**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review, the facility failed to invite resident to care plan meetings for 1 of 3 residents sampled. (Resident #2)The findings include:On 7/14/25 at 5:02 PM, an interview was conducted with Resident #2. She stated she had not participated in any care plan meeting since she arrived at the facility. She further stated she had not been invited to any care plan meeting. A review of Resident #2's medical record was conducted with Staff A, the MDS coordinator. Resident #2 was admitted on [DATE]. A record of the most recent care plan meetings indicated they were conducted on 5/2/25, 2/27/25 and 11/29/24. Care plan meeting forms were signed and dated by Staff A and the Social Services Director. There was no indication that Resident #2 was in attendance. On 7/15/25 at 9:27 AM, an interview was conducted with Staff A. She stated that Resident #2 did not participate in the care plan meetings. She was unsure of the reason Resident #2 did not attend. A review of the facility's policy and procedure was conducted. The facility policy titled, Care Plan Invitation, dated 11/30/2014, revised 9/25/2017, stated The resident and/or the resident representative shall be invited to attend each of the interdisciplinary Care Planning Conferences for the specific resident. Deliver a Care Planning invitation to the resident 7-14 days prior to the date of the conference Place a copy of the invitation in the medical record. Request that the resident and/or resident representative contact the facility designee to confirm or reschedule the date/time for the resident's conference. Have all attended to the Care Planning Conference, including resident and resident representative sign the Care Plan Conference Record to verify their attendance.

Based upon interview, observation, and record review, the facility failed to maintain a clean environment in 2 out of 4 halls observed.The findings include:On 7/14/25 at 10:02 AM, during the initial tour, hallway 300 was noted with has a very strong urine-like smell.On 7/14/25 at 10:04 AM, Staff C, a housekeeper, was interviewed. She stated she works three days a week from 8:00 am to 2:00 pm. She will have two hallways assigned for cleaning duties. She steted she does not work on weekends. She stated sometimes she would have two extra hallways assigned when someone did not come to work. Upon asking if she was able to finish her assignments, she stated she does what she could. She stated her assignments were to clean surfaces and sweep and mop floors.On 7/14/25 at 10:17 AM, an interview was conducted with Resident # 7. She stated sometimes on the weekends she did not see housekeeping personnel. She further stated staff would sometimes come in and pick up the trash, but they would not mop or wipe the tables.On 7/14/25 at 10:27 AM, an interview was conducted with Resident #8. She stated the last time she saw housekeeping was on Saturday (7/12/25) when they came in and picked up the trash. She further stated that housekeeping doesn't clean on the weekends.On 7/14/25 at 10:43 AM, hallway 100 also had a very strong urine smell.On 7/14/25 at 10:47 AM, Resident #5 was interviewed. She stated housekeeping came in her room every 2 to 3 days. She stated they clean the floors and the table. She further stated she does not recall staff ever coming on a Sunday but they did come in the room on Saturday 7/12/25. It was noted during the interview with Resident #5 that the floor is sticky. Upon inspection of her bathroom, there was a very strong urine-like smell.On 7/14/25 at 5:02 PM, an interview was conducted with Resident #2. She stated housekeeping did not come on weekends and that they did not clean enough. On 7/14/25 at 5:12 PM, a second tour of the facility was performed and hallways 100 and 300 still had a very strong urine-like smell. On 7/14/25 at 5:43 PM, the Director of Nursing (DON) was made aware of the strong urine odor in 100 and 300 hallways. She stated there were no housekeeping staff available at this time at the facility as they had all gone home. On 7/15/25 at 11:15 AM an interview was conducted with Staff B, the Manager of Housekeeping/Laundry. He stated the expectation for housekeeping staff was to clean the rooms every day, which includes sweeping, mopping, and wiping surfaces. Upon request, he was unable to provide documentation of staff daily workload verification.

Based on observation, resident and staff interviews, and record review, the facility failed to develop a comprehensive person-centered care plan to maintain the resident's highest practicable level of physical functioning for 1 of 28 sampled residents. (Resident #88) The findings include: On 02/10/25 at 01:56 PM during an interview with Resident # 88, the resident was asked if they are ever gotten out of bed. The resident replied that their wheelchair is too large and they cannot maneuver it because of the size. She stated she cannot sit up straight due to right-sided weakness and because it is very painful. The resident stated that they have not gotten out of bed but would like to if they had a more comfortable wheelchair. Resident #88 states that they have told staff but nothing has been done. On 02/12/25 at 12:10 PM, an interview was conducted with Staff H (Unit Manager for the 100, 200, and 300 halls). She stated she is new to the position since December and is still learning her role and that she was unaware of any requested equipment needs. She stated that this resident does refuse to get out of bed but could not identify any documentation of refusal and had no answer as to why the resident might be refusing. A review of medical record reveals an order dated 5/25/2024 stating May have restorative/maintenance programs as indicated. The discharge notes from therapy services indicated that the resident had received services from 5/27/2024 to 7/18/2024. The resident was discharged from therapy at that time due to achieving maximum potential. There was recommendations for a Restorative Splint and Brace program with splint to Left Upper Extremity (LUE) and Left lower extremity (LLE) knee for contracture prevention and Bed Mobility Program. Prognosis was noted as Good with consistent staff follow-through. A review of the Care Plan for Resident #88 reveals that she is care planned for an Alteration in Usual Functional Performance in Mobility/Transfer status related to weakness, impaired mobility, balance and gait with reference to Independent resident performance of wheelchair use in room and hall. However, there is no care plan referencing Restorative Nursing or Splint and Brace Program recommended for prevention of contractures.

