerated/as will allow thru NRD. Review of Resident #23's Quarterly/Comprehensive Participation Review, dated 1/29/24, revealed the resident always watched TV/soap opera's & movies, enjoyed country and R&R music, coloring/painting & basketball. Enjoys Diet MT. Dew. Is verbally invited & offered activities of his preference, as tolerated/as he will allow on & off the Memory Care Unit. Continues to attend coffee social & parties/music off the unit often throughout the week. The review revealed the resident's activity goal had been met. Review of Resident #23's March CNA Task documentation showed the resident had not participated in any as needed snacks, 1:1 activities, group activities, church/prayer/religious/spiritual, bingo/games, or self-directed activities. Review of Resident #50's admission Record showed the resident was admitted on [DATE] and 3/14/23. The record included the resident's diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Sequelae (of) traumatic subdural hemorrhage without loss of consciousness, and other seizures. Review of Resident #50's Quarterly MDS, dated [DATE], revealed a BIMS score of 99, revealing the resident was rarely or never understood. The resident's Annual MDS, dated [DATE], revealed the resident did not have any activity preferences per staff interview. Review of Resident #50's care plan showed the resident was at risk for social isolation due to residing on the memory care unit, a language barrier related to Spanish being the resident's primary language, and in the past as to having little interest or pleasure of doing things - used to enjoy parties/music, food related events, used to enjoy playing cards and being outdoors,and needed verbal invites and escort. The resident's activity goal was to be verbally invited/offered & encouraged to participate in activities of (resident's) preference at least 1x. daily, as tolerated/as he will allow thru NRD. The interventions show staff are to Document (resident) response to interventions. Review of Resident #50's Quarterly/Comprehensive Participation Review, dated 2/2/24, revealed Has Language Barrier as Spanish is (resident) Primary Language, but (resident) does seem to understand some very simple English. Can become easily anxious/agitated at times. Is up in (resident) w/c daily & out of (resident) room daily. Is verbally invited & escorted to activities, such as: small group acts., socials, parties & music & outside social/walks. The review showed Goals were not met but resident progress was achieved. Review of Resident #50's March CNA Task documentation showed the resident had not participated in any as needed snacks, additional fluids, 1:1 activities, group activities, church/prayer/religious/spiritual, bingo/games, or self-directed activities. Review of Resident #80's admission Record showed the resident had been admitted on [DATE] and included diagnoses not limited to severe unspecified dementia with other behavioral disturbance, low vision right eye category 1, and blindness left eye category 5. Review of Resident #80's Annual MDS, dated [DATE], revealed a BIMS score of 3, indicating a severe cognitive impairment. The family/representative of Resident #80 revealed listening to music and going outdoors were somewhat important to the resident. Review of Resident #80's care plan showed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs and hobbies and interests were unknown at this time but does seem to enjoy parties/music, coffee, snacks/hydration, walking/outdoors. and required verbal invites and escort. The goal was for the resident to attend/participate in/with activities of her preference at least 1x daily, as tolerated/as resident will allow thru NRD. The interventions instructed staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Review of Resident #80's Quarterly/Comprehensive Participation Review, dated 2/7/24, revealed the resident was verbally invited, encouraged and escorted to activities, both on (and) off the Unit, such as: coffee social, parties (and) music and outside walk on the patio area, ambulates self independently and is out of room daily - has the potential for exit seeking and elopement. The progress towards goals were met. Review of Resident #80's March CNA Task documentation showed the resident had not participated in any as needed snacks, 1:1 activities, group activities, church/prayer/religious/spiritual, bingo/games, or self-directed activities. The policy - Activities, implemented and revised date unknown, revealed the following: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction with the community. 2. Activities will be designed with the intent to: a. Enhance the resident sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. e. Promote or enhance emotional health. f. Promote self esteem, dignity, pleasure, comfort, education, creativity, success, and independence. g. Reflect residence interest in age. h. Reflect cultural and religious interests of the residents. i. Reflect choices of the residents. 4. Activities may be conducted in different ways: a. One-to-One programs. b. Person Appropriate activities relevant to the specific needs, interest, culture, background, etcetera for the resident they are developed for. c. Program of activities to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. 5. Scheduled activities are posted in the residence room, where appropriate, in in a prominent place in the facility. 6. Residents are encouraged, but not mandated, to participate in scheduled activities. 7. Space and equipment necessary are provided to ensure the residents care plan is followed. 9. Special considerations will be made for developing meaningful activities for residents with dementia and /or special needs. These include, but are not limited to, considerations for: a. Residents who exhibit unusual amounts of energy or walking without purpose, b. Residents who engage in behaviors not conducive with a therapeutic homelike environment, c. Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space, d. Residents who go through others belongings, e. Residents who have withdrawn from previous activity interest/ customary routines, and isolate self in room/ bed most of the day, f. Residents who excessively seek attention from staff and/ or peers, g. Residents who lack awareness of personal safety, h. Residents who have disillusioned and hallucinatory behavior that is stressful to themselves. 10. Staff will assist residents to and from activities when necessary. 12. Activities can occur at any time and are not limited to formal activities provided by the activity staff and can include other facility staff members, volunteers, visitors, residents, and family members. 14. The facility will provide one or more rooms designated for resident dining and activities. These rooms will be: a. Well lighted b. Well ventilated c. Adequately furnished; and d. Have sufficient space to accommodate all activities. During an interview on 3/21/24 at 1:16 p.m. the Director of Nursing stated residents should be treated as equals and would expect staff to interact with the residents. The DON stated the facility did have an activity aide quit about a month ago and have interviewed a couple of people.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and five errors were identified for five ( #57, #83, #7, #76, and #98) of eleven residents observed. These errors constituted a 18.52% medication error rate. Findings included: 1. On 3/19/24 at 11:01 a.m., an observation of medication administration with Staff N, Registered Nurse (RN) was conducted with Resident #57. The observation showed the residents electronic medication profile was colored red, showing the medications were late. The staff member dispensed the following medication: - Venlafaxine 150 milligram (mg) Extended Release (ER) capsule Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), informed the staff member Resident #57 was in the Main Dining Room. Staff Z, Interim Staff Educator, arrived, stood at the medication cart with Staff N and reported being there to help Staff N. The Director of Nursing (DON), also arrived to the area, stood behind the staff member, stating the resident was in therapy. The resident was brought to the unit and the medication was administered. Review of Resident #57's March Medication Administration Record (MAR) showed the resident was scheduled at 9:00 a.m. to receive Venlafaxine 150 mg ER capsule by mouth one time a day for depression. The observation revealed Resident #57 had received the antidepressant Venlafaxine two hours after the scheduled time. Review of Resident #57's progress notes, on 3/19/24 at 11:24 a.m. did not reveal the physician had been notified prior to the administration of the late medication. 2. On 3/19/24 at 11:11 a.m., an observation of medication administration with Staff N, Registered Nurse (RN) was conducted with Resident #83. The observation showed the residents electronic medication profile was colored red, showing the medications were late. The staff member dispensed the following medication: - Amlodipine 5 mg tablet The resident was observed sitting in the common area of the unit and was taken to room at 11:13 a.m. where the medication was administered. Review of Resident #83's March MAR showed the resident was scheduled at 9:00 a.m. to receive Amlodipine 5 mg - one tablet by mouth one time a day for hypertension (HTN). The observation showed Resident #83 received the calcium channel blocker (antihypertensive) medication, Amlodipine two hours after the scheduled time. Review of Resident #83's progress notes on 3/19/24 at 11:25 a.m., did not reveal documentation the physician had been notified prior to the administration of medication According to mayoclinic.org, (https://www.mayoclinic.org/drugs-supplements/amlodipine-oral-route/proper-use/drg-20061784), Amlodipine should be taken at the same time each day. 3, On 3/19/24 at 5:01 p.m., an observation of medication administration with Staff O, Registered Nurse (RN) was conducted with Resident #7. The staff member dispensed the following medications, laying packaging on top of med cart. - Ascorbic Acid 250 mg - 2 tablets - Trileptal 300 mg tablet - Trileptal 300 mg 1/2 tablet - Potassium 15 milliequivalent's (meq) Extended Release tablet - Carvedilol 25 mg tablet - Baclofen 5 mg tablet - Baclofen 10 mg tablet - ClearLax 17 gm mixed in small plastic cup with water The staff member confirmed eight tablets had been dispensed. Staff O administered medications to the resident. Review of the Resident #7's March MAR showed the resident was to receive 2 tablets of Potassium ER twice a day for hypokalemia. 4. On 3/20/24 at 11:39 a.m., an observation of medication administration with Staff P, Registered Nurse (RN) was conducted with Resident #76. The staff member obtained a blood glucose level of 264 from the resident. The staff member removed the resident's Insulin Aspart Flexpen from the medication cart, applied a needle, dialed the pen to 6 units and with gloved hands injected the insulin into the left arm of the resident. Immediately following the administration, Staff P confirmed not priming the insulin pen prior to administration. According to the manufacturer's information, accessed on 3/27/24 at 4:12 p.m. at https://www.novo-pi.com/novolog.pdf, users were instructed in the following procedure: Giving the airshot before each injection. - Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units; F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; G. Keep the needle pointing upwards, press the push-button all the way in (see diagram G). The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog FlexPen and contact Novo Nordisk at [PHONE NUMBER]. A small air bubble may remain at the needle tip, but it will not be injected. 5. On 3/20/24 at 4:27 p.m., an observation of medication administration with Staff Q, (LPN) was conducted with Resident #98. The staff member obtained a blood glucose level of 266 from the resident. Staff Q returned to the medication cart and removed the resident's Insulin Lispro pen, dialed the dose selector to 2 units and while holding the pen parallel to the floor primed the pen. The staff member dialed the pen to 9 units and injected the insulin into the left upper arm of the resident. Immediately following the observation, Staff Q confirmed holding the pen parallel to floor thinking the bubble would be at the top. According to the manufacturer's information, accessed on 3/27/24 at 4:29 p.m., (https://uspl.lilly.com/lispro/lispro.html#ug1), user's are instructed in the following procedure: Priming your Pen Prime before each injection. - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. - Step 6: To prime your Pen, turn the Dose Knob to select 2 units. - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. -- If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. -- If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose. On 3/20/24 at 4:52 p.m., an interview was conducted with the Regional Nurse Consultant (RNC) and the Director of Nursing (DON) regarding the observation of medication administration for Resident's #57 and #83. The RNC stated she had noticed Staff N's medication profiles were in the red and had informed Staff G the physician needed to be notified. Staff G showed this writer a text message sent at 10:58 a.m. on a cell phone to the provider revealing state was in the building and meds were late. Staff G and the RNC confirmed the message to the nurse practitioner (NP) did not specify which resident or which medications were late. The observed message did not reveal any specific information regarding residents, medications, or how late were the medications. The staff members confirmed the message was a generic meds were late message. Staff G stated the NP was notified state was in the building otherwise they would have shrugged shoulders. The policy - Medication Administration, implemented 3/24/23, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The compliance guidelines include the following: 10. Review MAR to identify medication to be administered. 