**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to protect and maintain the rights and dignity of three of 34 sampled residents (R) (RA, RB, and RC). Specifically, the facility failed to ensure that facility staff nurse, Licensed Practical Nurse (LPN) (LPN CC) treated RA, RB, and RC with dignity and respect in a manner and environment that promoted, maintained, or enhanced their quality of life. The deficient practice had the potential for negative psychosocial outcomes related to fear of retaliation if staff found out that residents reported the nurse. Findings included: Review of the LTCO (Long Term Care Ombudsman) report dated 4/17/2025 reported findings: Staff interaction with residents: Some staff work hard and are good with the residents, but the feedback I get more often is that they are sorely understaffed, and that residents' needs are not being met. On weekends and nights, there have been reports both inside and outside of the facility that staff are either nonexistent, not attentive, or disrespectful to residents. Residents at this facility, for years, have been very apprehensive about filing complaints and grievances as many times I have heard and believe that there is a real fear of retaliation. Other: Lots of management staff turnover, Staff in key roles are not adept and uncooperative. Continued review of the LTCO report revealed: Significant changes in this facility during the past year: 1. Resident Care: Many residents often do not appear well groomed: i.e., oily hair, need haircuts, long beards, and clean clothes, but do not report for fear of retaliation. 2. Residents are afraid of retaliation. 3. In a place that is relatively isolated, many residents have no family. 4. New DON (Director of Nursing). 5. It is difficult to reach the facility on the phone and get return calls from administrative staff. 6. Number of complaints received in past year: 28. Number of times each complaint code has been used over the past year: Abuse: Psychological-1 Rights: Dignity and respect-3 Response to complaints-1 Other rights and preferences-1 Care: Response to requests for assistance-1 Policies, Procedures, Practices: Administrative oversight-1 Staffing-1 1. Review of the electronic medical record (EMR) revealed RA had diagnoses of but not limited to Type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebrovascular disease, acquired absence of left and right leg below knee, depression, anxiety disorder, adult failure to thrive, phantom limbs syndrome with pain, and need for assistance for personal care. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating little to no cognitive impairment. Section GG-Lower extremity impairment, required partial/moderate to set-up assistance (assist) for care. Section N-received antianxiety, antidepressant, anticoagulant, opioid, and antiplatelet medications. Did not receive antipsychotic medications in the look-back period. Review of the care plan dated included but not limited to, has an amputation, bilateral bka (below knee amputation), requires assistance with ADL's (Activities of Daily Living) related to (r/t) bka, failure to thrive, no plans to discharge, is a smoker, requests to smoke, has little activity involvement due to preferring to spend most time in room or bed, risk for falls r/t bilateral bka, has phantom pain, on pain medication r/t chronic pain, is at risk for insomnia r/t taking sedative/hypnotic therapy medication, uses anti-anxiety medications r/t anxiety disorder, uses antidepressant medication r/t insomnia. Review of RA's MAR (Medication Administration Record) revealed night time medications (meds) and orders included but not limited to atorvastatin for cholesterol, eszopiclone for insomnia, melatonin for insomnia, trazodone for insomnia, carvedilol for hypertension, Eliquis for embolism and thrombosis, protein liquid for supplement, artificial tears for dry eyes, dicyclomine for irritable bowel syndrome, Zanaflex for muscle spasms, insulin for diabetes, Tramadol for pain prn (as needed), Norco for pain-(scheduled), pain assessment, monitoring for med side effects r/t antianxiety, anticoagulant, antidepressant, and sedative/hypnotic meds, behavior monitoring for insomnia and changes in sleep, monitor BM (bowel movement), fsbs (finger stick blood sugar) with insulin per sliding scale coverage. Observation and interview on 5/4/2025 at 12:56 pm during screening of residents, RA revealed that a facility nurse, LPN CC had a bad attitude toward RA, did not converse when providing care, did not ask if RA was alright, or needed anything, or had a bowel movement in five days, she says nothing. RA reported LPN CC withheld meds at times and gave them late. LPN CC worked on the night shift, and residents wanted their meds timely so they could go to sleep. If RA used the call light, LPN CC would come into RA's room and ask, what you want? RA would tell the nurse what was needed. At times the nurse would turn and walk out without saying anything and not come back with the requested item. Other times the nurse would say, tell the CNA (Certified Nursing Assistant), or at times LPN CC would tell the CNA (who was busy) and they would assist, sometimes much later. RA revealed being told that LPN CC was talking about RA to other residents, telling others not to talk to RA. When RA knew LPN CC was working the night shift, RA got a sick feeling and said it made the resident feel anxious. When asked if RA had reported LPN CC or filed a Grievance, RA revealed no and indicated it was because of fear of retaliation if he talked or reported her. When asked what kind of retaliation, RAsaid the way they treat you, basically ignore you, will not talk to you, and will not get them things asked for or care needed. RA reported LPN CC did not talk to him now. She just walked in and did what she had to do and left, and if LPN CC found out they reported her, it would be much worse. 