Based on observation, staff interviews, and record review, the facility failed to provide equipment and restorative services to prevent a further decrease in range of motion for 1 of 3 residents sampled for limited range of motion. (Resident #88). The findings include: On 02/10/25 at 02:47 PM, Resident #88 was observed to have contractures of the left arm/wrist/hand. No supportive devices were noted in the room. On 02/11/25 at 02:10 PM, Resident #88 was observed to be receiving personal care in bed from the nursing aide. Resident #88's left arm and leg were noted to be severely contracted, affecting the resident's ability to change positions. On 02/12/25 at 09:45 AM, the Director of Physical Therapy stated that he has not received any requests for equipment needs for this resident. He verified that, unless consulted, a resident that is not receiving therapy services would not be evaluated for equipment needs. On 02/12/25 at 11:55 AM, an interview was conducted with Staff G, a Licensed Practical Nurse (LPN). She confirmed that equipment needs are provided through PT/OT but the nurse has to let them know if the resident is not receiving therapy. On 02/13/25 at 10:25 AM, a second interview was conducted with the Director of Therapy services regarding Resident #88's current mobility status. He stated that since the resident was not currently receiving services. He confirmed that he had not received any requests for re-evaluation of this resident until this morning. He stated that he was not aware of the extent of resident's contractures as he had not assessed them yesterday. No orders for therapy have been written. He concurred that the resident's condition may have deteriorated due to lack of staffing and a breakdown in communication between Nursing Services and Therapy. On 02/13/2025 at approximately 12:00 PM, Resident #88 verified that she has never been offered, received, or refused splints for her wrist or legs. In reviewing Resident #88's medical record, orders were noted on admission dated 5/25/2024 for physcial therapy to eval and treat as indicated. Rehab potential was defined as Good. In reviewing the discharge notes from Therapy Services, the notes indicated that the resident had received services from 5/27/2024 to 7/18/2024. The resident was discharged from therapy at that time due to achieving maximum potentia,l with recommendations for Restorative Splint and Brace program with splint to Left Upper Extremity (LUE) and Left lower extremity (LLE) knee for contracture prevention and Bed Mobility Program. Prognosis was noted as Good with consistent staff follow-through. Review of Medication / Task Administration records reveals no order or task identified for Restorative services or to apply wrist/leg splints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to provide appropriate urinary catheter care for 1 of 1 resident reviewed for catheter care. (Resident #97) The findings included: During a tour of the facility conducted on 02/10/25 at 12:50 PM, Resident #97 was noted with a urinary catheter. When asked how often the staff clean his catheter, Resident #97 stated the staff did not clean his catheter regularly. A review of Resident #97's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #97 had a medical history significant for Paraplegia, Hematuria, and Urinary Tract Infections. A review of Resident #97's admission Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview of Mental Status Score of 11, which indicates he had moderate cognitive impairment. This MDS documented the presence of the urinary catheter. Resident #97's physician orders revealed there were orders written on 01/11/25 regarding Catheter care every shift and as needed. An interview was conducted with Staff A, a Certified Nursing Assistant (CNA), on 02/13/25 at 9:30 AM. Staff A was assigned to care for Resident #97 that day. When asked about Staff A performing catheter and perineal care on Resident #97, Staff A stated she was unaware of how to perform catheter care. Staff A further stated she did not typically work on Resident #97's hallway. When asked if she had cared for other residents with catheters on the other hallways at the facility, Staff A she stated she had. A urinary catheter care observation was conducted with Staff A, CNA and Staff B, CNA on 02/13/25 at 10:33 AM. They gathered towels, washcloths, disposable chux, and an incontinence brief. Staff A and Staff B washed their hands and donned gloves. Staff A had a handful of gloves in her scrub top pocket that she used throughout the catheter care observation. Staff A filled two bath basins with warm water in Resident #97's bathroom while Staff B removed Resident #97's sheets and incontinence brief. Staff A washed her hands and donned a new pair of gloves from her pocket prior to beginning the catheter care. At Staff B's recommendation, Staff A picked the catheter bag up off the bed frame and, raising it above the level of the bladder, moved it onto the bed. There was no catheter securement device present. Staff A placed multiple washcloths in both bath basins and a bar of soap in one bath basin. Staff A then removed a washcloth from the water bin containing the bar of soap, applied soap onto the washcloth, and proceeded to clean Resident #97's penis, from the head back up the shaft. Staff A then verbalized she did not know how to pull back Resident #97's foreskin, so Staff B assisted her in this task, revealing Resident #97's glans penis. The glans penis had a large buildup of white smegma present. Staff A used a new washcloth with soap to clean the glans penis. She continued using the same area of the washcloth while applying new soap to the washcloth for the whole glans penis, removing the smegma until it appeared clean. She then used a new washcloth with soap to clean Resident #97's catheter tubing and scrotum. Staff A then used a new washcloth with clean water to wipe clean the resident's glans penis, catheter tubing, and scrotum. She then dried the area with a clean towel. After changing Resident #97's incontinence brief, Staff A and Staff B sat Resident #97 upright in the bed and covered him with his sheets, again, raising the catheter bag above the level of the bladder to hang the bag back on the bed frame. Neither Staff A nor Staff B replaced Resident #97's foreskin until after being reminded to do so by Resident #97 himself. An interview was conducted with the facility's Director of Nursing (DON) on 02/13/25 at 12:45 PM. The DON was told about the above concern with the catheter care, including the gloves in the pocket, unawareness of how to perform catheter care, and the lack of catheter securement device. The DON stated she planned to perform competencies on the staff as she also had concerns about staff members not understanding how to perform catheter care on uncircumcised residents. During the Quality Assurance and Performance Improvement meeting conducted on 02/13/25 at 1:00 PM, it was mentioned that, on 01/20/25, the facility administration had identified that nursing competencies regarding urinary catheter care were not up to date. Review of the facility's polity titled Catheter Care, Urinary, revision date 09/05/17 revealed the proper procedure for performing catheter care involved the following: Remove catheter securement device Wash perineal area with soap and water Rinse well and dry Clean catheter tubing with soap and water, starting at the meatus, cleaning in circular motion along its length, moving away from the body. Rinse well using the same motion Reattach catheter securement device