11. Compare medication source parenthesis bubble pack, vile, etc. Parentheses with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 14. Administer medication as ordered in accordance with manufacturer specifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of the facility's policy titled Pest Control Program, the facility failed to maintain an effective pest control program, for two of two units and the kitchen, as evidenced by observation of pests on four (03/18/2024, 03/19/2024, 03/20/2024 and 03/21/2024) of four survey days. Findings included: 1. An observation on 03/18/24 at 10:05 a.m., revealed a corner on the secured unit near the smoking area door that had multiple flying insects on the walls. Photographic evidence obtained. An observation on 03/18/24 at 10:25 a.m., revealed a cockroach crawling around Resident room [ROOM NUMBER]'s bathroom. Photographic evidence obtained. An observation on 03/19/24 at 1:00 p.m. revealed multiple flying insects that flew around the secured unit nurses' station. During an interview on 03/19/24 at 09:40 a.m., Staff H, Pest Management (PM) stated that his company provides pest services to the facility on a weekly basis. Staff H, PM stated the company provided services that included outside area with exterior sprays, general pest services, kitchen services, setting of baits and interior services when needed. Staff H, PM stated he had not been notified of any pests concerns lately. An observation on 03/20/24 at 1:42 p.m. revealed two flying insects that flew around the conference room. An observation on 03/21/24 at 10:53 a.m. revealed one flying insect that flew around conference room. During an interview on 03/20/24 at 11:35 a.m., Staff J Director of Maintenance (DOM) stated staff were to report any insect activity to maintenance. Staff J, DOM stated the facility had a local pest company who came to the facility once a week to provide pest control. Staff J, DOM stated staff had not had any complaints lately regarding bugs in the facility. Review of the facility's Pest Sighting Log Sheet showed the following entries: -01/15/24- the nurses station bathroom had rat feces. -01/29/24- Ants in room [ROOM NUMBER]. -02/12/24- No issues reported. -02/26/24- Big roach in room [ROOM NUMBER] -03/20/24- No issues reported. Review of the local pest management company's Invoice and Service Report showed the following reports: - 03/19/24- room [ROOM NUMBER] suspected insect activity. Treated common areas, front office, nurses' stations, break room and dining room. - 03/05/24- Inspections of books and logs and discussion with management regarding building progress. - 01/29/24- Kitchen, dining rooms [ROOM NUMBERS] treated for ants. - 01/02/24- Kitchen sprayed and baited and dusted. Dining room, breakroom, administrator's offices and all exits. No issues reported. - 12/18/23- Rooms kitchen, break room, dining, hallways and exits were sprayed. Beauty salon treated as well. 2. On 3/18/24 at 10:24 an observation was made of a brown substance smeared on the wall of a small alcove located next to patio exit door. The observation revealed multiple small flying gnats on the wall near the brown smear. (Photographic evidence was obtained) 3. On 3/18/2024 at 9:10 a.m. a tour was conducted in the kitchen. During the initial tour of the kitchen there were four small flying insects flying around the food preparation tables and also in the dish machine room. There were also more than three small flying insects flying around the three compartment sink and near the floor drain. During an interview at the time of the observation, Dietary Aides Staff D and E revealed they were not aware at first of the insects, but then did see them flying around after they were pointed out. Staff D and E were not sure how long the insects have been in the building but added pest control comes into the kitchen routinely to treat for these type of flying insects. They could not remember exactly the last time pest control was in the kitchen. On 3/18/2024 at 9:50 a.m. through 10:10 a.m. observation of the High 100's hall to include rooms 172 - 183 revealed small black flying insects flying around, to include rooms: -room [ROOM NUMBER] Bathroom (one insect flying); -room [ROOM NUMBER] Bathroom (over three insects flying); -room [ROOM NUMBER] between A and B bed (two insects flying). The 100 hall nurse station was observed with four small insects flying around the hallway and at the nurse desk. On 3/19/2024 at 8:50 a.m. through 9:10 a.m. observations revealed over five small black flying insects flying around in resident rooms 176 bathroom, 177 room, and at the 100 hall nurse station. Review of the facility's Pest Control Program revised date 02/2023 showed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observations, staff interviews, and facility record review, the facility failed to ensure a working and properly maintained dish washing machine in the kitchen, during two of four days observed, (3/18/2024, and 3/19/2024). It was determined the low temperature chemical sanitizer dish washing machine either; 1. Was not meeting required wash and rinse temperatures, and 2. The chemical sanitizer was allocated and delivered well over acceptable ranges. Findings included: On 3/18/2024 at 9:10 a.m. an observation of the kitchen was conducted with Staff C, Dietary Manager, Staff C revealed the facility operates a low temperature dish washing machine and the expectations for wash temperatures was 125 degrees Fahrenheit (F)., and rinse temperatures was 125 degrees F. She was asked what the sanitizer level Parts Per Million (PPM) should range, and she replied, over 100 ppm. The dish washing machine was observed and the specification plate posted on the front revealed it was a low temperature chemical sanitizing machine where the wash temperature should reach 120 degrees F., the rinse temperature should reach 120 degrees F. and the chemical sanitizer should reach a ppm of 50 - 100. At 9:40 a.m. the kitchen was again toured with Staff C, Dietary Manager. Staff D and Staff E, Dietary Aides were noted in the dish machine area and starting to load crates with dishes into the machine. Staff C then stated, I will be back, I need to leave the kitchen to go out to my car and call the Dietician. She left the kitchen at 9:43 a.m. Continuing the kitchen tour, Staff D was observed to start running crates of dishes through the dish washing machine. At 9:52 a.m. (over nine minutes later), Staff C returned to the kitchen. At this time, Staff D had completed three crates of dishes through the machine. Staff C was asked if she or her staff could now perform a demonstration on how the dish machine operated. At 9:58 a.m. an interview with Staff D, Dietary Aide revealed he had been working in the facility for awhile and he uses the dish washing machine every day. Staff D explained the dish machine was a low temperature chemical sanitizing machine and explained the wash temperature should reach around 140 degrees F. and the rinse temperature should reach around 125 degrees. After consultation of the specification plate on the machine, he said the wash temperature should reach 120 degrees F., and the rinse temperature should reach 120 degrees F. Continuing the interview, Staff D confirmed there was chemical which ran through the dish machine, and the sanitizer level is tested via litmus paper test strips. He stated the test strips should show 200 ppm, before correcting himself, stating 200 ppm was for the three compartment sink sanitizing agent, and the dish machine should be at 50 ppm. At 9:59 a.m. Staff D was asked to run a crate of dishes through the machine when he was ready. Staff C confirmed the machine was operating correctly with both the water temperatures and the chemical sanitizer level. Once the crate of dishes were placed in the machine, and during the wash cycle, observation showed the temperature reached a maximum of 118 degrees F. After the wash cycle ended, the rinse cycle started and continued observation showed the rinse water temperature reading 117 - 119 degrees F. The temperature readings were found on an analog thermometer gauge attached to the machine. Staff C then grabbed a cylinder container of paper litmus test strips and pulled one out and placed it in the water return catch tray on the machine to test the chemical sanitizer ppm. He kept the test strip in the catch tray for about ten seconds and pulled it out and placed it on top of the litmus paper test strip bottle, which had color ranges. The test strip was a very deep blue/purple color, which indicated the ppm was over 200. Staff C confirmed the ppm on this test was over 200 ppm. Photographic evidence was taken. At 10:01 a.m. Staff D was asked to do a second demonstration of the use of the machine. Staff D pushed a crate full of soiled dishes through the machine and started the wash. The analog gauge was observed to reach a maximum of 117 degrees F. The machine then clicked and the rinse cycle started, and during the cycle the analog temperature gauge reached an maximum of 118 degrees F. Staff D and Staff E both confirmed the needle on the gauge was below the 120 degree F. mark and it should be 120 degrees F. and above. After the wash/rinse cycle Staff D was asked to test the chemical sanitizer again and he proceeded to take a new paper litmus test strip and placed it in the water catch tray. He held the strip in for ten second and removed it and placed it on the test strip bottle. The test strip was observed a very dark blue/purple color and when placed on the test strip bottle confirmed the ppm was over 200 ppm. Staff D confirmed there was too much sanitizer going through the machine. Staff C, Dietary Manager returned, and looked at the bottle legend and the strip and confirmed the color denoted over 200 ppm and said the machine should not be allocating that much sanitizer. She confirmed the ppm should be in a range of 50 - 100 ppm, which should be a very light blue/light purple color. Staff C provided the dish washing machine temperature logs for the past three months for review. It was determined for each meal service (breakfast, lunch, and dinner), and each day of the month, it was documented temperatures for wash and rinse reached over 120 degrees F. It was further revealed staff had documented for each meal service, the chemical sanitizer ppm reached 100. Staff C, Dietary manager only provided months 12/2023, 1/2024, and 2/2024 for review. Staff C was asked during the course of the survey for the logs 3/18/2024 through 3/21/2024, to include the current 3/2024 month's log, but was able to provide, or provide a reason for their absence. Therefore, it could not be identified if the machine was running at appropriate temperatures for the last twenty-one days in 3/2024. On 3/18/2024 at 2:00 p.m. Staff C provided paperwork to show the dish machine maintenance company previously came out to assess and fix the machine related to low wash and rinse temperatures. The report which was dated 2/23/2024 at 9:07 a.m. revealed upon testing, the machine wash temperature was at 109 degrees F., and the final rinse temperature was at 109 degrees F. The test further revealed a chemical sanitation test reading 100 ppm. The notes reflected: Water temp is too low, only at 109 degrees F. and should be 120 - 159 degrees F. Staff C also provided a maintenance request log which revealed date 3/15/2024, Temperature not adequate. Maintenance Department notified. The log revealed an action performed to include; Adjusted temperature on the boiler to 130 degrees F. and Monday was adjusted again to 125 degrees F. on the dishwasher. On 3/19/2024 at 8:45 a.m. Staff C was interviewed and confirmed staff should be running the dish machine around 9:30 a.m., 9:40 a.m. She replied, to be fair when you [state surveyor] tested the dish machine temperatures the day before on 3/18/2024, they had not primed the machine and her staff had not ran any dishes through the machine yet. Staff C was reminded in her absence from the kitchen on the previous day Staff D and Staff E were observed running three crates of dishes through the machine. Staff C responded, oh, I didn't know my staff ran crates of dishes when I left the kitchen to make a call to the dietician. On 3/19/2024 at 9:50 a.m. the kitchen was toured with the Staff C, Dietary Manager. She revealed the dish machine was operating appropriately and she had inserviced her staff how to use the machine and how to identify errant temperatures. Staff D, Dietary Aide was observed operating the machine and stated he had already ran crates of dishes through the machine. He noted he had been using the machine for approximately five to ten minutes. Staff D was asked to do a demonstration and the following was observed: The first demonstration at 9:53 a.m. revealed per review of the analog gauge, the wash temperature reached a maximum of 118 degrees F. The rinse temperature reached 121 degrees F. Staff D stated the gauge was wrong and maintenance had come in yesterday and used a digital thermometer to take the temperature of the wash and rinse cycle. Staff D revealed he did not have a stick analog or digital thermometer and that he nor Staff E did not use any thermometers today to see if the temperatures reached 120 degrees F. for the wash or rinse cycles. After the wash and rinse cycle was completed, Staff D then tested the sanitizer by using a litmus paper test strip. The results of the test strip revealed a very dark blue/purple color with a range of over 150 - 200 ppm. Staff D revealed the PPM should be at 50 - 100 ppm. At 9:55 a.m. Staff D performed a second dish washing machine demonstration. It was determined per review of the machine's analog temperature gauge, the wash temperature reached a maximum of 119 degrees F. and the rinse cycle temperature reached 121 degrees F. Staff D also tested the sanitizer by inserting a litmus paper test strip in the water catch container of the machine. The paper turned dark blue/purple and indicated the chemical sanitizer PPM was over 150 - 200 ppm. Staff D confirmed the results of the PPM was too high and he had mentioned this to Staff C. Staff E also confirmed the dietary manager had been told the machine had not been working appropriately in the past. Both Staff D and Staff E declined to comment further. Staff C revealed they would be using the three compartment sink to wash all the dishes and would do so at 12:00 p.m. On 3/19/2024 at 11:33 a.m. an interview was conducted with Staff C and an outside service technician who maintains the dish machine. The technician revealed he was out at the facility just last month in 2/2024 and had to make adjustments to the machine water temperature, as the temperatures were not meeting the low temperature machine specifications. He believed his report revealed the wash and rinse temperatures were only reaching 109 degrees F. and he had to increase the booster temperature to meet 120 degrees F. for wash and 120 degrees F. for rinse. The technician further revealed he had tested the sanitizer and it met requirements to be between 50 - 100 ppm (parts per million). He further revealed he did not have to do anything else back in 2/2024 with the dish machine during that visit. The technician confirmed verbally, and pointed out the machine specifications plate, that the machine was to be operated as a low temperature chemical sanitizing machine, with wash temperatures to reach 120 degrees F., and rinse temperatures to reach 120 degrees F. He further again confirmed that the chemical sanitizer range should be within 50-100 ppm. The technician revealed he was called out to the facility today on 3/18/2024 to look at the wash and rinse temperatures and found that the analog gauge on the machine was not working properly and he had to order a new one. He revealed the acceptable water temperature testing each shift would be to use a digital stick thermometer in the water return catch can on the machine to test water temperatures until a new gauge is installed. He was not sure when the new gauge would arrive and be installed. The technician revealed he had been called out to the facility again today, on 3/19/2024 because of a complaint there was too much sanitizer overflowing into the machine. The technician revealed the problem with the machine was a cam wheel was open too much and that was the reason for getting too much sanitizer. It was determined the dish machine was not working appropriately to include heavy use of sanitizer allocated for two days 3/18/2024, and 3/19/2024, and affecting at least four meal services in between those dates. A policy related to the use and maintenance of the dish washing machine was requested; however, the facility was unable to provide by completion of the survey.