2. Review of the EMR revealed RB had diagnoses of but not limited to multiple sclerosis (MS), lack of coordination, generalized weakness, major depressive disorder, anxiety disorder, and need for personal assistance. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating little to no cognitive impairment. Section GG, Functional Abilities and Goals-upper and lower body impairment on both sides, required total to moderate assist for all care needs, Section N, Medications-received antianxiety, antidepressant, hypnotic, diuretic, and opioid medications. Did not receive antipsychotic medications. Review of the care plan dated included but not limited to, has multiple sclerosis, incontinent of bladder and bowel r/t MS, neurogenic bladder, and restricted mobility, no plans to discharge, requires assistance with ADL's r/t restless leg syndrome, MS, weakness, history of falls, poor safety awareness, evaluated by therapy and is a Hoyer lift ONLY for transfers, is a smoker, requests to smoke, has a mood problem r/t anxiety, depressive disorder, history of suicidal ideation, and insomnia, risk for falls r/t MS, lower extremity weakness, alteration in musculoskeletal status r/t MS, has pain r/t restless leg syndrome, MS, neurogenic bladder, medication r/t chronic pain, is at risk for insomnia r/t taking sedative/hypnotic therapy medication, uses anti-anxiety medications r/t anxiety disorder, uses antidepressant medication r/t depression. Review of RB's MAR revealed night time meds and orders included but not limited to astorvastin for hyperlipidemia, Melatonin 2 tablets for sleep r/t insomnia, trazodone for major depressive disorder, Zetia for hyperlipidemia, metoprolol for hypertension, oxybutynin for neuromuscular dysfunction of bladder, artificial tears for dry eyes, buspirone for anxiety, gabapentin for MS, Requip for MS, baclofen for pain, Acetaminophen every 6 hours prn pain, Norco every 6 hours prn pain, monitoring for antidepressant and antianxiety med side effects, pain scale assess, behavior monitoring. Observation and interview on 5/5/2025 at 8:45 pm with RB revealed there was only one staff member that was bad, all of the others were pleasant. Staff nurse [LPN CC] does not care about the residents she sees. She treats them disrespectfully. RB revealed the whole mood of the residents changed when they realized LPN CC was working. LPN CC worked the night shift. 3. Record review revealed RC had diagnoses of but not limited to essential primary hypertension, atherosclerotic heart disease, repeated falls, muscle weakness, difficulty in walking, unsteadiness on feet, reduced mobility, anxiety disorder, depression, and need for assistance with personal care. Review of the Quarterly MDS assessment for RC dated 3/28/2025 revealed a BIMS score of 11, indicating mild to moderate cognitive impairment. Section GG, Functional Abilities-required set-up or supervision for most care needs. Section N, Medication-received antidepressant and opioid medications. Did not receive antipsychotic medications. Review of the care plan for RC dated included but not limited to, potential for adjustment difficulty r/t facility placement, entered for short-term rehab, history of adult maltreatment prior to admission, risk for psychosocial well-being concern r/t male resident attempting a financial manipulative situation, uses antianxiety medications, uses antidepressant medication r/t depression, risk for generalized pain, on pain med therapy r/t generalized pain, occasionally incontinent of bladder and bowel, requires assistance with ADLs r/t activity intolerance and weakness, behavior problems r/t anxiety, risk for falls r/t gait problem, unaware of safety needs, history of falls. Review of RC's MAR revealed night time meds and orders included but not limited to Aricept for dementia, sertraline for depression, Systane Ophthalmic drops for dry eye syndrome, hydrocodone-acetaminophen every 4 hours prn pain, pain scale assess, monitoring for antidepressant med side effects, behavior monitoring. Observation and interview on 5/5/2025 at 8:50 pm with RC revealed that one staff member was very difficult, and all of the others were good, the nurse was [LPN C] she did not care about the residents and treated them disrespectfully. The whole mood of the residents changed when they realized LPN CC was working. LPN CC worked at night. Review of the Resident Council minutes from June 2024 to April 