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records contained complete and accurate information for 3 of 28 residents reviewed for medical records. (Residents #92, #5, #105) The findings include: Resident #92 During a tour of the facility conducted on 02/10/25 at 12:33 PM, Resident #92 was noted receiving oxygen via a nasal cannula. Closer observation revealed the oxygen tubing was dated 01/26/25 (photographic evidence obtained). A review of Resident #92's medical record revealed she was admitted to the facility on [DATE]. Resident #92 had a medical history significant for Acute and Chronic Respiratory Failure, Apnea, Bipolar, Depression, and Dependence on Supplemental Oxygen. A review of Resident #92's Quarterly Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview of Mental Status (BIMS) score of 15, which indicates she was cognitively intact. A review of Resident #92's Care Plan revealed a care plan was written on 10/01/24 regarding altered respiratory status, history of respiratory failure-oxygen via nasal cannula, change tubing . as ordered. A review of Resident #92's physician's orders revealed an order was written on 09/20/24 for Respiratory: Oxygen 2 liters nasal cannula Continuous every shift. Further order reviews revealed an order was written on 01/17/25 for Change oxygen tubing, mask and/or nasal cannula weekly. May change sooner as needed. Every night shift every Friday. A review of Resident #92's Treatment Administration Record (TAR) revealed a staff member documented the oxygen tubing was changed on 02/07/25 (photographic evidence obtained). Resident #5 During a tour of the facility conducted on 02/10/25 at 12:40 PM, Resident #5 was observed receiving oxygen via a nasal cannula. Closer observation revealed the oxygen tubing was dated 01/26/25 (photographic evidence obtained). A review of Resident #5's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #5 had a medical history significant for Paralysis, Chronic Obstructive Pulmonary Disease, Heart Failure, and Traumatic Brain Injury. A review of Resident #5's Quarterly MDS, dated [DATE] revealed he had a BIMS score of 8, which indicates he had moderate cognitive impairment. A review of Resident #5's Care Plan revealed there was no care plan written regarding oxygen use. A review of Resident #5's physician orders revealed orders were written on 09/11/24 for Oxygen 2 liters per minute via nasal cannula as needed and Change tubing, mask and/or nasal cannula weekly. May change sooner as needed for hygiene AND every night shift every Friday. A review of Resident #5's TAR revealed a staff member documented the oxygen tubing was changed on 02/07/25 (photographic evidence obtained). An interview was conducted with Staff M, a Licensed Practical Nurse (LPN), on 02/12/25 at 2:50 PM. Staff M stated the night shift nurses were responsible for changing resident's oxygen tubing, but she could not confirm how often it was changed. She stated, to my knowledge, they are supposed to label it when it's changed. An interview was conducted with the facility's Director of Nursing (DON) on 02/12/25 at 4:05 PM. She stated the expectation would be for whoever performed care, such as changing oxygen tubing, would sign it off in the resident's medical record. In this instance, the night shift nurse should not have signed off that the oxygen tubing was changed. The DON further stated the expectation was that oxygen tubing would be changed weekly and labeled with the date of the change. Resident #105 During a tour of the facility conducted on 02/10/25 at 12:45 PM, Resident #105 stated he had a peripherally-inserted central catheter (PICC) line in place for antibiotic use. Closer observation revealed the PICC dressing was dated 02/01/25. An interview was conducted with Resident #105 during this observation. He stated he did not know when the PICC dressing was changed last by the facility staff (photographic evidence obtained). A review of Resident #105's medical record revealed he was admitted to the facility on [DATE]. Resident #105 had a medical history significant for Cellulitis of the Right Upper Limb, Acute Osteomyelitis Right Hand, and Deep Vein Thrombosis. A review of Resident #105's admission MDS, dated [DATE], revealed he had a BIMS score of 13, which indicates he was cognitively intact. A review of Resident #105's Care Plan revealed a care plan was written on 01/10/25 regarding he was on IV medications related to right 3rd finger Osteomyelitis and right-hand Cellulitis. A review of Resident #105's physician orders revealed an order was written on 01/15/25 for Change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Every day shift every Wednesday. A review of Resident #105's Medication Administration Record (MAR) revealed a staff member documented the PICC line dressing was changed on 02/05/25 (photographic evidence obtained). Additional observations were conducted on 02/11/25 at 12:20 PM and 1:45 PM of Resident #105's PICC line dressing, which remained dated 02/01/25. An interview was conducted with Resident #105 on 02/12/25 at 3:06 PM, in which he stated his PICC line had been removed the evening of 02/11/25. An interview was conducted with Staff M, LPN on 02/12/25 at 2:45 PM. Staff M stated the PICC line dressings were changed every three to five days. She said the staff should be assessing the PICC line dressings every time they go into the resident's room. She further stated the LPNs could assess the dressings, but a registered nurse had to perform the dressing changes. Staff M continued to explain that there was one nurse who performed the dressing changes on night shift and either the DON or Assistant DON who performed the dressing changes on day shift. Staff M confirmed that her initials were on the MAR as having signed off the PICC dressing change on 02/05/25. When asked why she signed off that the dressing change was completed on 02/05/25, she stated she would have told one of the nurses that Resident #105's PICC line was due for a dressing change and assumed the nurse had changed it. An interview was conducted with the facility's DON on 02/12/25 at 4:05 PM. She stated the expectation would be for whoever performed care, such as changing a dressing change, would sign off the resident's medical record. In this instance, the LPN should not have signed off that the PICC line dressing was changed. The DON further stated the LPN should have looked at the dressing to see if it had been changed and had the registered nurse sign off that the dressing change was completed. Review of the facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection, date revised November 2011 revealed the staff should mark . with date and initials and change the oxygen cannula and tubing every seven days, or as needed. Review of the facility policy titled Guidelines for Preventing Intravenous Catheter-Related Infections, date revised August 2014 revealed the staff should change transparent semi-permeable membrane (TSM) dressings on central venous access devices every 5-7 days or as needed if damp, loosened, or visibly soiled and gauze dressing covered with TSM dressing should be considered a gauze dressing and changed at least every 48-hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to maintain proper isolation precautions for 2 of 2 residents reviewed for Enhanced Barrier Precautions (EBP) (Resident #97 and #67), and the facility failed to ensure proper handwashing practices during medication administration opportunities for 2 of 20 observations (Resident #71 and #563). The findings include: Resident #97 During a tour of the facility conducted on 02/10/25 at 12:50 PM, Resident #97 was noted with a urinary catheter present. Resident #97 stated the staff did not clean the catheter regularly. A review of Resident #97's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. He had a medical history significant for Paraplegia, Hematuria, and Urinary Tract Infection. A review of Resident #97's admission Minimum Data Set (MDS), dated [DATE] revealed he had a Brief Interview of Mental Status (BIMS) Score of 11, which indicates he had moderate cognitive impairment. This MDS documented the presence of the urinary catheter. A review of Resident #97's physician orders revealed there were orders written on 01/11/25 regarding Catheter care every shift and as needed and Enhanced Barrier Precautions. A urinary catheter care observation was conducted with Staff A, Certified Nursing Assistant (CNA), and Staff B, another CNA, on 02/13/25 at 10:33 AM. They gathered their needed supplies from a linen cart and entered Resident #97's room. Staff A and Staff B washed their hands and donned gloves. Staff A had a handful of gloves in her scrub top pocket that she used throughout the catheter care observation. Neither Staff A nor Staff B donned an isolation gown for performing the catheter care. Resident #67 During the initial record review conducted on 02/10/25 at 3:34 PM, Resident #67 was noted with pressure injuries present on his left heel, left groin, right ischium, and sacrum. A review of Resident #67's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. He had a medical history significant for Paraplegia, Malnutrition, Osteomyelitis, Colostomy, Depression, Atrophy, and Muscle Weakness. A review of Resident #67's Annual MDS, dated [DATE] revealed he had a BIMS score of 15, which indicates he was cognitively intact. This MDS documented the presence of pressure injuries. A review of Resident #67's physician orders revealed there were orders written on 11/08/24 regarding wound care procedures for each of his wounds. A wound care observation was conducted with Staff C, Licensed Practical Nurse, and Staff D, Nurse Practitioner. Staff C gathered supplies from the wound care cart prior to entering Resident #67's room. Staff C and Staff D washed their hands and donned gloves. Neither Staff C nor Staff D donned an isolation gown for performing the wound care. Resident #71 On 02/13/25 at approximately 08:19 AM during Med Pass observations for Resident # 71, Nurse J was observed to dispense medications to Resident #71 without washing her hands or using hand sanitizer. Hand sanitizer was readily available on top of the medication cart and a sink and soap was available in the resident's room. She then proceeded to prepare medications for the next resident without sanitizing her hands between residents. On 02/13/25 at approximately 09:00 AM, Nurse K donned gloves to hang the IV antibiotic for Resident # 563 and was observed to use a gloved hand to place the used bag into a trash can aand then used the same hand to flip hair out of her face, but she did not change gloves. She proceeded to use contaminated gloves to wipe the hub of a medication vial with alcohol and the insert spike of IV tubing. Nurse K then proceded to continue medication pass to Resident # 84. She removed her gloves but did not use hand sanitizer or wash hands between residents. Nurse K was also observed to place her finger inside a medication cup while opening medication cart to obtain ordered medications. A review of the facility policy titled Enhanced Barrier Precautions, dated August 2022 revealed the following: Gloves and gowns are applied prior to performing high contact resident care activity Examples: providing hygiene, device care or use (including urinary catheters), wound care. EBPs are indicated for residents with wounds and/or indwelling medical devices EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk Signs are posted in the door or wall outside the resident's room indicating the type of precautions and personal protective equipment (PPE) required PPE is available outside of the resident's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure vaccination consents were obtained and maintained for 4 of 5 residents reviewed for Influenza and Pneumococcal Vaccinations (Resident #101, #51, #105, and #96). The findings include: A review of Resident #101's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #101's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #101 was missing a consent form for the Pneumococcal vaccine. A review of Resident #51's medical record for vaccinations revealed she was admitted to the facility on [DATE]. A review of the Immunization section of Resident #51's electronic medical record revealed she had refused the Influenza vaccine. A review of the immunization consent forms provided by the facility revealed Resident #51 was missing a consent form for the Influenza vaccine. A review of Resident #105's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #105's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #105 was missing a consent form for the Pneumococcal vaccine. A review of Resident #96's medical record for vaccinations revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE] after an extended hospitalization which lasted approximately 3 weeks. A review of the Immunization section of Resident #96's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #96 was missing a consent form for the Pneumococcal vaccine from his initial admission in October 2024. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 02/13/25 at 11:10 AM regarding the missing Influenza and Pneumococcal vaccination consent forms. The ADON stated she would work with the Medical Records Department to find the missing consent forms. The ADON returned at 12:15 PM and confirmed she and the Medical Records personnel were unable to find the missing consents. The ADON then showed the surveyor a check list that the staff follow for each new resident admission, which contained directions that the staff are to obtain consents for Influenza and Pneumococcal vaccines. She stated in speaking with the Medical Records personnel that she was told, after things are scanned into residents' charts, the forms are then disposed of and not kept. Review of the facility's policy titled Influenza Vaccine, revised date March 2022 revealed the influenza vaccine shall be offered to residents, and a resident's refusal of the vaccine shall be documented on the informal consent for influenza vaccine and placed in the resident's medical record. Review of the facility's policy titled Pneumococcal Vaccine, revised date March 2022 revealed residents are offered the vaccination within 30 days of admission to the facility, vaccines are administered to residents per our facility's protocol, and if refused, appropriate information is documented in the resident's medical record indicating the date of the refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure vaccination consents were obtained and maintained for 3 of 5 residents reviewed for COVID-19 Vaccinations (Resident #101, #51, and #105). The findings include: A review of Resident #101's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #101's electronic medical record revealed he had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #101 was missing a consent form for the COVID-19 vaccine. A review of Resident #51's medical record for vaccinations revealed she was admitted to the facility on [DATE]. A review of the Immunization section of Resident #51's electronic medical record revealed she had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #51 was missing a consent form for the COVID-19 vaccine. A review of Resident #105's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #105's electronic medical record revealed he had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #105 was missing a consent form for the COVID-19 vaccine. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 02/13/25 at 11:10 AM about the missing COVID-19 vaccination consent forms. The ADON stated she would work with the Medical Records Department to find the missing consent forms. The ADON returned at 12:15 PM and confirmed she and the Medical Records personnel were unable to find the missing consents. The ADON then showed a check list that the staff follow for each new resident admission, which contained directions that the staff are to obtain consents for COVID-19 vaccines. She stated in speaking with the Medical Records personnel that she was told, after things are scanned into residents' charts, the forms are then disposed of and not kept. She said the Medical Records personnel also told her, Sometimes things get stuck together and that may have been why the consents were missing from the charts. A review of the facility's policy titled COVID-19 Vaccine-Resident, revised date 11/17/21 revealed the staff should review the COVID-19 consent with the resident/resident representative, obtain signature indicating acceptance or declination, and file the consent form in resident electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and policy review the facility failed to take precautions to ensure safety of residents during smoking times for 6 of 10 residents reviewed. (Residents #4, #5, #6, #7, #8, and #10) The findings include: On 12/10/24 at approximately 9:00 AM an interview was conducted with Staff Member B, a Certified Nursing Assistant (CNA). She indicated that the CNA's escort the residents outside for smoking in addition to their daily assignments. She said there are quite a few smokers at the facility and no dedicated staff assigned to supervise smoking. She explained that residents get impatient waiting to go out and some of the higher functioning residents occasionally go outside to smoke without supervision. She also said that several residents in the facility have their own lighters and cigarettes that they keep in their rooms. She said Resident #4 goes out and needs close supervision because she is blind. She indicated that Resident #8 keeps a lighter in her purse and is always wanting to go outside to smoke. On 12/10/24 at approximately 9:00 AM, Staff Member A, another CNA, was interviewed. She indicated agreement with what Staff B and reiterated concerns with the supervision of the residents during smoking. She said sometimes they have 20 residents smoking at a time. They have to stop what they are doing to take residents out who smoke outside. Residents who smoke often get agitated while waiting to go outside. They have to stop resident care to take the smokers outside. On 12/10/24 at approximately 9:04 AM, Resident #4 was observed seated in a wheelchair in a common area asking several staff members if it was time to go outside to smoke yet. She told staff members that normally she goes out to smoke by now. It appeared that she had trouble with her vision and could not clearly see or identify staff members. Staff members in the area did not respond to the residents' requests. On 12/10/24 at approximately 9:08 AM, there were several residents in wheelchairs observed waiting at the door to the smoking area. Resident #5 was seated in his wheelchair next to the exit to the smoking area. He had a lighter and cigarettes in his pocket. Resident #6 was also seated in the next to the exit door. An interview was conducted with Resident #5. Resident #5 said, I have my lighter with on me all the time. Resident #6 was also observed with a lighter in his hand. On 12/10/24 at approximately 9:30 AM, smoking time was observed. Staff Member S, another CNA, was present with residents at the time. There were no smoking safety aprons present in the area. Resident #5 and #6 lit cigarettes and began smoking. A few minutes later, Resident #7 pulled a lighter out from his pocket. Resident #8 removed a lighter from her purse and began to smoke. Staff Member S was asked to point out the safety aprons. Staff Member S indicated that he did not know where the smoking aprons were. The staff member was asked to see the area where smoking supplies are kept for the residents. Staff Member S stated that several of the residents normally keep their cigarettes and lighters with them. He explained that Resident #9 was not allowed to keep his lighter with him but many of the other residents keep their smoking supplies with them. He explained that he did not know where the box of smoking supplies or the aprons were kept. He indicated that he was a temporary staff member who came up after the hurricane. He indicated that he worked for a sister facility and has received training regarding safety in resident smoking areas. After the interview, Staff Member S stepped inside and left the residents smoking in the smoking area without supervision for approximately 1 minute. At approximately 9:34 AM, Staff Member B came out to assist. On 12/10/24 at approximately 9:40 AM, the Assistant Director of Nursing (ADON) came out to the smoking area. She was asked if the residents should have their lighters in their possession at all times. The ADON explained that residents should not have lighters with them. She explained that the facility has a smoking box that is supposed to come out with the aprons at smoking time. Resident #10 had a lighter in her hand at the time. The ADON collected the lighters from Resident #5, #6, #7, #8 and #10. At approximately 9:50 AM, a staff member brought Resident #4 outside to the smoking area. Resident #4 said, I can't see. Where is my cigarette? The staff member told her they are getting her an apron to wear for smoking. Resident #4 shifted impatiently raised her voice slightly as she said, I don't wear no apron. Where is my cigarette? Resident #4 was asked if she normally wears an apron when she smokes. She replied: No, No, No Ma'am. I don't know what they are giving an apron for. I have never worn an apron. As the staff member applied the apron, the resident said, What is this apron for? I have never used an apron. This is the first time they ever done this. On 12/10/24 at approximately 10:00 AM, a review of the record of Resident #4 revealed that she was admitted on [DATE]. Resident #4's care plan indicted that she had impaired vision and loss of vision in both eyes. The surveyor was unable to locate a smoking evaluation in the electronic record for Resident #4. Additionally, there was no mention that the resident smokes in the care plan. There was no indication she ever received any smoking related injuries or mishaps. On 12/10/24 at approximately 11:00 AM the ADON provided copies of two smoking evaluations for Resident #4, one dated 11/27/24 at 5:33 PM and the other dated 12/10/24 at 10:12 AM and the facility smoking policy. A review of the smoking evaluation dated 11/27/24 was conducted. The evaluation indicated that Resident #4 does not smoke. A smoking evaluation was not completed on that date. A review of the evaluation completed on 12/10/24 at 10:12 AM indicated that Resident #4 smoked. The assessment indicated that her vision was inadequate. She was determined to be a safe smoker. The assessment indicated that Resident #4 requires constant supervision while smoking. There was no mention of use of the smoking apron in the evaluation. Page 7 of the updated care plan indicated that Resident #4 was a smoker. Date initiated 12/10/24. Goals: The resident will not smoke without supervision through the review date. Date initiated 12/10/24. Interventions included the resident was instructed about the facility smoking policy on 12/10/24. The resident requires a smoking apron while smoking. Date initiated 12/10/24. The resident requires SUPERVISION while smoking. Date initiated 12/10/24. The resident's smoking supplies are to be stored at the nursing station. Date initiated 12/10/24. On 12/10/24 at approximately 12:00 PM, a review of the facility smoking policy dated 11/30/2014 was conducted. The policy stated, Residents that wish to smoke will be evaluated on admission/readmission, quarterly, and with change of condition to determine if assistance or supervision is required for smoking. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking the center will include the appropriate information on the care plan. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. The policy also stated that the center will retain and store matches, lighters etc . for all residents, which was not the case for Residents #5, #6, #7, #8 and #10.