Based on interview and record review, the facility failed to report a reasonable suspicion of a crime to law enforcement for 1 of 4 incidents reviewed. (Resident #3). Law enforcement was not notified after a 30-day supply of the anti-anxiety/ anti-seizure medication Klonopin was found to be missing from the medication cart, was never signed in as received and was not entered on the facility's controlled substance inventory list. The findings include: Review of a facility reported incident that was submitted on 5/6/2022 regarding an allegation of misappropriation of resident property revealed the Nursing Home Administrator (NHA) at the time of the incident submitted the report and initiated an investigation. According to the report's investigative findings, Resident #3 had diagnoses of autistic disorder, schizophrenia, anxiety disorder, and hypertension. Further review revealed the nurse caring for Resident #3 on 5/5/2022 noticed that the card for Klonopin 0.5 mg was not in the narcotic box on the cart. A nurse then called the pharmacy and confirmed that it was delivered on 5/4/2022. Staff A, Licensed Practical Nurse (LPN), was the nurse to receive the medication from the pharmacy on the morning of 5/4/2022. The medication was not entered on the controlled substance inventory list and the requisition sheet from the pharmacy was missing. The nurse and evening supervisor searched for the card of medication on all medication carts, but it was not located. The report indicated that the resident representative and the abuse registry were both notified on 5/6/2022. There was no indication the incident had been reported to law enforcement. Upon entrance to the facility on 7/11/2023 at approximately 8:20 AM, the surveyor met with the Director of Nursing (DON) and requested all documentation pertaining to the aforementioned facility reported incident. On 7/12/2023 at approximately 11:00 AM, a telephone interview was conducted with the former Nursing Home Administrator (NHA) in the presence of the current NHA, the Regional Clinical Director, and the Divisional Risk Manager. The surveyor stated that so far during this complaint investigation, there has been no evidence that law enforcement was notified. When asked if the incident was reported to law enforcement for investigation, the former NHA responded, Yes, it was. It would be in the investigative file. When asked who would have been responsible for notifying law enforcement, she replied the (former) DON. Following this interview, the current NHA went to search for evidence that a report was made to law enforcement but was unable to locate the documentation in the facility's investigative file. On 7/12/2023 at approximately 12:00 PM, the current NHA reported that she called the Pinellas Park Police Department and was informed she would have to submit a public record request since the incident was from 2022. The surveyor invited the NHA to share any documentation received from the request even if it was after survey exit. By 7/18/2023, no additional information pertaining to the police report had been received from the facility. On 7/18/2023 at 10:38 AM, a telephone interview was conducted with Police Records Technician from Pinellas Park Police Department. At the request of this surveyor, the Police Records Technician reviewed the 2022 reports/intakes in their computer system and stated that no report in which Resident #3 was the alleged victim or Staff A was the alleged perpetrator had been received by the department. Review of the facility's Narcotic Management and Destruction policy and procedure implemented 2/18/2023 revealed that the drug diversion process includes Notify police and follow additional guidance provided by them. Review of the facility's Reporting Reasonable Suspicion of a Crime policy and procedure implemented 9/27/2022 revealed It is the policy of this facility pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime against a resident of this facility. Review of section 5 under Policy Explanation and Compliance Guidelines revealed notification will include Each covered individual's independent obligation to report the suspicion of a crime against a resident or individual receiving care and services from the facility directly to law enforcement. Further review of section 5 revealed the timeframe requirements for reporting reasonable suspicion of crimes as follows: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion no later than 24 hours after forming the suspicion. The policy also stated, Although it remains the responsibility of each covered individual to ensure that his/her individual reporting responsibility is fulfilled, in addition to reporting directly to law enforcement and the State Survey Agency, it is the policy of this facility that employees also report suspicions to the Administrator, or designee. The policy continued that The Administrator, or designee, will then assist the covered individual with reporting requirements and ensure specified timelines are met accordingly for both the initial and follow-up investigation reports and any other State level required reporting. Further review revealed Examples of situations that would be considered crimes in all subdivisions include, but are not limited, to: . g. Drug diversion for personal use or gain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, and homelike environment on 2 of 2 hallways on the South (memory care) Unit, 1 of 2 day rooms (#2), and 1 of 1 shower room observed. The findings include: On 7/11/2023 at 3:05 PM, photographic evidence was obtained for each of the following concerns noted during a tour of the facility's South (memory care) Unit: 165 - One of three drawers of the dresser in room [ROOM NUMBER] which was designated for A bed contained missing knobs. The particle board leg on the left side of the dresser was deteriorated to the extent that the dresser sloped downward to the left. The dresser was originally white, but contained a mismatched drawer replacement on the bottom that was brown. The particle board dresser top was warped and contained patches where the material had bubbled and the surface coating was discolored or absent. The footboard side of the room spanning both A and B beds contained approximately 10 areas of patched wall. This was evidenced by white smears on top of the yellow paint. The seat of a wheelchair designated for A bed was heavily soiled. The left armrest was in disrepair as evidenced by approximately two-thirds of the armrest had the interior foam exposed. The black exterior coating that was peeling away around the edges created a jagged surface. Two cigarettes were situated between the wheelchair seat cushion and the left side panel. To the left of the bathroom door there was a missing wall corner guard. The corner contained a long vertical crack, and the surrounding wall was rough and uneven. This corner contained white smears approximately four feet up the wall from the floor. 164 - One of two doors on the wardrobe in room [ROOM NUMBER] designated for A bed contained a missing knob. Dark brown drip marks from a dried liquid spanned approximately two-thirds of the width of the wardrobe at the base and rose to about 1.5-2 feet from the floor. To the left of the air conditioning unit, approximately 3 feet of the rubber baseboard was peeled away from the wall. Also to the left of the air conditioning unit was a damaged floor tile that was missing a corner. 163 - room [ROOM NUMBER] was a private room with two patched areas on the headboard side wall. The top left corner of the top nightstand drawer was missing. 162 - One of two drawers located at the bottom of the wardrobe in room [ROOM NUMBER] designated for A bed had no handle. The top of this wardrobe was being used for storage as a pile of clothes and a faux plant were sitting on top. Red lettering was affixed to the top of the wardrobe that read: FIRE & SAFETY LAWS PROHIBIT ANYTHING ON TOP SHELVES as items located near fire sprinklers may impact the effectiveness of the system. The wall above A bed's headboard contained a patched area of wall approximately the size of a soccer ball. The edges of the bathroom mirror were de-silvering. A raw piece of lumber was nailed vertically to the left side exterior of the bathroom vanity. One of three vanity lightbulbs was missing. The wall mounted toilet paper dispenser was missing the toilet paper holder rod. 161 - The edges of the mirror in room [ROOM NUMBER]'s bathroom were de-silvering. One of three vanity lightbulbs was out. The wall mounted toilet paper dispenser was missing the toilet paper holder rod. The wall behind room [ROOM NUMBER]'s door contained a golf ball sized hole within a softball sized patched area. The dresser designated for B bed had missing laminate/vinyl which spanned the length of the dresser top and exposed the underlying particle board. 160 - room [ROOM NUMBER] contained two residents and had no privacy curtains. The dresser designated for A bed had one of six drawers with functional handles/knobs. Some of the hardware present was mismatched. The front and top of the dresser showed wear and tear as evidenced by scratch marks on all forward facing surfaces and discoloration on the top where the original dark wood stain had worn away. 158 - room [ROOM NUMBER] was a double occupancy room, but only B bed was occupied at the time. The wall behind A bed's headboard contained an approximately 4-foot-long patched area. The door of A bed's nightstand was missing a knob. The window wall and headboard wall for B bed contained approximately 4 patched areas. 156 - Across from the bathroom door in room [ROOM NUMBER] is an area of patched wall approximately 1.5 x 2.5 feet. The side and rear wall surrounding the wardrobe belonging to A bed contained approximately 3 patched areas. The wall above B bed's headboard contained 3 patched areas. The wall above the rear left corner of B bed's dresser contained two patched areas, one of which was approximately 1.5 x 1.5 feet. The bathroom mirror was de-silvering around the edges and most notably in the bottom left corner. The bathroom floor is originally beige in color but stained black around the toilet from the vanity to the wall. The bathroom walls were visibly rough and uneven with layers of patchwork. 154 - In room [ROOM NUMBER], the floor in front of the air conditioner contained a broken tile. The wall in-between A and B bed's nightstands contained a patched area approximately 1.5 x 1 feet. 152 - In room [ROOM NUMBER]'s bathroom, the wall mounted toilet paper dispenser was missing the toilet paper holder rod. Two of three vanity lightbulbs were out. The floor around the toilet was dirty and in disrepair. 146 - The top of the dresser in room [ROOM NUMBER] designated for B bed was scratched and peeled away in the front middle and front left corner. In room [ROOM NUMBER]'s bathroom, the wall mounted toilet paper dispenser was missing the toilet paper holder rod. One of three vanity lightbulbs was out. The left side of the bathroom vanity had a raw piece of plywood nailed to it. The bathroom contained a light-colored floor but the areas around the base of the toilet and vanity contained a buildup of a dark brown substance. 144 - The wardrobe in room [ROOM NUMBER] designated for A bed contained a mismatched set of drawers, one of which had no handle. 143 - The dresser in room [ROOM NUMBER] designated for B bed contained 3 of 6 drawers with no knobs. The stain on the top of the dresser was also worn away in areas exposing the lighter color below the surface. 142 - The wall in room [ROOM NUMBER] next to A bed's wardrobe contained black horizontal scuff marks and a patched area of wall. There were also approximately 5 small, patched areas of wall above A bed's headboard. The dresser designated for B bed had four of eight knobs missing. The dresser contained signs of wear and tear like chipped surfaces. The set of drawers on the wardrobe designated for B bed contained mismatched hardware. The wheelchair cushion designated for B bed contained dried food debris. 141 - In room [ROOM NUMBER], the floor at the base of the left side doorframe (from hallway) contained broken tile. The wall next to A bed was missing the rubber baseboard leaving the damaged wall behind it exposed. The rubber baseboard was also peeled away from the wall in the bathroom behind the toilet, around the vanity, and on two other walls. 140 - The wardrobe in room [ROOM NUMBER] designated for B bed contained a set of drawers with a missing handle. The exterior coating of the wardrobe door was peeling away around the bottom edges. All three drawers of the nightstand designated for B bed were misaligned and in need of repair. In the bathroom, a potent urine smell was present, and the floor contained yellow discoloration around the toilet. The bathroom contained a white patch of unpainted wall the size and shape of a soap dispenser to the right of the vanity. Approximately 5 patched areas were present on other walls of the bathroom. 139 - In room [ROOM NUMBER], the floor at the base of the right-side doorframe (from hallway) contained broken tile. 138 - In lieu of hardware, the wardrobe door in room [ROOM NUMBER] designated for A bed contained a makeshift handle made of fabric. The A bed was made but contained a stained pillowcase and soiled bed linens. 136 - In room [ROOM NUMBER], the dresser designated for A bed contained four of four drawers with loose knobs and one of these drawers was missing a knob. The dresser contained signs of wear and tear like chipped and scratched surfaces. The top of the nightstand designated for B bed contained a warped surface and liquid stains. In the bathroom, the rubber baseboard was missing from the wall to the right of the door. 135 - In room [ROOM NUMBER], the wall corner just to the left of the doorway (from the hall) was in disrepair and missing the rubber baseboard. The flooring at the base of both sides of the doorframe was damaged as it contained broken tiles. The wall beneath the air conditioning unit was damaged as evidenced by discoloration and exposed layers of drywall material. 134 - In room [ROOM NUMBER], the wardrobe designated for B bed was missing one of two drawers. 133 - The blinds in room [ROOM NUMBER] were in disrepair as evidenced by broken slats. 132 - In room [ROOM NUMBER], the dresser designated for B bed contained a broken handle, scratches, and chipped paint. Day room [ROOM NUMBER] contained a rusted two-drawer filing cabinet. Day room [ROOM NUMBER] also contained damaged wall where a sink and soap dispenser had been removed. A wooden box was nailed to the wall to conceal the plumbing. The door to the closet that stores the activities supplies in day room [ROOM NUMBER] has a hole where a doorknob had previously been as well as missing paint around the knob. The mosaic tile floor of the shower room contained mismatched sections of tiles. The shower floor contained dark brown stained tiles and grout. The shower walls contained areas of brown stained grout. The ceiling air vent by the nurses' station contained droplets of condensation and black biological growth. The mechanical lift by the smoking patio was uncovered and contained a layer of gray film. Hair was spun around the wheels. On 7/11/2023 at 3:27 PM, during the aforementioned tour, the Nursing Home Administrator (NHA) approached this surveyor to inquire about the concerns identified so she could get them addressed overnight. The surveyor stated that it would be difficult for the facility to address all environmental areas of concern by tomorrow. Due to the extent of concerns and the fact that evidence gathering was still in progress, the surveyor walked the NHA through room [ROOM NUMBER] as an example and pointed out the concerns noted in the tour above. Regarding the wheelchair utilized by A bed, she stated housekeeping is responsible for deep cleaning wheelchairs every other month and nursing staff are supposed to be wiping down resident equipment daily/after each use. The NHA questioned the environmental concerns pointed out by the surveyor. When asked if her home looks like this (patched areas of wall, furniture in disrepair, etc.), she replied No. On 7/12/2023 at 9:56 AM, an interview was conducted with the Director of Maintenance/Environmental Services. He stated he has been in this role since the end of October (2022). He added that he has an assistant that started around the middle to end of January (2023). When asked if there's a system in place to ensure all resident rooms were audited at some regular interval to identify needed repairs/maintenance, he replied No. He added that the rooms he is in regularly are those of residents who clog the plumbing several times a day. When asked for the primary reason the memory care unit appeared in its current condition, he stated that it has been a slow process because they try not to have maintenance activities affect the residents, so they try to keep work and projects limited and confined to small areas. He added that he would like to make faster progress. When asked if there was any furniture that had been reported on any maintenance logs as needing replacement, he replied No. He added that the previous administration had mentioned the intent of having some furniture replaced. On 7/12/2023 at 10:26 AM, an interview was conducted with Staff I, Housekeeper. She stated she works 4 days per week and strictly on the memory care unit (South). She further stated she has worked at the facility for about 6-7 months. When asked to describe the protocols and procedures for cleaning shared resident equipment (e.g., lifts) and individual resident equipment (e.g., wheelchairs and walkers), she stated that housekeeping does not clean those items. She added that housekeeping handles linens, but not resident equipment. Staff I continued that she is also a certified nursing assistant (CNA) and when she is working as a CNA, she will wipe down equipment after use. Staff I stated that when she is working as a housekeeper, if she sees a wheelchair that is really bad, she will wipe