2025 included but not limited to the following concerns related to resident rights: Night nurse has attitude: 4/16/2025 Call lights not being answered at night: 1/15/2025, 12/18/2024, 10/16/2024 Short staffed night shift: 11/20/2024, 10/16/2024, 9/18/2024, 8/21/2024 Not enough staff: 2/19/2025, 6/19/2024 Short staffed every weekend: 2/19/2025, 7/24/2024 Meds not passed on time: 4/16/2025, 3/19/2025, 8/21/2024, 7/24/2024, 6/19/2024 Not getting changed in a timely manner: 12/18/2024 Residents are not gotten up (weekends): 3/19/2025 Staff need to stay off phones: 1/15/2025, 12/18/2024, 11/20/2024 Interviews during the Resident Council (RC) review meeting on 5/6/2025 starting at 1:50 pm with five residents revealed issues with night shift LPN CC. Residents revealed they knew how to file a Grievance but did not because they were fearful of retaliation by LPN CC. Asked what they meant by retaliation, and to give specific examples, residents reported LPN CC's bad attitude, she would hold your meds (medications) and/or would not give on time, would intentionally take a long time to give meds, when they asked LPN CC for something she wouldn't do it. She would say, What do you want? We would tell her and she would walk out and never come back or would say tell the CNA, or she would tell the CNA and the CNA would bring what was needed a long time later. One resident reported LPN CC would come in and ask what they wanted, the resident would tell her, LPN CC would repeat the request and say, so you want . (such and such, whatever the request was), turn and walk out and not come back. Residents remarks included, Her bedside manner is brutal. She will make your life miserable. One resident revealed when he knew LPN CC was scheduled to work the night shift he felt sick and anxious. Three residents reported, She is prejudiced against white people, and prejudiced against smokers. She would come in the room and stand over the resident, make negative remarks like, Uh, you smell like smoke. Then she will go and get some kind of spray and start spraying heavily in the rooms of smokers. The spray was strong, it stank, and you could hardly breathe after she sprayed the room. Residents revealed it was normal practice to get meds on time, except for when LPN CC worked. She worked the night shift, and residents revealed they wanted and needed their meds so they could go to sleep. Residents felt LPN CC at times would intentionally withhold meds until late causing residents not to be able to go to sleep, or they would go to sleep and awakened. Interview on 5/7/2025 at 10:12 am with the Administrator and the Regional Operations Manager revealed what they have done to address the complaints about the nurse by multiple residents. The Administrator revealed they started an investigation and suspended the nurse pending investigation. The Administrator revealed, depending on resident interviews, that would determine if LPN CC would be terminated, and if she would file a FRI (Facility Reported Incident) to the State Survey Agency (SA). She revealed they had begun collecting interviews with staff, doing education on abuse and customer service, and have done questionnaires for the residents. Interview on 5/7/2025 at 10:15 am the Regional Operations Manager revealed they completed interviews with all residents the prior day, and the interviews were being reviewed. She provided a copy of the interview questions which included: Do you believe you are receiving good care from staff? Are there any specific problems that you are having with your care? Are staff polite when they interact with you? Are any members of the staff mean towards you? Have you ever been in seclusion or witnessed any seclusion of any other residents? Have you ever been physically, verbally, mentally, sexually abused or have you ever witnessed such acts? Do you know of any acts throughout the facility where residents are punished for misbehavior? Do you feel safe living at [named facility]? Interview on 5/7/2025 at 11:30 am the Regional Operations Manager revealed to the survey team that they had finished reviewing all the resident interviews and based on answers to the Quality of Care Questionnaire they would be submitting a report (FRI) to the SA. Review of a FRI (202504675) dated 5/7/2025 for staff-to-resident abuse revealed that the Administrator was notified of residents stating LPN CC was giving them attitude, didn't address them, will not speak to them, they were afraid of retaliation by the nurse if they reported, and they may have to wait on care or medication. An investigation was started and included but not limited to interviewing residents and the education of the staff. Observation and interview on 5/7/2025 at 2:40 pm during a walk-through of the facility, the Administrator confirmed there were no state agency or Elder Abuse Act posters or signage with information on reporting complaints. She revealed the signs should be by the Ombudsman poster. The Administrator stated, The Ombudsman came about six weeks ago and changed out her contact information on the Ombudsman poster and must have taken down the facility's signs for reporting complaints.