Based on resident and staff interviews, review of the facility grievance log, and policy and procedures, the facility failed to make prompt efforts to resolve grievances for 2 of 3 residents reviewed. (Residents #2 and #3) The findings include: On August 14, 2024 at 2:07 pm, a telephone interview was conducted with the husband of Resident #2. He stated he has filed two grievances with the previous administrator, one in August 2024 and another in July 2024. He stated they had voiced numerous complaints to the previous Nursing Home Administrator (NHA) and nothing was ever done about it. On August 14, 2024 at 2:20 pm, an interview was conducted with Resident #3. She stated that several grievances have been filed with the previous NHA about two Certified Nursing Aides (CNAs) that speak disrespectfully to the residents and failed to render assistance when needed, but nothing ever gets done about it. The same staff who disrespect and ignore the call lights continue to work on this hallway according to the resident. She also stated that, after she had lodged complaints against this CNA, the CNA was serving meal trays on the hall but skipped over their room. She stated to the CNA that We never received our trays. The CNA stated, I don't want to walk in that room, because she knew we had previously complained about her behavior. Review of the medical record for Resident #2 revealed a Brief Inventory for Mental Status (BIMS) listed as 15 (no impairment of cognition) and the resident's diagnose include hemiplegia/hemiparesis post stroke affect left dominant side; and difficulty walking, among others. Review of the medical record for Resident #3 revealed also revealed a BIMS score of 15 (no impairment of cognition) and a below the knee amputation left side. A review of the Grievance Logs since March 2024 through present revealed there were no complaints or grievances for Resident #2 or Resident 3 during the month of August or July, even though both residents expressly stated they filed a grievance. The Regional Director was interviewed concerning these grievances. He stated that these were grievances were submitted to the previous Administrator, who claimed they had followed up on these issues. They did not discover the failure of the previous administration to follow up on these grievances until after the previous administrator had left. Review of Policy and Procedures Subject Complaint/Grievance Document Name N-1042 Effective Date 11/30/14 and Revision Date 10/24/22 revealed the Procedure as follows: 1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. -Complaint/Grievance forms will be available 24 hours per day 7 days a week in an unsecured common area. -Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. 2. Original grievance forms are then submitted to the Grievance Officer /designee for further action. 3. The Grievance Officer /designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/grievances in Monthly Grievance Log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a clean, safe and home-like environment for 11 of 94 occupied areas. The findings include: On 2/28/24 at 10:34, during the initial tour of the facility, the following environmental concerns were observed: Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains. Occupied room [ROOM NUMBER]-B had an overhead table with exposed edges. Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains. Occupied room [ROOM NUMBER]-A had a fall mat with sticky tape covered with a dark brown substance. Occupied room [ROOM NUMBER]-B had a fall mat with sticky tape covered with a dark brown substance. Occupied room [ROOM NUMBER]-A had wall paper peeling off the wall and a patched up white substance on the wall. Occupied room [ROOM NUMBER] had overhead tables with the plastic rim detached, exposing particle wood. Occupied room [ROOM NUMBER]-A had an overhead table with edges that are chipped. Additionally, the bed's frame is rusted. Occupied room [ROOM NUMBER]-A had an overhead table with the plastic rim detached, exposing particle wood. Occupied room [ROOM NUMBER]-B had an overhead table with the plastic rim detached exposing particle wood, and dresser also had particle wood exposed on the edges. In the public 200 Hallway, there was an approximately 6 foot long baseboard that was detached from the wall. (Photographic evidence was obtained) On 2/29/24 at 12:50, a follow-up tour was conducted with the Administrator, DON and Regional Consultant. The Administrator stated all the overhead tables and the fall mat would be replaced for new ones. The DON stated the wall paper in room [ROOM NUMBER] would be replaced immediately. The Administrator further stated the bed in room [ROOM NUMBER]-A would be fixed by a new one once the impending shipment arrived. Invoices showing this bed was ordered was requested but were not provided.