it down. Staff I further stated that the night staff sometimes get a team together to clean resident wheelchairs while residents are asleep. When asked how she handles identified items in need of repair or replacement while she is in resident rooms cleaning, she stated she often sees the Maintenance Director in passing and will verbally express needs and he will write it down, or she will have him paged or she will write it down in the logbook. When asked what type of memory care unit concerns she has brought to the Maintenance Director's attention over the last 6 months, she stated clogged plumbing, mold, and hand sanitizer dispensers coming loose from the wall in common areas. On 7/12/2023 at 10:48 AM, an interview was conducted with the Housekeeping Manager. She stated she has been at the facility for about a year. When asked to walk through housekeeping's cleaning process, she stated their routine is to wipe down windowsills, air conditioning units, tops of wardrobes, handles, bedrails as well as empty bed mattresses, clean cords, dust off lights, disinfect call lights, and clean IV (intravenous) poles containing obvious spills. When asked about the cleaning process for resident equipment, she stated that wheelchairs are power washed on a bi-monthly basis for each unit, the South Unit is done one month and then the North Unit the next, but her team is not responsible for this. When asked if that included lifts she replied, No. The Housekeeping Manager added that there was a meeting held by the NHA about a month ago in which they were directed to start cleaning the lifts once a month. The Housekeeping Manager explained that there was an individual in central supply who used to have this duty, but they are no longer doing it and it has since been reassigned to housekeeping. When asked who is responsible for bed linens, she replied that CNAs change out bed linens, but housekeeping washes them. When asked if she conducts any quality assurance checks of staffs' work, she said there are rooms that are assigned to be deep cleaned daily and she checks those rooms which includes completion of a form in which she checks a box for satisfaction or unsatisfaction. When asked how she handles unsatisfactory audits, she stated she approaches the staff and lets them know it was a miss and that it needs to be redone. When asked if there is any sort of re-education that is provided as part of that process, she replied that she just refers them back to the terminal cleaning checklist which covers all items to address. On 7/12/2023 at 12:09 PM, an interview was conducted with Staff F, CNA. Staff F stated she has worked at the facility for approximately 5 years and is solely assigned to the memory care unit (South). When asked to provide examples of items she would report to maintenance for repair/replacement, she stated broken furniture, broken toilets, stuff hanging off the wall, broken lights, and problems in the shower room such as a non-functional shower hose or no warm water. When asked to explain the facility's process for reporting these concerns, she stated there's a maintenance logbook at the nurses' station to enter the date, time, location (e.g., resident room, dayroom, etc.), reporter's name, and summary of concern. When asked if she had identified any reportable issues today, she replied Yes, we noticed the hand sanitizer dispenser was hanging off the wall in the dayroom. Maintenance took care of it right away. When asked if there was anything else that seemed in need of repair/replacement, particularly in resident rooms, she replied No. When asked if the furniture all appeared to be in good working condition, she replied, Well, no, there are drawers that are broken but maintenance is aware of that, and I'm told it is going to be replaced. When asked if the resident rooms appeared homelike, she replied No, not all of them, it could be better. Review of the facility's Safe and Homelike Environment policy and procedure implemented 6/24/2023 revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. The policy defined environment as any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. The policy further provided the following definition of sanitary includes but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. Section 3 of the policy revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Section 4 of the policy revealed The facility will provide and maintain bed and bath linens that are clean and in good condition. Section 6 of the policy stated, The Maintenance Director will perform periodic rounds to ensure functioning lights. Review of section 9 which included general considerations revealed Report any furniture in disrepair to Maintenance promptly. Review of the facility's Cleaning and Disinfection of Resident-Care Equipment policy and procedure implemented 6/24/2023 revealed the Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control and Prevention) recommendations in order to break the chain of infection. Item 3 under Policy Explanation and Compliance Guidelines revealed Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow professional standards of practice for wound care for two residents (#7 and #8) of six sampled residents related to improper wound cleansing and inadequate hand washing between wounds and after wound care. Findings included: 1. On 12/21/22 at 10:00 a.m. an observation was conducted of Resident #8's wound care for an abscess on the left side of his back that was draining moderate yellow. Staff E, Licensed Practical Nurse (LPN) set up supplies on the overbed table with a clean towel as a barrier, cleansed her hands very quickly and donned gloves. Staff E was observed to cleanse the wound with a saline gauze in an up and down motion over the open wound and back instead of a circular motion. Staff E used a cotton tip applicator and applied Santyl to the center of the wound. Staff E touched all over the dressing when folding the gauze with a gloved hand then applied a border gauze. Staff E then washed her hands. An interview took place immediately after this observation. Staff E stated, related to the need to wash hands for 20 seconds and careful wound care, that she would be more careful. Review of Resident #8's admission Record revealed an admission date of 2/2/21 with a diagnoses to include unspecified protein-calorie malnutrition. Physician orders dated 12/21/22 included: *11/13/22 Start Date: Santyl Ointment 250 Unit/GM (collagenase) Apply to Left back topically every day shift for abscess until healed. *12/22/22 Start Date: Santyl Ointment 250 Unit/GM (collagenase) Apply to Left back topically every day shift for abscess until healed apply clean dry dressing. Record Review of the Wound Assessment Details, dated 12/20/22, revealed the open abscess of the left back had been in treatment for 6 weeks and measured 0.7 cm (centimeters) length x 2.5 cm width x 0.2 depth. The Wound Assessment Details, dated, 12/13/22 revealed the wound measured 1 cm length x 3 cm width x .1 cm depth. 2. On 12/21/22 at 10:15 a.m. observation of Resident #7's wound care provided by Staff E, LPN revealed the resident had two open wounds left shoulder and coccyx. Both previous dressings were removed. Staff E washed her hands quickly and applied gloves. Staff E cleansed the left shoulder terminal ulcer with normal saline (NS) using a straight motion going from skin to wound instead of a circular motion from center of the wound out. The resident moaned when the NS gauze touched her. Staff E applied Santyl ointment, to the center of the wound, with a cotton tip applicator. She then applied a dry dressing. Staff E doffed her gloves and washed her hands very quickly, for 12 seconds timed. Then Staff E applied new gloves and cleansed the coccyx terminal ulcer with NS using a straight down motion instead of a circular motion from center of the wound out. Staff E applied Santyl using a cotton tip applicator, to the center of the wound. Staff E applied a dry dressing. She disposed of the dressings, repositioned, and covered the resident. Staff E washed her hands for 15 seconds and dried them with a paper towel. At this time, Staff E stated the resident was considered terminal and has comfort measures only. A record review of a listing titled, Non Pressure Wounds, provided by the Director of Nursing, showed Resident #7's wounds as a coccyx terminal ulcer [NAME] (in house acquired), and a left shoulder terminal ulcer [NAME]. A review of the wound care notes showed both wounds as pressure wounds: Left shoulder as acquired Stage III with granulation tissue present 25% no odor, tunneling or undermining, and the coccyx as Unstageable, granulating 25% of the wound bed has an odor present .no signs of infection. The wounds were first noted on 12/20/22. Review of Resident #7's admission Record revealed an initial admission date of 11/25/22 with a diagnosis of Alzheimer's Disease and unspecified protein-calorie malnutrition. In addition, the resident was readmitted to the facility on [DATE] from the hospital with a displaced intertrochanter fracture closed fracture with routine healing and Aftercare following joint replacement surgery. Physician orders dated 12/21/22 included: *12/20/22 Phone order: coccyx and left shoulder, cleansed with NS apply Santyl, cover with dry dressing daily and prn (as needed), as needed for pressure wound. *12/21/22 Verbal order: coccyx and left shoulder, cleansed with NS apply Santyl cover with dry dressing daily and prn, as needed for terminal wound. 12/16/22 Verbal order: Comfort measures only every shift for comfort measures. Review of the policy titled, Wound Treatment Management, dated 8/25/22, revealed: 1. Wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and frequency of dressing changes. Review of the policy titled, Hand Hygiene, dated 9/7/22, revealed: 5. Hygiene technique when using soap and water: a. Wet hands with water. Avoid hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off faucet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately report an alleged allegation of neglect related to an elopement to regulatory agencies as mandated for one resident (#49) out of 41 sampled residents. Findings included: Review of Resident #49's admission Record revealed he was admitted on [DATE] from an acute care hospital with diagnoses of unspecified mood [affective] disorder, altered mental status and unspecified symptoms and sign involving cognitive functions and awareness. Further review of the admission Record revealed Resident #49 was deemed incapacitated and resided on the South Unit of the facility which is the facility's secured unit. On 12/13/21 at 10:25 a.m. an interview was conducted with Staff Z, Agency Certified Nursing Assistant (CNA) and she stated she was on a one to one with Resident #49 because he had jumped the fence. She was unsure when it happened. An interview was conducted on 12/13/21 at 10:45 a.m. with Staff Y, Social Services. He stated less than a month ago the resident jumped over the fence that is located around the outside area off the secured unit. The Resident was found in the ditch past the fence. On 12/14/21 at 10:28 a.m. Resident #49 was interviewed about jumping over the fence and he stated, I'm not worried about that, I just need to go to the pharmacy to get cream for this rash I have on my legs. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status score of a 6 out 15 indicating severe cognitive impairment. Further medical record review revealed an elopement evaluation dated 10/14/2021 which revealed a score of 19 indicating the resident was at high risk for elopement. Review of Resident #49's order summary report as of 12/16/21 revealed a physician order dated 11/4/21 with no end date for one on one supervision every shift for increased behaviors. Review of the facility's Reportable log for November 2021 did not reveal a reportable incident for Resident #49. An interview was conducted on 12/14/21 at 3:35 p.m. with Staff X, Licensed Practical Nurse (LPN). She stated she was [Resident #49's] nurse that night. The residents were outside doing a smoke break, there was a staff member out there. I heard the CNA yell I need help; I need help! I was at the nurse's station. She said the patient, [Resident #49] climbed the fence. I called the supervisor immediately then the supervisor took over. I was at the nurse's station. [Resident #49] was found outside in the ditch. We had other staff members going to get him. [Staff W, CNA, Staff V, and Staff U, LPN], they went outside, and they brought the resident back in. When he came back, I did a full body assessment and there were no injuries. He did not resist coming back and I called the Psych doctor, the primary doctor and the healthcare surrogate to notify them. The Director of Nursing took over and was able to get orders from the physicians. We put him on a one to one. We did a head count to make sure everyone else was accounted for in the whole facility. No one else was missing at that time. From the time I was notified that he was climbing over the fence to the time he was escorted back in couldn't have been more than 15 minutes, everyone was on it. He was safe and had no injuries. He was an elopement risk prior to this incident that's why he is on the locked unit. On 12/14/21 at 3:53 p.m. Staff W, CNA was interviewed. He said, I have worked here 12-13 years. The residents were outside on their smoking break [Staff D, CNA], the CNA who was monitoring the smoking break, said [Resident #49's] over the fence. [Staff D, CNA] kept her eye on the resident, and I went out the side door by the clock in station and he wasn't in the ditch, he was almost in the ditch. I just reached my hand out and I said you don't have to go into work today [Resident #49], because all day he was talking about how he needed to go to work. When I said you don't have to go to work today, he said are you sure? I said yes. He took my hand and walked back in the building with me. He didn't have any injuries. [Staff D, CNA] was new to the smoking area, she has worked here for a while but she was new to watching the smoking, but she knew [Resident #49] and she kept her eye on him because when I walked out the door, she said I see him he's that way and she pointed towards the street; then that's when I saw him just outside the side door in the grass partly in the ditch, but not really. Maybe he thought he could do that because he didn't know [Staff D, CNA] but [Staff D, CNA] knew him. Review of Resident #49's progress note dated 11/3/21 at 7:30 p.m. created by Staff X, LPN revealed, staff member bringing residents in from south secure unit smoking area outside yelled for help saying resident is jumping the fence. Other nurse and staff members ran out to assist. This writer called 3p.m.-11p.m. supervisor and notified her. Further review of Resident #49's progress notes revealed a note dated 11/4/21 at 5:21 p.m. Created by Staff S, the 3-11p.m. supervisor, On 11/3/21 at approximately 7:30 p.m. while in a meeting with DON (Director of Nursing) and North Manager this writer was notified by nurse that resident on south secure unit jumped the fence. This writer ran to south unit to assist, upon arrival was updated on what had occurred. This writer ran out the side of the facility off the secure unit and was met with two facility staff CNA's assisting resident back to secure unit. Directed resident nurse to notify medical doctor and Power of Attorney/Healthcare Proxy of incident. Further progress note review revealed a note dated 11/4/21 at 5:32 p.m. Created by the DON. The note documented, On 11/3/21 at approximately 7:30 p.m. this writer was in a meeting with the north unit manager and 3-11 supervisor, when 3-11 supervisor received notification that resident on secure unit jumped the fence this writer paged over head for assistance, and Nursing Home Administrator notified. This writer then proceeded to the front parking lot and around to the side of the building, did not encounter resident or any staff member. Upon entering south secure unit observed resident at nurses' station with nurse and staff members, resident appeared agitated and pacing, repeatedly stating I have to be at work by 6 in the morning. Directed nurses to do a head-to-toe assessment and place resident on one-on-one supervision. This writer spoke with Nurse practitioner covering for the resident's primary physician, verbal orders received for one time Haldol 5mg (milligram) IM (intramuscular) may repeat in fifteen minutes if resident remains combative and agitated. An interview was conducted with the DON on 12/15/21 at 10:30 a.m. she stated on 11/3/21 I was in the facility in my office, and I had the 3p.m.