Based on staff interviews, record review, and review of the facility's policy titled, Resident Funds: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year, the facility failed to assure that residents with trust funds were able to get access to requested funds. The deficient practice affected three of 74 residents (R) (R276, R29 and R11) with trust funds. Findings include: Review of the facility's policy titled Resident Funds: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year revealed under Policy: Resident funds are maintained in accordance with the guidelines of the state, the management of the funds of the resident is the responsibility of the Administrator, Controller, Central Business Office, and the Resident Trust Account Custodian (bank teller). This policy has been established to ensure compliance with maintaining a complete and accurate accounting of resident funds. Under Procedure: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year. Interview on 5/4/2025 at 11:17 am with R29 stated that he always received his money late. He stated that money was distributed on a first come first serve basis. He stated that it happened all the time, he was used to it. Interview on 5/4/2025 at 1:10 pm with R11 stated that her money came when it came. She stated that she hasn't gotten it this month. She stated that for last month's distribution, she just got her money a week ago. She stated that the facility doesn't send enough money to everyone in the whole facility to get their money. She stated that 1/3 of the residents got their money last week for the month of April 2025. Review of Grievances on 5/6/2025 at 9:45 am revealed that there was only one grievance reported regarding money, which was reported by R231. The grievance was filed on 6/19/2024 to the Social Services Director (SSD). The SSD revealed that R231 stated that the SSD had not done what she was asked by sending a referral for money following the resident. SSD stated that she made a phone call and sent an email while R231 was present. Review of Petty Cash Withdrawal Records revealed that for the months of June 2024 through April 2025, residents were receiving their money that they requested two to three days after the requested date. Interview on 5/6/2025 at 10:10 am with the Business Office Manager (BOM) revealed that if residents were mobile they could come to her office and request money. If they were not mobile, someone (CNA or Nurse) would let me know and I would go to their room and talk to them regarding requesting money. They could get their money as long as we had it in the building. Otherwise, the BOM must send a request to corporate. She stated that she sent up a request, and corporate would issue a check. She stated that she would give the Administrator the check and the administrator would get the check cashed. She stated that the process usually takes two to three days. Interview on 5/6/2025 at 2:08 pm with the Administrator stated that she felt that $600.00 was enough on hand for the residents here; however, they probably do get close to running out of money for the residents. She stated that when the petty cash gets low as $30.00 to $50.00, they started the process of requesting petty cash. She stated that she felt that the residents wanted the full $70.00 and a lot of the time it was already at the end of the month or a week before the beginning of the month. She stated that when the residents requested the money during that period, the facility didn't have the money to reimburse. She stated that residents received their money as soon as the BOM informed her. The Administrator verified that they didn't have $70.00 per resident, they only had the $600.00 total in the replenishing box (Petty Cash). She stated that the money was expended first come-first served. She stated that it took 24 hours for the residents to receive their money. Interview on 5/6/2025 at 3:14 pm with the Administrator and Regional Consultant along with a team of five surveyors. The surveyors reported one of two main issues that was brought to our attention: What is your process for residents being able to get their money? She stated that the BOM kept up with the resident's accounts, she maintained around $600.00 dollars in petty cash, and she would replenish the petty cash and when the money started getting low, she would go ahead and request money/a check from corporate. She stated that the check would be received in a couple days. She stated that if it was not enough petty cash, they would have to request money from corporate, even for ten dollars. She stated that the BOM should report that the petty cash was running low to the Administrator, then the BOM would send all the receipts up to corporate, and they (corporate) would reconcile. On average do you monitor how much is requested? It was not acceptable for residents to have to wait a few days, or around the 20th of the month, if they requested money on the 1st, 2nd, or 3rd of the month. She stated that on nights and weekends, Petty Cash ranging around $30.00 to $35.00 dollars was left on the nurses' cart if residents requested money. Interview on 5/7/2025 at 9:45 am with Regional Accounts Receivable verified that they (the facility) do not have enough petty cash on hand to fulfil all of the residents requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, Advance Directive, the facility failed to provide residents and/or their representative with written information regarding the right to accept or refuse medical or surgical treatment for four of 34 sampled residents (R) (R38, R49, R34, and R32). Findings include: Review of policy titled Advanced Directives dated January 2025 revealed under Policy: The facility must inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advanced directive. Under Process: Upon admission/readmission, the facility Social Services Director will inform and educate the resident, or POA (Power of Attorney) in writing about the right to refuse medical and surgical treatment and their right to an advance directive. Review of the sample residents revealed four residents' Advanced Directive did not have evidence that options or written information about the right to accept or refuse medical or surgical treatment was provided. The Regional Operations Manager confirmed these four residents' (R38, R49, R34, and R32) Advanced Directive did not include language about being informed of medical and surgical treatment options. 1. Review of medical records revealed R38 was admitted to the facility with primary admitting diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, atrial fibrillation, essential primary hypertension, cardiomyopathy, and history of malignant neoplasm of prostrate. Review of Physician orders revealed R38 had an order for Full code-attempt resuscitation with a revision date of 12/3/2024. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed R38 was assessed with a BIMS (Brief Interview for Mental Status) score of 13, indicating little to no cognitive impairment. Review of R38's admission packet dated 2/21/2022 revealed the admission Packet Control Sheet had a checklist of required paperwork, and under the section Advance Directive Record, an X indicated it had been scanned. Also, the POLST (Physician's Orders for Life Sustaining Treatment) was scanned and on chart. Review of R38's POLST revealed his wishes for cardiopulmonary resuscitation, medical interventions, antibiotics, and artificially administered nutrition/fluids. The POLST was signed by R38 on 2/22/2022. Review of medical record for R38 revealed no signed acknowledgement or evidence in the record that R38, or a resident's representative, was provided with options and/or written information about the right to accept or refuse medical or surgical treatment. Interview on 5/5/2025 at 12:10 pm with the Corporate Nurse Consultant revealed the Social Services Coordinator/Social Worker (SW) was in charge of getting the advanced directive checklist completed at admission. She confirmed the SW did not complete the advance directive checklist for R38. 