Based on record review and staff interview, the facility failed to administer a medication as ordered by a physician for 1 of 3 resident sampled for medication administration. (Resident #2) The findings include: On 2/29/24, a review of Resident #2's medical record was conducted. A physician order stated to inject dexamethasone sodium phosphate (a medication used to treat many inflammatory and autoimmune disorders) 8 mg intramuscularly one time only for pain related to gout. This order was dated 12/29/24 with an end date of 12/30/24. The physician order summary was reviewed and stated it was completed. The Resident's Medication Administration Record (MAR) revealed medication was not documented as given on 12/29/23 and on 12/30/23 documentation was signed with nurse initials BT31 with a code number 9 that indicated see progress notes. A review of progress notes dated 12/30/23 at 00:40 AM and signed by Staff A, a Licensed Practical Nurse (LPN) stated dexamethasone sodium phosphate injection solution medication unavailable to administer. On 2/29/24 at 11:22 AM, an interview was conducted with Director of Nursing (DON). She reviewed Resident #2's medical record and stated the facility kept the medication onsite. She further stated Staff A, LPN, should have notified and follow up with the doctor. The DON added that this omission should not have happened.

Based on record review and interview, the facility failed to provide transfer or discharge notices to 2 out of 2 resident sampled for discharge notices. (Residents#30 and #1) The findings include: A record review revealed that the facility did not provide transfer or discharge notices at the time Residents #30 and #1 were discharged to the hospital. An interview was conducted on 11/15/23 at approximately 2:58 PM with the business office manager. She was asked where the transfer or discharge notices could be found, as they were not part of the record. She stated that medical records could provide a copy. An interview was conducted on 11/15/23 at approximately 3:08 PM with medical records. The medical records staff stated they did not have a copy of any transfer or discharge notices for Residents #30 and #1. An interview was conducted on 11/15/23 at approximately 4:19 PM with the Social Services Director. She stated she is the one that sends the discharge notices to the Ombudsman. When asked for a copy of the discharge notices for Resident #30 and Resident #1 that were sent to the ombudsman, she stated she did not have it and has no idea where to get it. She stated she has not done those particular discharges because she has not been in her current position for very long. A follow up interview was conducted on 11/28/2023 at approximately 9:48 AM with the local Ombudsman office. She verified that the facility has not been sending discharge notices.

Based on record review and interview the facility failed to provide bed-hold notices to 2 out of 2 resident sampled for hospital discharge. (Residents #30 and #1) The findings include: A record review revealed no evidence that the facility provided a bed-hold notice at the time Residents #30 and #1 were discharged to the hospital. On 11/15/23 at approximately 2:58 PM, an interview conducted with the Business Office Manager, who stated that the facility does not do bed-hold notices. She stated, We do not do bed-hold notices for anyone, we do not need to do that. On 11/15/23 at approximately 3:20 PM, the Facility Administrator provided a copy of the facilities bed-hold policy, which states, At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed-hold.

Based on record reviews and interviews, the facility failed to develop a comprehensive care plans for antibiotic use for 1 of 1 residents sampled. (Resident #34) The findings include: On 11/13/2023, a record review was conducted for Resident #34. The resident's care plan only included a nutrition care plan. There was a baseline care plan document scanned into Point Click Care under the Miscellaneous tab that was not legible. No evidence of a care plan related to her antibiotic use could be located. (photographic evidence obtained) On 11/15/2023 at approximately 9:12 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. When asked about the comprehensive care plans for antibiotic use not being completed for Resident #34, the MDS Coordinator stated she has another MDS Coordinator who comes in and helps her and she would have been the one who did the assessment for Resident #34. The MDS Coordinator stated she is not sure why she didn't complete the care plans and stated, Honestly, she just failed to do it. When asked where the paper copy for the baseline care plans that was scanned could be found, she stated that copy was probably thrown away. When asked if she could look at the care plan document scanned in, she verbalized that the baseline care plan is not legible to her. She reached out to medical records and reported that documents, once they're scanned into the system, are then shredded, and no copy is left in the chart.