-11p.m. supervisor and the unit manager for North. The supervisor received a call from a nurse on the south unit and I'm quoting who went over the fence that's when we all jumped up. I do not know where the other two headed but I headed from my office toward the front door grabbed the phone at the reception area and I paged a code [NAME] 3 times and I ran out the front door towards US-19 in the parking lot. I made a right, if you were facing US-19 and I stood there and I'm looking down the building waiting for a resident, for staff, I see no one. I had my cell phone I called my Administrator and I informed her. I hang up because no one came. I went down the side of the building I came into the building from the side door where the clock in station is. I went to the secure unit where my staff and the resident were. I started my investigation. I needed to know who, what, when, where. I had just found out some of the residents had returned in from the smoking area. The staff told me [Staff D, CNA] was supervising residents outside and that [Resident #49] had climbed the fence when she was in the process of bring a resident in who was in a wheelchair. She heard the fence rattling that's what made her turn around and she saw that [Resident #49] was climbing the fence and she yelled for help. She had yelled he jumped the fence! When I learned it was [Resident #49] who climbed the fence I directed the nurse to call the doctor, family or healthcare surrogate, do a head to toe, put him on a one to one and call the Psych physician. Then I wanted to know which one of my staff brought him into the building and the staff said [Staff W, CNA] and [Staff R, CNA]. They were not by the nursing station so I had [Staff D, CNA] show me where she was outside after she had yelled for help. If you go out the secure unit door there is an upper part, the screened in porch area, she heard the fence, saw him climbing, yelled for help she watched him the whole time. I found [Staff R, CNA] and [Staff W, CNA] in the breakroom so I asked them what happened. They said they heard [Staff D, CNA] screaming for help, they were on the secure unit at the time. [Staff D, CNA] had directed the staff to go on the other side of the fence where the resident was so [Staff W, CNA] and [Staff R, CNA] ran off the secure unit and out the door by the time clock and ran down the right side of the building. Both CNAs said the minute they went out the door they saw [Resident #49] and I wanted to know where he was and how he was. So I had them take me to show me. [Staff R, CNA] said [Staff W, CNA] had taken [Resident #49] by the hand and [Staff W, CNA] said he just put his hand out and [Resident #49] grabbed him and he kept saying he needed to go to work and they just walked with him to the side door and the [Staff V, LPN] let them in the side door because they can't get in the side door from the outside. By the time they got into the door my supervisor, [Staff S] was there and encouraged the resident and talked to him and he went back on the secure unit. Then, the DON took the surveyor outside and reenacted what her staff said. The DON brought the surveyor out the side door by the clock in station and immediately looking to the right she Pointed to where the resident was found. The resident was approximately 100 yards from the side door squatting down next to the drain ditch. The DON and the surveyor walked to the exact spot the resident was found. The side door of the building was visible and the back patio smoking area was visible. The DON stated the resident climbed the chain link fence just past the screened in porch area. It was observed there was a ramp leading down from the screened in porch area to the outside patio area both surrounded by an approximately 8ft chained linked fence. Inside of the chained linked fence was an approximate 4 foot tall handrail going down the ramp and against the chained linked fence. The DON stated at the time it was getting dark, it wasn't dark yet. She also stated if she had to give a timeline it had to of been less than a few minutes from the time the call was placed to the supervisor to the time she went back on the unit and saw the [Resident #49]. The DON continued to say he [Resident #49] was on one to one, he was taken care of, they did a head to toe they didn't find anything on him. After I finished with the staff interviews, I called my Nursing Home Administrator (NHA) back told her what happened, the NHA was different from the NHA we currently have but she was the abuse coordinator at the time, and I notified her of what happened and my investigation. It was not reported to the state agencies. Me and the NHA discussed it and she had asked me questions and I was able to answer them and she said ok this wasn't an elopement and I expressed to her that at no time did my staff lose site of the resident. Yes, he climbed the fence but my staff had eyes on him the whole time so it was my understanding since my staff had eyes on him the whole time that's why we didn't believe it was an elopement. The DON confirmed Resident #49 was at an elopement risk prior to this event, he is on the secure unit, and her expectation is that he did not leave the fenced in area. The DON stated, I know what you are thinking he did make it over the fence, that day that this incident happened we had an all staff meeting at 3:00 p.m. and we covered elopement, we had therapy CNAs, Nurses, and we educated about elopement at 3:00 p.m. I directed the 3:00 p.m.-11:00 p.m. Supervisor to go to the North and South Units to do a head count and everyone was accounted for. I did a risk assessment to see if we could do anything different, like was the locked door not working or something. There were no issues that I identified at the time. The risk assessment was completed on 11/4/21, the IDT (interdisciplinary) team and maintenance came with me. I had asked how come I don't have a second door to the screen room and Maintenance had told me that was a safety issue, and since it was starting to get dark; I had Maintenance check all the lighting and that was working, and there is also lighting in the patio area. Review of the facility's policy Resident Elopement Risk Management Guidelines Version 1.1, dated May 2021 revealed, Purpose the facility will strive to provide a safe environment for residents and implement measures to identify resident at risk for elopement, as well as preventative measures to minimize elopement. Definition ELOPEMENT-An elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. Review of the facility's policy Resident mistreatment, Neglect and Abuse Prohibition Guidelines Version 1.1 dated May 2021 revealed .definitions .Mandated reporting: is a legal obligation for mandated reporters to formally report suspected, believed, or witnessed abuse, neglect or mistreatment of residents in accordance with state and federal laws Reporting/Response regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that the facility responsibilities to protect the residents and promptly investigate occurrences may be et. The facility administration is required to report the state licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a care plan problem area with a goal and interventions was developed related to Isolation Precautions, for one resident (#156) of forty-one sampled residents Findings included: On 12/13/2021, 12/14/2021, 12/15/2021 and 12/16/2021 Resident #156's room was approached and the door was closed. Further observations revealed the front of the door had a posted sign that indicated, Attention, Droplet Precautions. The sign detailed what type of Personal Protective Equipment (PPE) one should wear upon entering the room. Also, the front of the door had hanging Personal Protective Equipment to include gowns, gloves and masks. It was determined that Resident #156 was in this room and was on Isolation Precautions. (Photographic Evidence Obtained) Resident #156 resided in the room alone. During all days observed, Resident #156 was noted in her room and in bed. An interview on 12/14/2021 at 9:00 a.m. with Staff A, Certified Nursing Assistant (CNA) , and Staff B, Licensed Practical Nurse (LPN)/Unit Nurse, who had Resident #156 on their assignment, both confirmed Resident #156 was a newly admitted resident and she was on Contact precautions and is in a room that was isolated for observations. They both confirmed that only when providing hands on care; staff are to follow the PPE instructions as noted on the door. Staff A and B both revealed that Resident #156 does not currently have an infection and the Contact was precautionary only. Neither knew if Resident #156 was care planned for Isolation precautions. An interview with Resident #156 on 12/14/21 at 10:00 a.m., while she was in her room, confirmed she was just admitted to the facility a few days ago and was unsure what Isolation, or Contact precautions meant. On 12/15/2021 at 10:00 a.m. an interview with the Director of Nursing (DON) revealed Resident #156 was a new admission from the hospital and when newly admitted , they (residents) are put on Isolation as a precautionary for a period of fourteen days. The DON confirmed Resident #156 does not currently have any type of infection but will still be monitored as part of their policy and protocol. On 12/16/2021 at 9:00 a.m. an interview with Staff C, CNA, who had Resident #156 on her work assignment; confirmed the resident was on Isolation precautions but was not really aware of the reason. She revealed that she believes the resident does not have an infection but is on precautions anyway. She was unable to say what type of PPE she was supposed to wear when providing care in the room. Review of the medical record revealed Resident #156 was admitted to the facility on [DATE] and was admitted from the hospital. Review of the current diagnosis sheet revealed diagnoses to include: dementia, and adult failure to thrive. Review of the current Order Summary Report dated for the month 12/2021 revealed Resident #156 was not currently receiving any medications or treatments for any type of infections. The orders did reveal an order to include: Isolation Droplet precaution - Presumptive for COVID on admission every shift for 14 days with the start order date of 12/10/2021. Review of the nurse progress notes dated from 12/9/2021 to 12/16/2021 did not indicate any documentation of Resident #156 with a current infection. Review of a nurse progress note (admission), dated 12/9/2021 at 04:26 (a.m.), revealed; On droplet precautions. Review of a nurse progress note (COVID monitoring), dated 12/11/2021, revealed; On enhanced barrier precautions. Review of a nurse progress note (COVID monitoring), dated 12/13/2021, revealed; On enhanced barrier precautions and is not on quarantine. Review of a nurse progress note (COVID monitoring), dated 12/15/2021, revealed; On enhanced barrier precautions and is not on quarantine. Review of the current care plans with the next review date of 3/10/2022 did not reveal or indicate any problem areas, goals or interventions related to Resident #156 being on Isolation Precautions while in her room. On 12/15/2021 at 11:10 a.m. an interview with the MDS (Minimum Data Set)/Care Plan Coordinator confirmed Resident #156 was ordered for Isolation Precautions and there was no care planning problem area to include goals and interventions related to that. The MDS/Care Plan Coordinator revealed since Resident #156 did not have an active infection, she stopped at the assessment and did not develop a care plan for isolation. She revealed the isolation is a precaution for residents who were admitted from the hospital and observed as isolation precautions for fourteen days. The MDS/Care Plan Coordinator continued to say this area should have been care planned to indicate the reasoning with goals and interventions. She further confirmed they usually care plan any resident who is on isolation precautions, whether or not they have an infection. A review of the policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of 12/20216, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation revealed the following: #8 The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; k. Reflect treatment goals, timetables and objectives in measurable outcomes; o. Reflect currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, staff interview and record review the facility failed to provide a timely discharge for one resident (#45) out of 41 sampled residents. Resident #45 had an increase in anxiety related to her discharge which resulted in an increase in her antianxiety medications. The facility was made aware on 9/9/21 that all Comprehensive Assessment and Review for Long-Term Care Services (CARES) applications must be submitted via email. The application was not resubmitted until 9/28/21. Findings included: An interview was conducted with Resident #45 on 12/13/21 at 11:00 a.m. The resident was observed walking independently, dressed in day clothes, hair and makeup done, clean and well-kept. The resident said can you please help me. I have been here for 3 months and no one will help me. The hospital made a mistake and sent me here. I live at an Assisted Living Facility (ALF), I tripped and had a compression fracture to my Spine at T12. The hospital sent me here to do therapy but I didn't really need it. They may have come in once to help. After about the third day of tripping my back has felt fine. I can walk I can do everything myself. They have me on this secured unit and no one can help me get back to my ALF where all my stuff is. I do not need to be here and my brother is paying for both places and he is not very happy about that. He tells me I should just call a cab and leave but I'm starting to get frustrated because I ask why I can't go back to my home and everyone keeps telling me they are waiting on my level of care I don't even know what that is and no one will explain it to me. I want to yell at someone because I'm so angry about it but I know if I do yell, they will think I'm crazy and believe that I really do belong here. Can you please help me because no one else will listen to me or help me. Review of Resident #45's Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns documented a Brief Interview for Mental Status revealed a score of 12 out of 15 indicating moderate cognitive impairment. Review of Resident #45's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. The resident was incapacitated, and her Power of Attorney was a family member. The resident had a primary diagnosis of; fracture of T11-T12 vertebra, with routine healing. Other diagnoses include but were not limited to dementia without behavioral disturbances, major depressive disorder, and anxiety disorder. A family interview was conducted on 12/14/21 at 10:24 a.m. with Resident #45's Power of Attorney. He said, I am trying to get my sister on Medicaid for financial reasons for her ALF. The ALF is costing $3,000.00 a month. The situation was we sold her condo and moved her to an ALF and now the money from the condo is gone. She has been at the ALF for 4 years. I want her to go there, all her stuff is there. I just can't afford to pay out of pocket for the ALF. I am retired and paying $3,000.00 a month is a lot and has become a financial burden on me. We are waiting on trying to get her on Medicaid, but this has been going on now since July (2021). The facility initially said it would take 60 days to get that going and now they are saying that it may take another 60 days or more. We don't want to lose the place at her ALF just because we are waiting for Medicaid to get approved. The Social Services Director said [Resident #45] can't leave because she will go to the bottom of the Medicaid list. We got a call from Medicaid on November 30th, 2021, and they just asked us medical questions. [Resident #45] was only supposed to go to the nursing home for