2. Review of the electronic medical record (EMR) revealed that R49 did not have an Advance Directive on file. Resident R49 diagnoses included but not limited to dementia with other behavioral disturbances. R49's MDS revealed a BIMS score of 00, which indicates resident is not cognitively intact. Review of EMR for R49 revealed no signed acknowledgement or evidence in the record that R49, or a resident's representative, was provided with options and/or written information about the right to accept or refuse medical or surgical treatment. Review of Physician orders revealed R49 had an order for Full code-attempt resuscitation. Interview on 5/5/2025 at 12:10 pm with the Corporate Nurse Consultant revealed the Social Services Coordinator/Social Worker (SW) was in charge of getting the advanced directive checklist completed at admission. She confirmed the SW did not complete the advance directive checklist for R38. 3. Review of the EMR revealed R34 was admitted to the facility with diagnoses that include but are not limited to end stage renal disease, elopement, hypertensive heart and kidney disease with heart failure and stage 5 chronic kidney disease, difficulty walking, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R34's BIMS score of 13, indicating intact cognitition. Interview on 5/5/2025 with the Corporate Nurse Consultant revealed the Social Worker Coordinator was in charge of getting the advanced directive check list completed at admission. She revealed the SW did not complete the advance directive checklist for R34. 4. Review of the EMR revealed that R32 did not have an Advance Directive on file. Interview on 5/5/2025 at am with the Corporate Nurse Consultant, (CNC), revealed and verified that R32 did not have an Advance Directive. CNC stated that the Social Worker Coordinator, oversaw getting the advanced directive check list completed at admission. She revealed that the SW did not complete the advance directive checklist for R32.

Based on record review, staff interview, and the facility policy titled, Advance Beneficiary Notices (ABN) 2025, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for three of 34 sampled residents (R) (R32, R42, and R56). Findings include: Review of the undated facility policy titled Advance Beneficiary Notices 2025 revealed under Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. 5a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CM-10055. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R32 was discharged from Medicare Part A skilled services on 1/6/2025 and remained in the facility. R42 was discharged from Medicare Part A skilled services on 3/21/2025 and remained in the facility. R56 was discharged from Medicare Part A skilled services on 2/13/2025 and remained in the facility. There was no evidence provided that the SNFABN was provided to R32, R42, or R56 and or their responsible party. Interview on 5/7/2025 at 10:35 am with the Minimum Data Set (MDS) Coordinator revealed prior to surveyors coming into the facility, she was not aware she was to use the SNFABN form when residents discharged from Medicare Part A services. The MDS Coordinator confirmed that she did not provide SNFABN forms to R32, R42, and R56 and or their representatives. She revealed when she found out about the ABNs on 5/6/2025, she called all three resident representatives and notified them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Freedom of Abuse, Neglect, Exploitation and Abuse Prevention: Fast Alerts, the facility failed to report abuse and neglect for two of 34 sampled residents (R) (R11 and R21) to the State Agency (SA). Findings include: Review of the facility policy titled Freedom of Abuse, Neglect, Exploitation and Abuse Prevention: Fast Alerts revealed under Reporting/Investigation/Response Policy: .Ensure that all alleged violations involving abuse, neglect, expoitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Under Administrator Duties: .Immediate Response: .6. Verbal notification to RNSs (Regional Nurse Supervisor) then to the State Health Department and other regulatory agencies per individual state reporting requirements. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R11 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Interview on 5/4/2025 at 10:30 am with R11 revealed that Licensed Practical Nurse (LPN) CC was mean to them, she ignored them, and she did not ask how they were feeling. Interview on 5/5/2025 at 8:45 pm with R11 revealed that LPN CC was very difficult. R11 said, There is only one staff member that is bad, all of the others are pleasant. R11 stated LPN CC did not care about the residents. She treated them disrespectfully. R11 revealed the whole mood of the residents changed when they realized LPN CC was working. On 5/6/2025 at 2:30 pm during a resident council meeting, R11 revealed that LPN CC sprayed air freshener in the air in their room because she said they smelled like smoke and frowned her face at them. The spray hit their faces because she sprayed so much of it. The residents stated that she told them she made her own spray, and she brought it from her home because their room smelled like smoke. She would come in the room and stand over us, make (sniff gesture) and make negative remarks like, Uh, you smell like smoke. She would spray something in the rooms of smokers, it was strong, it stank, and you could hardly breathe. R11 revealed it was not normal practice to not get medications on time, except for when LPN CC was working and intentionally withheld our medications. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R21 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Interview on 5/6/2025 at 4:46 pm with R21 revealed retaliation by staff if he talked. When asked what kind of retaliation, he stated you can just tell by the way LPN CC treated you, they basically ignored you. R21 reported one nurse, LPN CC would not speak to him, never asked if he was ok, never asked if he needed something, never asked if he had a bowel movement, never talked to him. She just walked in and did what she must do and left. He suspected or had been told LPN CC was telling other residents not to talk to him. Residents had concerns about retaliation if they talked or reported anything on LPN CC. On 5/6/2025 at 5:00 pm interview with the Administrator and the Regional Operations Manager revealed they both were informed of allegations of LPN CC made by several residents. Interview on 5/7/2025 at 10:12 am with the Administrator and the Regional Operations Manager revealed they started an investigation and suspended LPN CC pending investigation. They stated depending on resident interviews will tell us if she will be terminated, and we will decide if we will do a report to the State Agency. We have begun collecting interviews and doing training on abuse and customer service and have done questionnaires for the residents. The Regional Operations Manager also revealed they had completed interviews with all residents yesterday and they were in review. She later revealed that they had started a FRI (facility reported incident)/state report to submit to SA. Interview on 5/7/2025 at 3:00 pm with the Administrator confirmed that when she received information from the survey team, she felt it was more of a customer service issue with LPN CC. However, today she discussed and thought more about what was revealed, that this should have been reported as neglect and verbal abuse allegations. She confirmed that she should have reported this within 2 hours as the regulation instructed. She was informed of the allegations on 5/6/2025 around 5:00 pm and reported to the State Agency on 5/7/2025 at 1:10 pm.