Based on interviews and records review, the facility failed to develop and implement written standards, policies, and procedures for the Infection Prevention and Control Program (IPCP) and failed to conduct an annual review of its IPCP. The findings include: On 11/15/23 at approximately 10:50 AM, in an interview with the Director of Nursing and Unit Manager, they disclosed that they are both recently trained in Infection Control. They stated that the facility does not have a formal training program on Transmission Based Precautions (TBP), education is provided on a case by case basis. Surveillance of compliance is conducted intermittently and as needed. Any cluster of 2 or more infections are tracked and recorded. Department of Health (DOH) contact is used as a resource and reporting is done according to their DOH guidelines. On 11/15/23 at 12:10 PM, a review of Infection Prevention and Control Program (Revised date: October 2018) in the Quality Assurance and Performance Improvement manual with the Administrator revealed no review of the IPCP in the past 12 months of records. The documents provided as the facility IPCP was lacking specific Policies and Procedures for Standard and TBP/Isolation Procedures. A monthly report of Infection control surveillance was verified in monthly QAPI meeting. Education In-service records were reviewed and found to include Enhanced Barrier Precautions on 7/8/2023, Isolation Covid Precautions/Donn/Doff Personal Protective Equipment (PPE) education 6/28/2023 & 6/29/2023 and Hand Hygiene In-Service on 6/28/23-6/29/2023 and 9/2/2023.

Based on interviews and record review, the facility failed to develop, maintain, or follow policies and procedures for immunization of residents against influenza and pneumococcal disease in accordance with national standards of practice for 2 of 5 clinical records reviewed. (Residents #36 and #46) The findings include: On 11/15/23 at approximately 10:50 AM, an interview was conducted with the Director of Nursing (DON) and the RN Unit Manager (UM). Patient records for five sampled patients were reviewed. Of the five residents sampled, 2 were lacking documentation of Route of Administration, amount administered, Location given, Manufacturer's Name, expiration date or Lot number for the Influenza vaccine as required by Facility policy. (photographic evidence obtained) The remaining 3 residents had signed refusals on file. The DON and UM confirmed that required documentation was not in the records provided. Per the UM, a possible secondary source of documentation could be in the pharmacy records but the missing documents cannot be retrieved because it would be kept by the previous Contracted Pharmacy service who can no longer provide information due to a contract change as of 11/02/2023. Only one of 5 resident charts contained documentation of dates of vaccination for Pneumococcal and Covid Vaccines. Both the DON and UM confirmed there was no scanned documentation in medical records of education that was provided to the residents or health care surrogates regarding Risks/Benefits of the vaccines. On 11/15/2023, a review of facility policy and procedure for Influenza and Pneumococcal Vaccines indicates that For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record. The Centers for Disease Control states documentation of vaccine administration must include, at a minimum, the date of administration, the name of the manufacturer of the vaccine, the Lot number, and the name of person administering vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 On 11/13/23 at approximately 12:40 PM, Resident #1's room was observed to have dark stains on the floor, piles of trash bags full of trash, water damage on the walls, a broken towel rack in the bathroom and warped floorboards. The peeling floorboards were between the bed and the window. Opened bags of briefs were observed leaning against the wall with the water damage. During the observation, the resident stated she did not like living in such a dirty place. On 11/14/23 at approximately 3:56 PM, the residents room still had the dark stains. In addition, there was a large spill of a red liquid on the floor and her opened bags of briefs were still leaning against the wall with the water damage. After moving the briefs, the wall paint was observed chipping off. A pile of dirty bedding was also observed on the floor by the foot of the bed. On 11/16/23 at approximately 1:46 PM, an interview with Staff A, Licensed Practical Nurse (LPN), was performed. When Staff A was asked about the environmental concerns of the room, she stated she was very concerned about the briefs leaning against the wall. She stated, I do not think it is acceptable that someone lives with her briefs touching humidity or with such a dirty floor. Staff A also stated the dark substance on the floor could be blood, because Resident #1 pulls her scabs often and her arms bleed. Staff A also stated that it was hard to clean in the room because Resident #1 does not like staff touching her stuff. Staff A was asked what the process was to report items that needed to be fixed. She explained staff need to add the issue to the maintenance log book, located at the nurses station. Immediately following the interview, the log was reviewed. Nothing regarding Resident #1's room was noted. Based on observations, interviews, record review and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 26 residents sampled. (Residents #1, #46, #70 and #242) The findings include: Resident #46: On 11/13/23 at 12:12 PM, an interview was conducted with Resident #46. She stated the facility did not have enough supplies to provide incontinence care and did not have enough linens. She further stated she had personal clothing missing for months, including last week when laundry took some new clothes that she bought and they have not been returned yet. On 11/13/23 at 12:21 PM, an interview was conducted with Staff G, a Certified Nurse Assistant (CNA). She stated she was aware Resident #46 had been missing clothing for 30 days. She stated laundry kept telling her that they would find her clothes and they did not. She further stated the facility was always short on had washcloths, towels, and linens. A review of the facility's grievances was conducted. Resident #46's grievance stated she sent 2 church outfits to laundry and they had not been returned. The facility's findings of the investigation stated inventory sheets did not reflect any of the missing items and items could not be found. The Social Services Director (SSD) and the care team will continue to work on insuring people's belongings are accounted for on the Performance Improvement Plan (PIP). Resident #242: On 11/13/23 at 12:41 PM, an interview was conducted with Resident #242. She stated she was recently hospitalized and, when she returned, her clothes were missing. On 11/15/23 at 01:08 PM, an interview was conducted with Resident #242's mother. She stated they did not provide an inventory sheet for her daughter on her most recent admission. She further stated she had labeled the clothes but her clothes still ended up missing. On 11/15/23 at 01:22 PM, an interview was conducted with Resident #242's pastor. He stated he brought in 4 pairs of pajama pants and 5 long sleeve shirts to the resident 2 weeks ago which were labeled with a permanent marker. He confirmed those items were missing from her room. He stated Resident #242 was not provided with an inventory sheet. On 11/15/23 at 12:13 PM, an interview was conducted with the facility's Director of Nursing (DON). She explained the facility's process to ensure the resident's clothes were covered. She stated the family members or the CNA's would label the clothes, then the CNAs would ensure the inventory sheet is filled upon admission and signed by the resident. She further stated extra clothing is added to the inventory sheet. The DON stated the inventory sheet is uploaded to the electronic medical record (EMR). A review of Resident #242's EMR was conducted with the DON. Resident #242 was admitted on [DATE]. The DON confirmed there was no inventory sheet uploaded into the EMR. The DON also confirmed Resident #242 did not have a paper inventory sheet on file. On 11/15/23 at 12:25 PM, an interview was conducted with Staff B, a Registered Nurse (RN) and unit manager. She stated the facility was trying to remediate the issue with the inventory sheets of not being filled and uploaded and the facility was aware there were multiple issues of clothing missing. Staff B stated it was an ongoing issue at the facility and the facility had been working on it for months. On 11/15/23 at 12:34 PM, an interview was conducted with the Social Services Director (SSD). The SSD reviewed Resident #46's grievance dated 10/17/23 and stated there have been issues with the facility's clothing not being returned back to residents. The SSD further stated the facility had a recent in-service on how to fill up the inventory sheet. The SSD stated the facility did not currently have an efficient system in place and was aware labeling with markers was not working. The SSD stated the facility had started a Performance Improvement Plan (PIP). Upon review of Resident #242's missing inventory sheet, she stated the staff education had not been effective. On 11/16/23 at 11:50 AM a review of Resident # 242's EMR and paper medical records was conducted with Staff B, RN, unit manager. Upon reviewing, Staff B confirmed there was no inventory sheet. On 11/16/23 at 12:28 PM, an interview was conducted with Staff F, Medical Records. She stated the inventory sheet was part of the forms to be completed upon admission. Staff F verified Resident # 242 had no inventory sheet uploaded into the EMR. On 11/15/23, a review of the facility's education in-service dated 10/26/23, Labeling personal items and completing the inventory sheet was conducted. A review was conducted with Social Services Director. SSD reviewed resident # 242 medical record and confirmed there was no inventory sheet for resident 242. SSD stated Medical Records was responsible of uploading the inventory forms into the Electronic Medical Records (EMR). A review of facility policy Personal Property-loss or theft revised 7/24/2017 was conducted. Policy stated at admission resident's belongings will be identified and recorded. Laundry On 11/14/23 at 1:24 AM a tour of the laundry room was conducted with Staff C, laundry personnel. During the tour, 1 of 2 washer machines and 1 of 2 dryers were observed to be non-operational. On 11/14/23 at 1:30 PM, an interview was conducted with Staff C, who stated the washing machine had not been functioning for about a year and the dryer had not been working for about 6 months. On 11/16/23 at 10:31 AM, an interview was conducted with Staff H, a Personal Care Assistant (PCA). Staff H stated the facility still did not have enough clean clothes to assist residents that are incontinent as of today. On 11/16/23 at 12:56 PM, an interview conducted with the Corporate District Manager who managed Housekeeping and Laundry services at the facility. The Administrator was also present. The Manager stated she had brought some towels and linens in this week. She also stated there was an issue with keeping up with the laundry because there was only one washing machine and one dryer. The Administrator added he had recently purchased more towels, washcloths, gowns and under pads. An invoice was reviewed and revealed order was placed on 11/15/23 at 1:21 PM. Resident #70 On 11/13/23 at 2:51 PM, an interview was conducted with the family of Resident #70, who stated that the family has purchased numerous clothing items for Resident #70 and yet he continues to not have any clothes to wear. She stated the facility is losing his clothes and, when they purchase more, the facility will lose them as well. On 11/14/23 at 4:11 PM, an observation of Resident #70 revealed he was in his bed wearing a hospital gown. At this time, the Director of Nursing (DON) was present while this surveyor conducted an observation of the closet for Resident #70. The closet only had one suit/jacket and pants and one pair of jeans and one pair of green khaki pants. No shirts, shoes, socks or other clothing items were observed. The DON confirmed the resident has no clothes to wear other than what was in the closet. She also confirmed that the resident wears the hospital gown daily. On 11/15/23 at 09:54 AM, 12:43 PM, and 2:53 PM, Resident #70 was in his room in bed, still wearing only a hospital gown. On 11/15/23 at 12:20 PM an interview with Staff B, Registered Nurse (RN), revealed that there has been a chronic issue with missing clothing so the Social Services Director (SSD) had a call and invited all the resident's family members to participate and discuss a new laundry process for a net bag and new processes for ensuring the residents clothing stays together during the laundry process. She stated they also reeducated the aides to watch for families bringing in new items to ensure they get them labeled appropriately. Review of the resident's medical record revealed there was no resident inventory sheet. Review of the facility policy for Personal Items Inventory, dated 10/24/22, revealed, Residents have the right to retain and use personal belongings including but not limited to furnishing, clothing and other personal items, as long as space permits, and it does not interfere with the rights or health and safety of other residents. The Procedure for this policy includes entering the resident name, room number and medical record number and the date of the inventory on the Inventory of Personal Effects Identify articles as listed, indicating the quantity and presence with check.