rehab since she had a fall and fractured her T11 and T12. She was fine before leaving the hospital but, since she had a back brace, the ALF wanted her to get therapy. Well, she got a little therapy, but she isn't getting it anymore. The ALF even came to the nursing home and assessed [Resident #45] to make sure she can be independent at her ALF, and they said she can come back, she can do everything on her own. I just don't want her to lose her room at the ALF but, it seems that she is stuck at the nursing home, and no one knows when she'll be able to leave. I really hope you can help us because we need help. An interview was conducted with the Director of Rehab and with Staff Q, Doctor of Physical Therapy (DPT) on 12/14/21 at 1:20 p.m. they indicated Resident #45 came to the facility for rehab because she had a TLSO (thoracic lumbar sacral orthotic). She started both physical therapy and occupational therapy on 7/15/21 and she was discharged from therapy on 7/28/21 because she met all her goals. Physical therapy was working on balance with gait and transfers and occupational therapy was working on upper body dressing, lower body dressing, safety with performing toileting tasks and donning and doffing her TLSO. The only goal she has not met yet for physical therapy is the patient will negotiate community obstacles including ramps, uneven surfaces, steps, curbs, with supervision with no assistive device or least restrictive assistive device. The Director and the therapist indicated at this time this goal has not been assessed. The Director of Therapy indicated the resident was only at the facility waiting for her Medicaid application to get approved and they have been told Medicaid is behind on their applications. Review of Resident #45's Psychiatric Evaluation dated 10/20/21 revealed, .patient is seen today per staff request for anxiety. Patient was observed by the nurse's station on the phone attempting to call lawyers because she was placed here by accident from the hospital. Staff reports that it is a daily occurrence and reports that patient frequently goes up to the nurse's station daily, several times a day to discuss discharge or attempt to call people on the phone about being discharged to go home. Patient was seen later in her room eating lunch. Patient reports she has history of irritable bowel syndrome which flares up with her anxiety. Reports her anxiety is high at this time due to her belief that she was discharged to the wrong facility. Patient reports anxiety occurs daily and occurs all day long and reports having difficulty sleeping at times due to anxiety. Staff reports no acute changes or concerns in appetite and sleep. Staff reports she is compliant with medications with no issues .Recommendations: at this time increase Buspar (Antianxiety medication) 7.5mg (milligrams) BID (twice a day) for anxiety. An interview was conducted with Staff Y, Social Services on 12/13/21 at 10:50 a.m. and he said Resident #45 is waiting on her level of care to come back from CARES. We have been waiting on that for over 60 days CARES is backed up. Staff Y, Social Services could not explain what a level of care was. An interview was conducted with the Admissions Director on 12/15/21 at 12:47 p.m. she indicated that she was the one who submits the Medicaid applications, and she received Resident #45's level of care last week. The process is everything starts with the Medicaid application. It is completed online then the facility collects the clinical and financial information and sends the clinical information to Elder Affairs (CARES) to determine the level of care. The financial information is sent to the Department of Children and Families (DCF) to determine the liability or if the patient is eligible. Not until Elder Affairs gives the level of care to DCF, DCF will not give the final decision if Medicaid is approved or not. The whole process between applications, document submissions, level of care and determination by DCF takes approximately 60 days. Elder Affairs is taking longer than 60 days and we have information they are behind by like three months. The admission Director indicated the business office usually sends all of the Medicaid application packets to Elder Affairs but the facility didn't have anyone in the business office at the time, so she faxed Resident #45's Medicaid packet. Then she was informed she had to send the packet by email not by fax. Review of the Send Result Report dated 8/9/21 revealed a referral cover sheet to CARES for applicant: Resident #45 revealed a fax result of ok. Review of emails provided by the Admissions Director revealed an email dated 9/9/21 at 8:48 a.m. and documented, Hi, we got a phone call from CARES saying that they are receiving the requests via fax when the requests should be emailed to them. Can you please make sure all request for LOC (level of care) are emailed to CARES? On 9/9/21 at 11:34 a.m. an email from the Department of Elder Affairs was sent to the Admissions Director indicating every email submission to CARES must be submitted to [email provided]. Further email review revealed on 9/28/21 at 10:33 a.m. an email from CARES to the admission Director revealed, this case was closed on 8/30/21 because a referral packet was not received for this client, after several attempts were made to your facility for such. The case will be reopened as of today since the referral packet is included with this email. Review of Resident #45's care plan dated 7/15/21 revealed [Resident #45] is here for short stay placement related to dementia: Resident representative clearly express desire to discharge from facility. Plans to discharge from facility when medically cleared. Goal: resident/representative will participate in discharge planning process throughout stay to ensure safe discharge. Interventions included: Assess needs of patient/family beginning on the day of admission and continue assessment during stay Discuss discharge plans with resident/representative. keep involved in discharge process. Involve therapy during stay in facility as applicable Discuss progress toward discharge throughout stay Obtain discharge order from physician as needed Determine need for outside services: home health, DME (durable medical equipment), Meals on wheels-contact provider and set up services. An interview was conducted on 12/16/21 at 3:00 p.m. with the Director of Nursing and Nursing Home Administrator, they confirmed Resident #45 was only at the facility waiting for her Medicaid application to be approved. The DON also indicated standard practice is to start discharge at the time of admission and there is not a policy on that. Review of the facility's Transfer or discharge, preparing a resident for, revised December 2016 revealed: Policy Statement Residents will be prepared in advance for discharge.

Based on observations, staff interview and record review the facility failed to ensure one of one walk in freezers was operating in a manner to be free from ice blocking and heavy frosting. It was observed that heavy ice was formed on the ceiling, motor fan housings, shelving, and various packaged food items for two days of four days observed (12/13/2021 and 12/16/2021). Findings included: On 12/13/2021 at 9:56 a.m. a facility kitchen tour was conducted with the floating kitchen manager. Upon approaching the walk in freezer, the outside digital thermometer screen was not able to be read. The screen read what appeared to not be numbers. It did not indicate what the internal temperature was. Once the door was opened and the freezer was entered, it was observed with approximately five foot shelving on either side of walls and the back wall. Above the right side shelving, was observed with a double plastic fan housing with a motor attached. Further observations revealed heavy ice build-up on the ceiling in front of the fan housing, on both fan housing cases, and very large ice chunks built-up on the tubing leading from the motor to the side wall Also, there was heavy ice blocking/build-up on the top right shelf under the fan and motor housing, as well as heavy ice blocking/build up on three packages of food items. Several blocks of ice were noted approximately four inches in diameter. The ice build-up on the packages of food items were approximately three to four inches thick in areas. (Photographic Evidence Obtained) On 12/16/2021 at 11:00 a.m. another kitchen tour was conducted with the oncoming kitchen manager. The oncoming kitchen manager indicated they had removed the ice blocking/build-up and have a work order with maintenance. The walk in freezer was approached and the door was opened. Once entered, the large amount of ice blocking had been removed. However, it appeared that the same areas were already starting to build up with frosting/icing. It was determined that the ice building was an ongoing issue. An observation of the internal thermometer revealed a temperature of minus thirteen degrees Fahrenheit. It was determined that the freezer held appropriate temperatures inside. An interview at this time with the oncoming kitchen manager revealed the floating kitchen manager was not aware of how long the ice had been building in the freezer. She was unsure if there were any work orders with maintenance with relation to the heavy ice build-up. It was confirmed through interview with the Maintenance Director and the Nursing Home Administrator on 12/16/2021 at 1:00 p.m., there were no current work orders with regards to the kitchen walk in freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review the facility did not ensure dignity was maintained for residents on one unit (South Unit) of two units for four days (12/13/21, 12/14/21, 12/15/21, and 12/16/21) of 4 days related to failure to provide furnishings in resident rooms to include lack of pillows, blankets, and personal effects and 2. failed to ensure fitted clothing for one resident (#306) of a total of sample of 41 residents. Findings included: 1. During a facility tour of the South Unit on 12/13/21 at 9:43 a.m., observations were made of resident rooms without personal effects. The rooms were observed without pillows or blankets on the beds. All the beds were furnished with uniform white sheets, a top sheet, and a bottom sheet. The rooms were observed without any personal memorabilia, pictures, or decorations. The rooms observed without pillows included rooms 162, 164 beds A and B,158, 160 beds A and B, 168 bed A,146 bed B and 158. During the tour on 12/13/21 at 9:43 a.m., Staff H, Registered Nurse/ Unit Manager (RN/UM) indicated the South Unit was a secured area housing residents with primary diagnoses of dementia and or Alzheimer's and they would not be interviewable. Residents were observed wandering the halls during the tours. On 12/14/21 at 9:00 a.m., resident rooms in the South Unit were observed without any pictures on the walls in their rooms and without any personal possessions. The rooms were furnished with a bed with two sheets, wooden nightstand, and dressers. The walls were noted bare without any pictures, decorations, or personal effects. On 12/15/21 at 9:30 a.m., Resident #92 was observed lying in bed, his head resting on a rolled-up hospital gown for a pillow. The resident pointing to the rolled-up gown under his head stated, I need a foreign word for pillow Resident was asked if he wanted a pillow. Resident said, Yes. Resident spoke limited English but was able to communicate his needs. During a facility tour on 12/15/21 at 12:26 p.m. observations were made of resident rooms without pillows in the South Unit. On 12/15/21 at 12:40 p.m., an interview was conducted with a resident in room [ROOM NUMBER] bed B, the resident stated she did not know why she did not have a pillow. An interview was conducted on 12/15/21 at 12:29 p.m. with Staff G, Certified Nurse Assistant (CNA). Staff G stated that residents should have pillows on their beds. Staff G said, I'll correct that, I will make sure we get pillows. The residents should have comfortable furnishings in their rooms. On 12/15/21 at 1:30 p.m., an interview was conducted with the Staff H, RN/UM who confirmed that all residents are supposed to have appropriate linens. They should have pillows. Staff H said, I will conduct a walk through and make sure all residents have pillows. A follow up interview was conducted on 12/15/21 at 4:19 p.m. with the Director of Nursing (DON). The DON said residents should have pillows and personal effects and they were auditing all the rooms. The DON said, We will make sure the resident rooms look like the residents live here, not like we are housing them. The DON said, We will reach out to families to bring personal effects such as pictures. The DON stated this would help calm them down and dignify them. On 12/16/21 at 10:05 a.m., a facility tour of the South Unit was conducted. Rooms were noted with pillows and uniform white sheets. The resident rooms were observed without any personal effects, no blankets or bed covers, no pictures, memorabilia, or decorations. These rooms included 152, 143, 144, 156 158 bed B, 159, 161, 163, 162, 165, 164, 167 and 168. On 12/16/21 at 10:08 a.m., an interview was conducted with Staff H, RN/UM. The Staff H stated they have replaced pillows in the resident rooms and have contacted families about helping to personalize the rooms. Staff H, RN/UM said, We want residents to be comfortable. The UM did not know why the rooms did not have blankets or covers. 2. On 12/13/21 at 2:11 p.m. and on 12/14/21 at 12:51 p.m., Resident #306 was observed with loose blue jean pants, and holding onto his pants as he walked around so they did not fall. Resident #306 stated he would like a belt to keep his pants up. Resident #306 did not know what happened to his belt. On 12/15/21 at 12:56 p.m., an interview was conducted with Staff H, RN/UM. Staff H was asked why Resident #306 did not have a belt or fitted clothing. The UM stated that sometimes safety was the priority. Staff H was asked if a safety concern was the reason Resident #306 did not have access to a belt. Staff H said, No, not really. The UM stated he would call the resident's family and ask them to bring one. Staff H stated he thought the family took it [belt] home. On 12/15/21 at 2:55 p.m., Resident #306 was observed wearing a pair of jeans shorts, he was noted holding on to them as he walked around in his room. Resident #306 did not have access to his belt. On 12/15/21 at 1:45 p.m. the Regional Director Clinical Service stated there was no reason why the residents should not be wearing belts if they wanted to. The Regional Director Clinical Service said, They should be wearing fitted clothes. There is no rule about the belts. It is not our policy. The Regional Director Clinical Service stated they would make sure Resident#306 had a belt. An interview was conducted on 12/15/21 at 4:19 p.m. with the DON. The DON said, I reached out to my administration. They [residents] can have belts. It is not a facility policy. The DON stated that she preferred they have clothes that fit. A follow up was conducted with the Nursing Home Administrator (NHA) and DON on 12/16/21 at 10:40 a.m. The NHA stated the expectation would be for their residents to have comfortable facilities. The NHA stated she stressed the need for a clean comfortable environment. In an interview conducted with the Social Services Director (SSD) on 12/16/21 at 1:25 p.m. the SSD presented documentation showing an audit conducted for all the residents in the North and South Units. The audit confirmed the rooms in the South Unit did not have personal effects such as pictures on walls. The audit further identified eight residents with clothing that was poorly fitted or did not have a belt. The SSD said, We will definitely correct this. Review of a facility policy titled, Dignity, revised February 2021, showed that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. #2. The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, and beliefs. #13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and policy review the facility failed to ensure resident smoking materials were secured for three of four days (12/13/21, 12/14/21 and 12/15/21) on one unit (North Unit) of two units for seven residents (#39, #91, #18, #76, #74, #37, and #15) for a total sample of seven residents who smoked on the North Unit. Findings included: 1. During a facility tour on 12/14/21 at 12:12 p.m., Resident #39 was observed in her room, sitting on her bed. Resident #39 stated that she smokes whenever she likes day or night. Resident #39 stated she was an independent smoker and holds on to her cigarettes and lighter. Resident #39 stated that she holds on to a pack of cigarettes at a time. Resident #39 stated that she hides them under the seat of her wheelchair cushion. The admission Record showed Resident #39 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) for Resident # 39 Section C for Cognitive Patterns showed a Brief Interview for Mental Status score of 15, indicating intact cognition. Section G, Functional Status showed Resident #39 requires limited assistance with ADLs (activities of daily living). A care plan initiated on 04/28/21 showed that Resident #39 smokes independently and has been informed of the new facility smoking policy. The goal indicated Resident #39 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 10/07/21 under the Summary of Review Section C, Maintenance of Smoking Materials showed Resident #39 must request smoking materials from staff. 