Based on observations and staff interviews, the facility failed to provide information so that residents and/or visitors were aware of how to report complaints, abuse or neglect, to the state survey office. The facility census was 71 residents. Findings include: Tour and observation on 5/4/2025 during initial tour and screening of residents, and tour of the facility on 5/7/2025 at 2:00 pm on Hall 100, Hall 200, Hall 300, the front entrance area, common area, nurses station, and dining area of the facility revealed there were no signs posted with information on how residents could report complaints, abuse or neglect to the state agency (SA). Observation and interview on 5/7/2025 at 2:40 pm with the Administrator and the Team Coordinator for the state survey team during a walk-through, the Administrator confirmed there was no signage or Elder Abuse Act poster with information on how residents and/or visitors could report complaints. The Administrator revealed they did have signs up and they were next to the Ombudsman poster. The Administrator further revealed that the Ombudsman came about six weeks prior and changed out her contact information on the Ombudsman poster and she must have taken down the facility's signs for reporting complaints. The Administrator confirmed the information should be posted on how to contact the state office and report complaints, and she would put one up immediately. A phone call on 5/7/2025 at 2:57 pm was placed to the Ombudsman to inquire if she removed the facility's signs/poster/notice for reporting complaints. There was no answer. A message was left with a request to return the call. Observation on 5/7/2025 at 3:18 pm revealed a small notice had been posted. The notice appeared to be a 8 x 10 size piece of copy paper folded in half with typed information that read, For Concerns/Complaints . The information included a toll free (800) phone number, two (404 area code) Complaint Intake Unit phone numbers, and two email addresses, one for general inquiries and one to request records. The notice with printed information was small, hard to read, and placed beneath the Ombudsman poster at the far end of 200 hall.

Based on observations, staff interviews, and review of the facility policy titled, Food Handling Procedures, the facility failed to maintain the cleanliness of the facility minimizing the risk of food-borne illness and to promote safe food handling practices. The deficient practice had the potential to place residents who received an oral diet from the kitchen at risk of foodborne illnesses. Findings include: Review of the facility policy titled Food Handling Procedures with a review date of 4/14/2025 revealed under Subject: HAZARD ANALYSIS AND CRITICALCONTROL POINT (HACCP) FOR FOOD PREPERATION: Is a process control system that identifies critical points in the production and service of food items to prevent food safety and sanitation hazards. Under Procedures: . identify critical control points at which procedures may result in a food safety hazard An observation on 5/4/2025 at 9:56 am of the two-door stand-up refrigerator inside the kitchen revealed a clear plastic container labeled breakfast meat with a used by date of 4/5/2025 and a box of bell peppers with a use by date of 4/27/2025. There was a sealable plastic bag with meat opened with no use by date. An interview on 5/4/2025 at 9:59 am with the Dietary Manager (DM) confirmed that the meat did not have a use by date. The clear plastic container labeled breakfast meat had a use by date of 4/5/2025 and the bell peppers had a use by date of 4/27/2025. The DM stated that the date on the breakfast meat was wrong, the breakfast meat has the wrong use by date but she discarded the item. The DM also discarded the bell peppers and the meat in the sealable plastic bag. The DM revealed that staff discard leftovers after 3 days. An observation on 5/4/2025 at 10:50 am of the ice machine on the 300 hall revealed a black flakey substance and the machine had a rusty substance. The DM confirmed the ice machine on the 300 hall had a black flakey substance and rust on the machine. The facility turned the machine off on the 300 hall and the Administrator ordered a new ice machine for the hall. The DM stated the facility was getting additional ice until the new ice machine was delivered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, RAI (Resident Assessment Instrument) /Care Planning Management, the facility failed to create and revise /update (as needed) a comprehensive care plan related to a Stage two pressure ulcer for one of three sampled residents (R) (R1). The deficient practice had the potential to prevent R1's needs from being met. Findings include: Review of the facility policy titled RAI /Care Planning Management dated October 2023 indicated the purpose of this procedure is to ensure that based on nursing admission assessment, the physician orders and other information, immediate resident needs are identified, effective interventions are implemented, and measurable goals are established. The Interdisciplinary team (IDT) will review the interim care plan on the first business day after admission to assure care areas are addressed and family /RP (Responsible Party)/and /or resident involvement is occurring. The interim care plan is revised /updated as needed until the ID [interdisciplinary] C [care] plan is developed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for R1 revealed a