Based on observations and staff interviews, the facility failed to ensure call lights were maintained within residents' reach at all times for 1 of 37 sampled residents. (Resident #12) The findings include: An observation of resident #12 was conducted on 6/28/22 at approximately 9:21 AM. The call light was observed on the floor and not within her reach. The surveyor initiated the call light and Employee B, certified nursing assistant (CNA), responded to the call light. Employee B confirmed the resident could not reach the call light and provided the call light to the resident. She requested the resident demonstrate she was capable of using the call light. The resident initiated the call light demonstrating she was capable of using the call light. A follow-up observation of resident #12 was conducted on 6/29/22 at approximately 3:57 PM. At this time, the resident's call light was again observed on the floor and not within her reach. The surveyor again initiated the call light. This time, Employee C, CNA, responded to the call light. Employee C also confirmed the resident was capable of using the call light and that it was not within her reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations on the Long-term Care Unit (G&R Unit), interviews and maintenance log review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 1 of 2 units of the facility (G&R Unit) and for 2 of 2 residents observed for wheelchair disrepair. (Resident #4 and #41) The findings include: G&R Unit On 6/28/22 at approximately 10:25 AM, an observation was made in room [ROOM NUMBER] B. The bed was noted to have a mattress that was torn with foam exposed. (Photographic evidence obtained) On 6/30/22 at approximately 2:25 PM, an interview was conducted with Employee J, certified nursing assistant (CNA). She stated that was not how the mattress should look, and the mattress had been torn for about a month. She further stated that an entry in the maintenance log at the nurse's station should have been made to report the mattress was torn. A review of the maintenance log at the nurse's station on the G&R Unit revealed no entry was made to report the torn mattress. Residents #4 and #41 On 6/28/22 at approximately 11:15 AM, during the tour of the 100's hallway in the G&R Unit, the ceiling was observed with a brown-colored substance near the corner of the wall, the trim was pulled away from the base of the nurse's station, and the protection on the corner wall near the nurse's station was missing. On 6/30/22 at approximately 9:37 AM, resident #4 was observed ambulating with a wheelchair. The resident's wheelchair was observed with one of the arm rests covered with a silver-colored tape and the other arm rest was in disrepair with exposed foam. On 6/30/22 at approximately 9:38 AM, an interview was conducted with resident #4. The resident stated his wheelchair's arm rests had been in disrepair since December 2021 when he was admitted to the facility. On 6/30/22, at approximately 9:47 AM, resident #41 was observed with a left wheelchair arm rest in disrepair with missing fabric and a hole. On 6/30/22 at approximately 11:50 AM, an interview was conducted with resident #41. The resident stated therapy had recently fixed the right arm rest but not the left one. On 6/30/22 at approximately 11:15 AM, an interview was conducted with the Assistant Director of Therapy Services. He stated he was responsible for resident wheelchair repairs. Upon looking at pictures of resident #4 and resident #41's wheelchairs, he confirmed they were in disrepair. On 6/30/22 at approximately 1:39 PM, a tour was conducted with the Maintenance Director. He confirmed the 100-hall ceiling was dirty and stated it should be cleaned. He further stated the trim of the nurse's station needed repair and the wall's corner needed a protector.

Based on observation, staff interview and policy review, the facility failed to ensure staff served food in a sanitary manner during 1 of 2 meal observations on the long-term care unit(G&R Unit). (Lunch 6/28/22) The findings include: On 6/28/22 at approximately 12:22 PM, observations of the lunch meal service were conducted on the G&R Unit. Employee A, certified nursing assistant (CNA), was observed to serve resident #6 his meal tray. Employee A, CNA, was observed to touch and pick up the sandwich on the plate with her bare, ungloved hands and hand it to resident #6. At 12:30 PM, Employee A served resident #10 her lunch meal. Employee A was observed touching resident #10's sandwich with her bare, ungloved hands while cutting the sandwich in half. At 12:33 PM, Employee A served resident #74 her lunch meal. Employee A was observed touching resident #74's sandwich with her bare, ungloved hands while cutting the sandwich in half. On 6/30/22 at 10:09 AM, an interview was conducted with Employee A, CNA. She stated she should not touch food with her bare hands and she should have worn gloves. On 6/30/22 at 10:55 AM, an interview was conducted with the Assistant Director of Nursing (ADON), who stated the facility did not have a policy regarding safe food handling.