2. On 12/14/21 at 3:52 p.m. a tour of the smoking area was conducted and seven residents (#15, #18, #91, #37, #74, #39 and #76) from the North Unit were observed in the courtyard smoking independently. An observation of the area showed designated smoking area signs, smoking aprons hanging by the door, and metal cigarette receptacles available on each table. An interview was conducted with Resident #91. Resident #91 stated they smoke anytime they want to. Resident #91 stated he holds on to a pack of cigarettes at a time, but the rest are locked up. Resident #91 said, I keep my lighter and smokes on my person. The admission Record showed Resident #91 was re-admitted to the facility on [DATE]. The admission MDS for Resident #91 dated 11/04/21 Section C-Cognitive Patterns, showed the resident was unable to complete the BIMS assessment. A smoking care plan initiated on 01/27/21 showed Resident #91 smokes independently and has been informed of the new facility smoking policy. The goal indicated that Resident #91 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 11/02/21, under Summary of Review, Section C, Maintenance of Smoking Materials showed Resident #91 must request smoking materials from staff. 3. An interview was conducted with Resident #18 on 12/14/21 at 3:54 p.m. Resident #18 confirmed they [residents on the North Unit] smoke anytime. Resident #18 stated that he keeps his cigarettes and lighter on him. The admission Record showed Resident #18 was re-admitted to the facility on [DATE]. A Quarterly MDS for Resident #18 dated 09/22/21 Section C - Cognitive Patterns showed Resident #18 had a BIMS of 15 indicating intact cognition. A smoking care plan initiated on 01/27/21 showed Resident #18 smokes independently and has been informed of the new facility smoking policy. The goal indicated Resident #18 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 12/14/21, under Summary of Review, Section C, Maintenance of Smoking Materials showed Resident #18 must request smoking materials from staff. 4. A review of the smoking care plans and smoking evaluations for Residents #15, #37, #37, #74 and #76 also showed the residents should maintain smoking materials in a designated area and must request smoking materials from staff. On 12/14/21 at 3:57 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D was observed walking into the smoking area where the seven residents (#15, #18, #91, #37, #74, #39 and #76) were smoking. Staff D stated that the residents who were smoking at the time were independent and did not require supervision. Staff D explained that residents who need assistance or are assessed as dependent smokers follow a smoking schedule. Staff D stated that an assigned staff member comes to the courtyard with the residents' cigarettes and lighters stored in a box. Staff D stated the box is secured in the nurses' unit. Staff D stated this was not the practice for independent smokers in North Unit. Independent smokers hold on to their smoking materials. On 12/14/21 at 3:59 p.m., an observation was made of Staff E, Registered Nurse (RN) and evening supervisor in the smoking courtyard. Staff E approached Resident #18 and asked him if she could use his lighter. Resident #18 handed his lighter to Staff E. Staff E was observed lighting a cigarette for an unidentified resident. An immediate interview was conducted with Staff E. Staff E confirmed that independent smokers have been assessed to come and go on their own. Staff E said, they keep their lighters and smokes on them. On 12/15/21 at 9:25 a.m. an observation was made of Resident #39, #15 and #76 outside on the courtyard smoking. The residents had their cigarettes on them and lighters. These residents stated they keep their smoking materials on them all the time. On 12/15/21 at 1:55 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that North Unit smokers [#15, #18, #91, #37, #74, #39 and #76] have a box where they keep cigarettes and lighters. The NHA stated they have a schedule, but if they are deemed to smoke unsupervised, they can come and go on their own. When asked about their smoking materials the NHA stated the residents should get their articles for smoking and then go outside. When asked if the residents were permitted to hold on to their cigarettes and lighters the NHA said, No, they are supposed to turn them in. Residents should not be holding on to their cigarettes and lighters they acknowledged the policy. The NHA said, If staff are allowing them to, they should not. Now that I know, I will follow-up with the residents and staff. On 12/16/21 at 10:26 a.m., an interview was conducted with Staff F, Staffing Coordinator. Staff F was observed stationed by the North area exit door. Staff F was noted with a sign in/out log. Staff F stated that each resident has to sign in/out when receiving their cigarettes and lighters. Resident # 39 was observed signing out her smokes and lighter. Review of the facility's smoking policy titled, Smoking Policy - Residents, revised 02/14/2020, showed, #12 residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Resident's smoking paraphernalia will be kept in a designated secure location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (#88) of 39 sampled residents had a care plan implemented related to supervision for frequent falls. Findings included: Record review of Resident #88 revealed an admission date of 08/31/2020 with a diagnosis of Dementia without behavioral disturbances. A Minimum Data Set (MDS) Assessment was completed on 09/05/2020, which identified the resident as participating in the Brief Interview for Mental Status (BIMS) but scoring a 99, indicating his answers were nonsensical. The MDS identified that he had problems with his short term memory and was moderately impaired for decision making. The MDS assessment identified the resident as needing limited assistance by two staff for bed mobility, extensive assistance by two staff for transferring, having an unsteady balance but able to stabilize on his own, able to walk in his room with limited assistance by one staff, and toileting with limited assistance by one staff . The MDS assessment was not able to determine his fall history, but he had not had a fall between his admission date of 08/31/2020 and the assessment date of 09/05/2020. A baseline care plan was developed at admission and identified the resident's admitting diagnosis as Traumatic Subdural Hemorrhage with loss of consciousness. He had physical and occupational therapy ordered. The initial goal for the resident related to falls was resident will remain free from fall related injury with the intervention documented as PT (physical ) therapy. A care plan was initiated on 09/16/2020 for the Focus area of the risk for falls and/or fall related injury, related to impaired balance, unsteady gait, poor safety awareness, and needs assistance with transfers. Interventions initially included the supervision of the resident during transfers and ambulation due to unsteady gait and impaired balance, as well as providing hands on assistance during transfers; observing for use of appropriate footwear and assist as needed; keep environment clean and free of clutter in the walkways, physical and occupation therapy screens as indicated, and reporting falls to the physician and responsible party. The care plan was revised on 09/25/2020, after the resident sustained two falls on 09/24/2020, both of which occurred in his room, to include the following interventions: encourage resident to stay outside of his room, around the nursing station when out of bed to wheelchair; and toilet upon rising, before and after meals, before bed and as necessary. The resident was observed on 10/04/2020 at approximately 12:30 p.m. in the hall, in his wheelchair, self propelling in front of his room and the nursing station. Later that day at 2:20 p.m., the resident was observed sitting on the floor in his room, with his back against the bedside table. His wheelchair was observed near the end of the bed, the length of his bed away from him. The nurses were made aware that the resident was on the floor and they entered the room to assess and assist him back into his wheelchair. Once the resident was assessed as having no injury or pain, and brought out in the hall so staff could supervise him, the nurse (Nurse Q) reported that he just laughed when they asked him what had happened. On 10/05/2020, at 10:05 a.m., Resident #88 was observed assisted back to his room by his aide, in his wheelchair. She confirmed that he had just had a shower. The nurse asked the aide to allow him to remain in the hall so they could watch him. The resident was observed with nonskid socks on, but they were ripped at the right toe area and at the left heel. The hole in the sock at the left heel was large enough to expose the heel, so it was resting on the floor. At 11:50 a.m., that same day the resident was observed to unlock the brakes on his wheelchair and self propel into his room. The Unit Manager was observed to enter the room and ask him if he needed anything? The resident said he wanted to eat lunch in his room. The Unit Manager agreed and set up the over bed table in front of him as the lunch meal would be served shortly. When his [NAME] socks were pointed out the Unit Manager, she agreed that they shouldn't have been put on as the holes did not provide much nonskid protection. After lunch, at 12:30 p.m. , the resident was observed alone in his room, with his meal tray removed, self propelling around the room with no supervision. On 10/07/2020 at 11:30 a.m., the Director of Nurses (DON) reviewed the fall reports that Resident #88 had since his admission [DATE]. The resident had three falls, all occurring in his room, when he was by himself. According to the DON, on 09/12/2020 at 6:50 p.m., the resident had been found on the floor in his room. An assessment indicated no injury, and the resident was assisted back to his wheelchair and brought out to the hall. The DON discussed two additional falls that had both occurred on 09/24/2020. At 10:27 a.m. on 09/24/2020, Resident #88 was found on the floor of his room, at the side of the bed, having been incontinent of a large amount of stool. Upon physical assessment, a bruise was noted to the left hip but the resident did not complain of pain. Two staff assisted to transfer the resident to the wheelchair. When the nurse contacted the physician to make him aware of the fall, the physician discontinued the resident's colace and miralax and ordered a x-ray of the hip. Later that same day, at 2:46 p.m., the nurse's note documented a loud noise coming from the resident's room. The resident was found on the floor by the bathroom with his nonskid socks intact. A skin tear was noted to his left forearm. The DON reported that the incident report describing this fall did not indicate whether he had been found incontinent. She confirmed that the incident reports were not detailed and she would expect information that included what he had been doing prior to the fall, who saw him, who interacted with him last, where was his call bell, what was the last time he had been toileted, and what was on his feet. After the fall reports were discussed, the DON was made aware of observations of Resident #88 which indicated the staff were not implementing the care plan related to encouraging the resident to remain in the hall for supervision and ensuring that appropriate footwear was in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility failed to ensure one (#94) of one resident sampled for tube feeding out of 6 residents in the facility received tube feed nourishment in accordance with the physician order for two of four days observed (10/4/20 and 10/5/20). It was determined that nursing staff did not start the feeding timely, and did not provided a physician's ordered flow rate of the product. Findings included: Review of the medical record for Resident #94 an original admission date in 2018 and a readmission from the hospital in September of 2020. Review of the cumulative diagnoses sheet revealed diagnoses of Pressure Ulcer Left heel, Dementia, Gastro-esophageal reflux (GERD), Pneumonitis due to inhalation of food and vomit, and unspecified protein-calorie malnutrition. Review of the current Physician's Order Sheet (POS) dated for the month October 2020 revealed the following relevant orders: 1. Enteral Feed one time a day Jevity 1.5 at 65 ml/hr for 20 hrs (off 4 hours). This order date was 9/24/2020 at 1300. There was another identical order written on 9/27/2020 at 900. 2. HOB elevated at least 30 degrees every shift with current order date 9/21/2020. 3. Nothing by mouth diet, NPO texture, not applicable consistency for nutrition with current order date 9/21/2020 1748. 