recorded Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Functional assessment revealed dependent x 2 person assist. Review of the nursing admission note for R1 dated 8/9/2023 at 7:00 am revealed Stage two pressure ulcer to buttocks area with slough with thin watery drainage, partial thickness, skin loss with exposed dermis. Review of the care plan for R1 dated 8/9/2023 failed to include treatment plan for Stage two pressure ulcer. Interview on 11/16/2023 at 10:10 am with Registered Nurse (RN) UU verbalized that the facility failed to include a treatment plan for a Stage two pressure ulcer for R1. RN UU revealed no wound care had been provided, no treatment plan had been implemented, no physician orders or physician awareness of a wound had been completed, and no follow-up documentation in the resident's chart of a wound assessment. Interview on 11/16/2023 at 10:33 am with Licensed Practical Nurse (LPN) NN revealed she assisted with the admission assessment. She stated the clinical admission assessment is a pre-populated document. LPN NN stated that she started the baseline care plan and failed to follow-up with the Director of Nursing (DON) or the Wound Care Nurse to see if the wound evaluation had been completed. LPN NN confirmed no wound care had been provided, no treatment plan had been implemented, no physician orders or physician awareness of a wound had been completed, and no documentation in the resident's chart of a wound assessment. Interview on 11/16/2023 at 10:25 am with the Interim DON revealed discharge summaries from a hospital or other facility can be very limited with resident information for the continuum of care of that resident. He reported in the future with no full hospital discharge summary, he will call for more information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Skin Management Standard, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented for one of three residents (R) (R1). The deficient practice had the potential to prevent healing and promote infection and the development of new pressure ulcers. Findings include: Review of the facility policy title Skin Management Standard dated August 2021 revealed the purpose of this procedure is to monitor the status of each wound and provide information to the interdisciplinary team to assist determining the most appropriate treatment modalities. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed a Recorded Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The functional assessment revealed R1 was dependent with two person assistance. Review of the nursing note dated 8/9/2023 at 7:00 am revealed Stage two pressure ulcer to buttocks area with slough with thin watery drainage, partial thickness, skin loss with exposed dermis. Review of physician orders dated 8/9/2023 for R1 revealed no orders for treatment of the stage two pressure ulcer wound. Interview on 11/16/2023 at 10:10 am with Registered Nurse (RN) RN UU revealed the facility did not have a physician order for wound care obtained on admission for R1. RN UU confirmed a wound assessment was not completed by an RN for R1. RN UU confirmed no wound care had been provided, no treatment plan had been implemented, no physician orders or physician awareness of a wound had been completed, and no documentation was done in the resident's chart of a wound except for the clinical admission assessment on 8/9/2023. Interview on 11/16/2023 at 10:25 am with the Interim Director of Nursing (DON), the DON stated that with any assessment of a wound the nurse notifies the doctor, an RN must assess the wound within 24 hours, and the wound care nurse would be provided the information at the managers morning meetings. Interview on 11/16/2023 at 10:33 am with Licensed Practical Nurse (LPN) NN revealed LPN NN failed to follow-up with the DON or wound care nurse to see if the wound evaluation had been completed and physician has been notified of the wound status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the facility policy titled, Skin Management Standard, the facility failed to obtain physician orders for treatment of a stage two pressure ulcer for one of three residents (R) (R1). The deficient practice had the potential for R1's pressure ulcer to worsen, become infected, or develop new pressure ulcers. Findings include: Review of the facility policy titled Skin Management Standard dated August 2021 indicated the purpose of this procedure is to monitor the status of each wound and provide information to the interdisciplinary team to assist determining the most appropriate treatment modalities. Review of the subtitle Skin /wound Alert Procedure indicated the purpose of this procedure is that the nurse will notify the physician of the resident's wound and will obtain treatment orders as needed. The procedure also requires that the physician shall evaluate the resident's wound on his/her next visit following notification. Review of the current Minimum Data Set (MDS) assessment dated [DATE] for R1 revealed a recorded Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. The functional assessment revealed R1 was dependent with two-person assistance. Review of the Nurses Notes dated 8/9/2023 at 7:00 am revealed Stage two pressure ulcer to buttocks area with slough with thin watery drainage, partial thickness, skin loss with exposed dermis. Review of Physician Orders dated 8/9/2023 for R1 revealed no orders for treatment of the stage two pressure ulcer