PPE On 6/30/22 at approximately 9:07 AM, an observation was made of Staff L, Certified Nurse Assistant (CNA), entering resident #285's room which was under droplet isolation precautions. The CNA donned personal protective equipment (PPE) and entered the resident's room. A few minutes later, CNA L was observed to exit the room still wearing personal protective equipment (PPE). On 6/30/22 at approximately 9:11 AM, an interview was conducted with Staff L, CNA, during which she stated, I thought we had to come out with the PPE. I thought we are not allowed to take off PPE inside the resident's room. A review was conducted of the facility's COVID-19 Personal Protective Equipment Doffing Step by Step guideline edited on 4/10/20. The guideline explained doffing off PPE was required before exiting the room. Based on observations, staff interviews, and record review, the facility failed to implement appropriate infection control procedures during wound care for 1 of 1 observation of wound care (resident #11) and for 1 of 1 resident observed on Transmission-Based-Precautions (resident #285). The findings include: Wound Care On 6/30/22 at approximately 8:56 AM, an observation of wound care for resident #11 was conducted with Employee G, Licensed Practical Nurse (LPN). Employee G, LPN, washed hands, donned gloves and removed the old, soiled dressing from the resident's sacrum. Employee G then returned to the treatment cart outside the resident room door and gathered wound care supplies to include dressing supplies, a marker, and a bottle of wound cleanser not labeled for any resident. She sanitized her hands and returned to the resident's room with the supplies. She placed the supplies, to include the marker and bottle of wound cleanser, on top of the resident's rolling over bed table without cleaning the table or placing a barrier on the table. Employee G then applied clean gloves and sprayed wound cleanser on gauze and cleansed the wound. She removed the soiled gloves with the used gauze inside a glove and then used her now soiled hand to open the room door and return to the treatment cart outside the room. She did not sanitize or wash her hands after removing the gloves. She disposed of the gloves and gauze in a red bag observed to be tied to the treatment cart. Employee G sanitized her hands and returned to the resident room. She then applied new gloves and used one hand to roll the resident and dated the dressing with the other hand using the marker. She then packed the wound bed with dressing supplies and applied a new dressing. Employee G then removed her soiled gloves with the trash from the wound supplies in her gloves and again opened the door with her soiled hand and returned to the treatment cart in the hall. She did not wash or sanitize her hands after removing the gloves. She disposed of the trash and gloves in the trash bag on the treatment cart. Employee G then sanitized her hands and placed the bottle of wound cleanser and marker back in the treatment cart without cleaning the items. On 6/30/22 at approximately 9:11 AM, an interview was conducted with Employee G, LPN. She stated the bottle of wound cleanser is used for all residents with wounds. She then confirmed the bottle of wound cleanser would be considered contaminated since she set it on the over bed table. She stated she did not clean the marker or the bottle of wound cleanser before placing them back in the treatment cart and confirmed she did not wash or sanitize her hands before touching the door knob. Review of the facility policy for Dressing Change (document name N-1310 revised 12/6/2017) indicated staff should gather supplies to include a bag for dressing disposal per standard precautions and place on a prepped work surface. Review of the facility policy for Hand Hygiene (document name N-1530 revised 2/5/21) indicated staff should perform hand hygiene before and after patient care and after glove removal. The CDC (Centers for Disease Prevention and Control) defines hand hygiene as cleaning your hands by using either hand washing, antiseptic hand wash, or antiseptic hand rubs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure each resident room was equipped to provide full visual privacy for each resident for 2 of 17 occupied sampled rooms. (room [ROOM NUMBER] and #211) The findings include: On 6/28/22 at approximately 11:19 AM, an observation of room [ROOM NUMBER] B was conducted. The privacy curtain was not sufficient to pull around the end of the bed. room [ROOM NUMBER] B was observed in the presence of Employee H, Housekeeping Supervisor, on 6/29/22 at approximately 12:16 PM. She observed the curtain and confirmed it did not provide full visual privacy for 211 B and stated that she would have to obtain a ladder to adjust the curtain track for B bed. Further interview was conducted with Employee H on 6/29/22 at 12:42 PM, during which she stated she does not have enough privacy curtains to have them in every room. On 6/29/22 at approximately 1:14 PM, an interview was conducted with Employee I, certified nursing assistant (CNA). Employee I stated she had been aware for at least a month that the curtain would not pull around 211 B bed and had reported this to the previous housekeeping supervisor. On 6/28/22 at approximately 9:29 AM, an observation of room [ROOM NUMBER] B was conducted. The privacy curtain was observed to be too short and would not pull around to cover the entire length of the bed. room [ROOM NUMBER] B was observed in the presence of Employee H, Housekeeping Supervisor, on 6/29/22 at approximately 12:20 PM. Employee H observed the curtain and stated an entire section of curtain and hooks were missing and it would not provide full visual privacy for the resident. She confirmed the curtain left the end of the bed and resident exposed. On 6/29/22 at approximately 1:10 PM, an interview was conducted with Employee I, CNA, who stated she was aware the curtain would not fully pull around B bed but did not report the issue to anyone.

Based on observation, interviews and record review, the facility failed to provide a safe and functional environment in the laundry area. The findings include: On 6/30/22 at approximately 10:04 AM, a tour was conducted with Employee H, Housekeeping Supervisor. A sink at the entry had no running water and 1 of the 2 washing machines was non-functional. On 6/30/22 at approximately 10:14 AM, an interview was conducted with Employee H. She stated neither the sink nor the washing machine have been working for months. On 6/30/22 at approximately 10:59 AM, an interview was conducted with Maintenance Director. He stated the sink needed a pedestal to be functional so it had not been functional for a month. He further stated the washing machine had been non-functional since January 2022 because the facility was waiting for quote approval. A record review revealed the Maintenance Director obtained a quote for washer repair on 1/27/22. Further record review revealed email communication between the Maintenance Director and Administrator concerning obtaining approval for the quote on 2/14/22.

Based on observations, staff and resident interviews and policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This has the potential to affect all areas of the facility. The findings include: On 6/27/22 at approximately 7:00 PM, observations were made of the hallway in front of the long-term are unit's (G&R Unit) television room. A live, crawling, brown bug approximately 1.25 inches in length was observed on the floor. Resident #4 rolled his wheelchair toward the bug and smashed his shoe on the bug. He stated he often sees bugs in the facility. An observation of the G&R television area at approximately 7:15 PM revealed a live, crawling brown bug on the floor in the corner of the room. An observation of the 200 hall at approximately 7:48 PM revealed a live, crawling brown bug on the floor approximately 1 inch in length. On 6/27/22 at approximately 7:48 PM, an interview was conducted with Employee D, personal care assistant (PCA), during which she stated she observes live roaches in the facility almost every day she works. On 6/27/22 at approximately 7:52 PM, an interview was conducted with Employee F, certified nursing assistant (CNA), during which she stated she works about 2 days a week and has observed live bugs every day she has worked. On 6/30/22 at approximately 8:30 AM, an interview was conducted with the Administrator. She stated the pest control company had just treated the facility on 6/27/22 and the facility did not have a copy of the pest control contract. She stated the company was writing a new contract for the facility. Review of the facility policy for Pest Control (HL-200 effective 11/30/14) revealed the facility will maintain a pest control program, which includes inspection, reporting, and prevention. 1. A pest control contract will be maintained with a licensed exterminator. 2. The contract will include routine quarterly inspections. 3. Treatment will be rendered as required to control insects and vermin.