4. Check residual every shift and record quantity. If more than 60 ml hold feeding for 1 hour and notify MD with current order 9/21/2020 2300. Review of the orders did not reflect a start and/or stop time for the enteral feeding. On 10/4/2020 at 9:00 a.m. during a tour of the facility, Resident #94 was observed in his room, lying in bed, and under the covers. He was noted with his eyes closed and with the call light button placed within his reach. Further observations revealed that there was a tube feeding system at the bedside. The pump was off and the tubing was not attached. A bag of the tube feeding product was hanging from the pole. The bag was labeled with the name of resident, room number, date: 10/4/2020, time 3:00 a.m., rate 60 ml, Formula Jevity 1.5 1000 cc 3:00 a.m. and staff initials. The bag appeared to be full. Continued observations on 10/4/20 at 11:30 a.m., 12:05 p.m., 1:30 p.m., and 1:58 p.m. revealed the resident was in bed, with the tube feeding system at the bedside in the off position and not hooked up to the resident. On 10/4/2020 at 2:03 p.m., a nurse was observed exiting the room. The resident was now observed with the tube feeding system on. Observation of the tube feeding pump revealed it was operating at a flow rate of 65 ml/hr. The bag still appeared full, just as it was on 10/4/20 at 9:00 a.m. Immediately following this observation, interview with Nurse E revealed that she had just hooked up the tube feeding and turned on the pump. She did not know why it was not on at 3:00 a.m. as per the bottle label. She reported that she believed that it goes on at 1:00 p.m. She confirmed the tube feeding system was not tuned on until now, 2:03 p.m. On 10/5/2020 at 7:20 a.m., Resident #94 was observed in her room and lying in bed with the Head of Bed (HOB) elevated approximately 35 degrees. The lights in the room were observed off. The resident was observed with his call light in reach and eyes closed. Further observations revealed the resident was receiving tube feeding nourishment with the pump on. The following was observed on the nourishment bottle label: 1. Jevity 1.5, 2. Resident name, 3. Room number, 4. Date of 10/5/20, 5. Start time 3:00 a.m. to be ran at 60 ml hr. Review of the tube feed system pump, which was on, read on the digital screen that the flow rate was set at 55 ml. The bottle appeared to have about 750 ml's remaining. On 10/5/2020 at 7:50 a.m., the resident's room was approached and entered with the North Unit Manager. She confirmed that the nourishment bottle read Jevity 1.5, resident name, room number, date 10/5/20, and start time 3:00 a.m. to be ran at 60 ml hr. The Unit Manager further confirmed that the tube feeding system pump read a flow rate of 55 ml. On 10/5/2020 at 8:55 a.m., the North Unit Manager revealed that she had confirmed with the 11 PM to 7 AM shift nurse that the bag/bottles are placed on the system pole early every day after the stop time. She did confirm that the tube feeding system was not turned on until 2:00 p.m. on 10/4/2020 and it should have been turned on at 1:00 p.m. The Unit Manager further confirmed the flow rate was not correct this morning and does not know why it was not at the right flow rate. She confirmed the pump was providing 55 ml/hr. Review of the Nutritional risk assessment dated [DATE] revealed a summary: Increased Tube Feeding 65 ml/hr jevity 1.5 x's 20 hrs = 1950 kcal, 82g pro, zinc sulfide 220 mg daily x's 14 days, vit c 500 mg twice a day. Review of the current Minimum Data Set (MDS) assessment (5 day) dated 9/25/2020 revealed: Short Term and Long Term memory problem and moderately impaired decision making skills; Activities of Daily Living (ADL) - total dependence with Eating; Nutrition - Parenteral feeding- yes. On 10/4/2020 at 1:00 p.m., Resident #94's care plans were reviewed with a next review date of 12/20/20. The following relevant focus areas were identified: - Has potential for complications related to risk for aspiration pneumonia. Is NPO with enteral feeding with interventions to include: Vital signs as ordered, Labs as ordered, Assess lung sounds and respiratory functions, report changes to MD as indicated; observe for signs and symptoms (s/s) of recurring infection, notify the Medical Doctor (MD) if noted. - Risk for social isolation due to dementia with behavioral disturbances and anxiety. Has a feeding tube and is NPO at this time. - Risk for complications associated with enteral feedings due to dysphagia, is NPO and receives enteral feeding to meet nutritional and hydration requirements with interventions to include: Verify tube feeding placement as ordered, check enteral feeding residuals as ordered, administer feeding and flushes as ordered, keep HOB at 45 degrees during enteral feeding as ordered, weights ordered and as needed, perform stoma site care as ordered, routine Registered Dietitian (RD) assessment, Speech Language Pathologist (SLP) screen as indicated, observe for complications related to (r/t) enteral feeding, aspiration, dehydration, update MD if noted. - At risk for an alteration in nutrition and/or hydration . Resident is on tube feeding as ordered. Weight below ideal body weight (IBW) with interventions in place as reviewed to include: Provide diet as ordered, Encourage adequate intake at meals, Encourage adequate fluid intake, Supplements as ordered, RD consult as needed. On 10/6/2020 at 10:04 a.m., the North Unit Manager indicated that the Physician had just changed the flow rate of the Jevity 1.5 tube feeding nourishment from 65 ml/hr to 75 ml/hr. She indicated that the order was now clarified in the medical record to reflect that change. The North Unit Manager, confirmed that the resident had the incorrect flow rate on 10/5/20 as observed. On 10/6/2020 at 2:00 p.m., the facility's Registered Dietitian indicated that it was the responsibility of nursing staff to place and turn on the tube feeding system. She would expect that the run time and flow rate were monitored by a nurse and that she had not been made aware of the wrong flow rate on 10/5/2020, until 10/6/2020. She further revealed that she had recommended an increase of flow rate to the nourishment tube feed today, to make up for the loss from 10/5/2020. On 10/6/2020 at 10:50 a.m., the Nursing Home Administrator and Director of Nursing provided the Enteral Nutrition policy and procedure with a revision date of 11/2018. The policy statement revealed, Adequate nutritional support through enteral nutrition is provided to residents as ordered. The policy interpretation and implementation revealed, #10. Enteral feedings are scheduled to try to optimize resident independence whenever possible (e.g. at night or during hours that do not interfere with the resident's ability to participate in facility activities); #11. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: e. Volume and rate of administration; #12. The provider will consider the need for supplemental orders, including: a. confirmation of tube placement. Photographic evidence was obtained.

Based on observations, interviews, and policy review, the facility failed to ensure medications were labeled properly and expired medications were disposed of, for two (Cart 2 South, Cart 3 North) of three medication carts observed during the medication storage task. Findings included: An observation, on 10/6/20 at 10:45 a.m., of Cart 2 South was completed with Staff Member K, Licensed Practical Nurse/Nurse Supervisor (LPN). The observation revealed a bottle of Latanoprost 0.005% ophthalmology solution, opened 8/15/20. The pharmacy label indicated the bottle of Latanoprost should be discarded after 6 weeks. The Unit Manager confirmed the medication should have been discarded on 9/26/20. An open, undated, container of Breo Ellipta 100/25 inhalation was observed. The pharmacy label attached to the Breo Ellipta indicated that it should be discarded 6 weeks after opening. An observation of the North 3 medication cart was completed, on 10/6/20 at 11:07 a.m., with Staff Member J, Licensed Practical Nurse (LPN). An Asmanex HFA inhaler was observed to be open and undated. The pharmacy label for the Asmanex indicated the inhaler should be discarded 45 days after opening. Two bottles of Lumigan 0.01% ophthalmology solution were observed as opened and undated. According to https://allergan-web-cdn-prod.azureedge.net/allergan/allergannewzealand/media/allergannewzealand/products/lumigan-nz-cmi.pdf, Lumigan ophthalmology solution contains a preservative which helps prevent germs growing in the solution for the first four weeks after opening the bottle. After this time there is a greater risk that the drops may become contaminated and cause an eye infection. A new bottle should be opened. One bottle of Combigan 0.2-0.5% ophthalmology solution was observed as opened and staff had dated the pharmacy label as opened on 8/31/20 and expire (exp) on 9/29/20. According to https://www.drugs.com/uk/pdf/leaflet/1076219.pdf, the user pamphlet for Combigan indicated that the bottle should be discarded four weeks after opening to assist with the prevention of infections. Staff Member K confirmed the observations of the North 3 Medication cart. Review of The Storage of Medications policy, dated 2001 and Revised April 2007, indicated the following: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. - Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. - Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. Photographic evidence was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An observation of the laundry room was completed, on 10/7/20 at 10:14 a.m., with the Assistant Director of Nursing (ADON) and the Housekeeping Manager. On each of the two washers was a lint filter which were both covered in lint/dust. The Housekeeping Manager did not know the purpose of the filters but stated one of the washers (#2) would just shut off. A notice attached to the washers under the filters indicated, Notice, Clean Filter Daily. The Housekeeping Manager stated the filters do not get changed daily. Photographic evidence was taken during the course of the survey. Based on observations, interviews, and review of facility records, the facility failed to ensure resident rooms and other spaces in two of two units (North and South), were clean and free from disrepair during four of four days observed (10/4/20, 10/5/20, 10/6/20 and 10/7/20). Findings included: Observations on 10/4/2020 at 9:35 a.m. and 12:20 p.m., 10/5/2020 at 7:25 a.m., 10:00 a.m., and 12:55 p.m., 10/6/2020 at 8:20 a.m. and 1:00 p.m., and 10/7/2020 at 7:30 a.m. and 8:50 a.m. revealed: 1. South (Secured) unit: - The filters in the air conditioner units in resident rooms 134, 136, 137, 138, 139, 140, 141, 143, 144, and 146 were observed with a thick layer of dust and debris. - The ceiling vents in the main hallway for rooms 152 - 168 were observed during the initial tour on 10/04/2020 beginning at 9:35 a.m., to be caked with dust and debris with pieces of debris blowing down onto the floor and medication cart. - A ceiling vent, located near the nursing station, had a black substance on the ceiling tile around the perimeter of the vent and another tile next to the vent had a pink biofilm. - The end of the hallway near the day room was observed with two empty vending machines. On top of the last vending machine and towards the back of the wall, a white plastic disposable container with a lid was observed to be present with food inside of it. - The end of the hallway near the day room and vending machines was observed with a door and window framed section that led to the outside patio used for smoking. The corner section of the wall near the door frame was observed with a long plastic covering that was unsecured from the wall. Closer observation of this area revealed three metal screws that had the ends exposed and were accessible to residents who frequent this area, in order to go to the patio. - The wall in resident room [ROOM NUMBER] near the air conditioner unit and window was observed with a large section of dry wall that was peeling off and exposed a wet area with black biogrowth. This room was occupied by two residents and during one observation a resident was observed seated about one foot from this area. The section was approximately three feet by three feet. - The bathroom door for resident room [ROOM NUMBER] was observed with holes in it. - The wall section just under the window sill and above the a/c unit in resident room [ROOM NUMBER] was observed peeling off the wall and hanging in a manner where a resident could access it or scrape against it. - The shower room in the unit and near room [ROOM NUMBER] was observed with six shower tiles and grout lines near the floor with black biogrowth. - The bathroom wall in resident room [ROOM NUMBER] was observed to have a rectangular hole where the toilet paper roll holder was usually located. Pink - wispy insulation and the rough edges of the dry wall were observed in the hole. The toilet paper holder was observed sitting on the top of the toilet tank, with the toilet paper still attached. - On 10/05/2020, Housekeeping Staff P was observed bringing his housekeeping cart onto the secured south unit at approximately 10:15 a.m. Staff P confirmed, he was just starting to clean on the South unit. The mop bucket, located on the cart, was noted to be half full of water. The sides of the bucket, the rim of the bucket and the attached wringer were noted to be soiled with a dark matter. The wringer was dry and the dark matter was easily rubbed off of the edges and the grating that was part of the wringer. The Housekeeper was not able to explain why the bucket was so dirty and how he would clean using this dirty bucket. The Housekeeping Manager confirmed, on 10/5/20 at 11 a.m. , that the bucket was dirty and not just stained. He determined that it was soiled by running his fingers over the rim of the bucket and the grating of the wringer, which easily dislodged the dark matter. The Housekeeping Manager asked Staff P, Housekeeper, to take the bucket out of service and scrub the bucket before cleaning the south unit. -On Sunday, 10/4/20 at 10:22 a.m., observation with Staff Member M, Certified Nursing Assistant (CNA), of the one shower room on the South Secured unit revealed trash littered the floor and the trash bins did not have bags in them. No toilet paper was available for the residents and one of the walls had a splattering of a brown substance across it. Staff M reported that there were no showers given on Sundays. On 10/7/20 at 9:43 a.m., the Assistant Director of Nursing (ADON) stated he was, embarrassed when the observation of the secured unit shower room was discussed. - On 10/4/20 at 11:41 a.m., observation of Resident #62's room revealed the wallboard behind the air conditioner unit was pulled away from the wall, and a screw was in the wallboard not attached to the wall. On 10/4/20 at 3:18 p.m., the Maintenance Director observed the wallboard and screw. He stated he was in the process of renovating the secured unit and did not know who put the screw in the board. He removed the screw with his fingers by pulling it and confirmed the area was a safety issue. The Maintenance Director stated, someone could get a skin tear. The window blinds in the room were also observed to be broken. -During observation on 10/5/20 at 9:15 a.m., three male residents were observed smoking on the screened patio of the secured unit. The area was noted with the following concerns: - a blue ball was observed in the area with the fire blanket that was deflated and had a black substance attached to it; - a fabric and wooden chair that one resident was sitting in was mildewed and the wood was cracked. - a water jug, sitting on a utility cart, had dust, dirt, and other debris on top of the lid. Inside the jug was water with a bug on the bottom of it. - 2 tiles were observed sitting near the blue ball. Staff Member O, Certified Nursing Assistant, who had been supervising the residents while they smoked, confirmed the bug inside the water jug. She stated that the jug was changed daily when they did group activities outside, but due to COVID-19 group activities had been canceled. She was unsure of when the jug had last been changed. On 10/5/20 at 10:00 a.m., the curved end of the handrail, outside of resident room [ROOM NUMBER], was not attached tightly to the wall. Closer observation revealed the handrail had a broken bracket that left a large washer and screw exposed. A steel bracket was observed underneath a portion of the handrail. 2. North unit: - The shower room near resident room [ROOM NUMBER] was observed with three tiles and grout lines in one of one shower stall with black biogrowth. - The shower room across from room [ROOM NUMBER] was observed with one of one shower stall with black biogrowth on six wall tiles and grout lines near the floor. - The main wall outside resident room [ROOM NUMBER] was observed with three splatters of a brown sticky liquid/substance. - The main wall outside and between resident rooms 119/121 was observed with six pink dried liquid splatters. - The main wall outside and between the nurses station and room [ROOM NUMBER] was observed with five brown, pink dried sticky splatters. - The main hallway at the exit door, and across from resident room [ROOM NUMBER], was observed with a spider web with a live spider and many insect carcasses. The web measured approximately nine inches long by eight to ten inches across. On 10/7/2020 at 8:50 a.m., a facility wide tour was conducted with the Maintenance Director and the Housekeeping Director. They were provided with visual evidence of the above items. They were able to confirm all items and revealed that the areas should have been caught and cleaned or maintained through daily housekeeping rounds. The Housekeeping Director provided the daily and monthly cleaning schedule for review. He indicated that the ceiling vents and the room air conditioner filters wee cleaned once a month. He stated that they should be cleaned more frequently based on the observations. The Maintenance Director confirmed the condition of the walls in resident rooms and stated that he was not aware of it, but he was repairing walls in other rooms. The Housekeeping Director confirmed that during his rounds and his staff rounds, they should have caught the walls in disrepair and reported it immediately to the Maintenance Director. Interview with the North and South Unit Manager on 10/7/2020 both confirmed that if there were any cleaning or maintenance issues in resident rooms or other spaces, they write up job request forms and submit them to the Maintenance Director to fix.