wound. Interview on 11/16/2023 at 10:10 am with Registered Nurse (RN) UU revealed the facility did not have a physician order for wound care obtained on admission for R1. RN UU confirmed there was not a wound assessment completed by an RN for R1. RN UU revealed no wound care had been provided, no treatment plan had been implemented, and no physician orders or physician awareness of a wound had been completed. Interview on 11/16/2023 at 10:25 am with the Interim Director of Nursing (DON), the DON stated that with any assessment of a wound, the nurse notifies the doctor, an RN must assess the wound within 24 hours, and the wound care nurse would be provided the information at the managers morning meetings. Interview on 11/16/2023 at 10:33 am with Licensed Practical Nurse (LPN) NN revealed she assisted with the admission assessment and failed to follow-up with the physician and the DON or wound care nurse to see if the wound evaluation had been completed and treatment plan was ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy titled Bed Safety, the facility failed to ensure one resident (R)(R#9) of 18 sampled residents were accurately assessed for the use of side rails. Findings include: Review of the facility's policy titled Bed Safety revision dated 2007, revealed: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Bed rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using bed rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with bed rails. A consent shall be signed and dated by the resident/representative prior to use. 10. When using bed rails for any reason, the staff shall take measures to reduce related risks. During an observation on 1/07/2023 at 9:06 a.m. R#9 was lying in bed three ¼ rails in the up position. During an observation on 1/07/2023 at 1:47 p.m., R#9 was lying in bed three ¼ rails in the up position. During an observation on 1/07/2023 at 8:45 a.m., R#9 was lying in bed three ¼ rails in the up position. A review of R#9's Electronic Medical Record revealed resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include but not limited to Alzheimer's disease, major depressive disorder, psychotic disturbance, mood disturbance, anxiety, history of falling, repeated falls, cerebrovascular disease, displaced supracondylar fracture without intracondylar extension of lower end of the right femur and atrial fibrillation. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R#9 had a Brief Interview for Mental Status (BIMS) should not be conducted because resident is rarely/never understood. In addition, the MDS revealed R#9 requires extensive staff assistance of two staff for bed mobility and total dependence of two staff for transfer. A review of the care plan (last review date 10/26/2022) for R#9 revealed resident is at risk for fall/injuries due to poor safety awareness, history of falls, unsteady gait, history of syncope episodes and weakness. The goal established included R#9 will remain free from fall related to injuries thru the next review. Interventions that R#9 may use siderails while in bed to be enabled to assist with turning and repositioning and to enable freedom of movement while in bed. A review of R#9's Electronic Medical Record (EMR) revealed R#9 had been assessed for the use of side rails on 11/30/2022 indicating side rails are indicated and serve as an enabler to promote independence. Further review of the record revealed there is not a side rail consent with risk and benefits, there were no documented attempts for alternatives prior to the use of side rails and lack of assessment of entrapment risk. A review of the Occupational Therapy (OT) evaluation and plan of treatment dated 11/30/2022 revealed that resident was referred to OT due to recent fracture of right femur and subsequent hospitalization. Formal OT evaluation completed; however, resident was cognitively unable to follow commands and actively participate in skilled OT services at that time resulting resident not being a good candidate for skilled OT services at the time of the evaluation. The evaluation summary revealed physical, cognitive, psychosocial performance: resident presents with impairments in balance, gross motor coordination, dexterity, mobility, and strength resulting in limitations and/or participation restrictions in the areas of mobility and self-care. During an interview with Licensed Practical Nurse (LPN) DD on 1/8/2023 at 9:05 a.m., she revealed that she has not witnessed R#9 using the bedrails. LPN DD stated R#9 just lie in bed and she does not know why resident has the 3 bedrails up because she cannot physically use the bedrails. During an interview with Certified Nursing Assist (CNA) AA on 1/8/2023 at 9:12 a.m., she stated that R#9 at one time could move around in the bed, now she does not, but the bedrails up x 3 on residents' bed were used to prevent resident from falling out of the bed. CNA AA further stated that R#9 is not able to use the bed rails to reposition or assist with bed mobility. R#9 is a total dependent on staff. During an interview with Registered Nurse (RN) EE on 1/8/2023 at 9:30 a.m., she revealed that the nurses are responsible for completing the bed rail assessment on admission and quarterly. RN EE also stated that if a resident needs a bedrail the physician should be contacted and there should be an order for the bedrail that includes the indicated reason for the use of the bedrails. During an interview with the Director of Nursing (DON) on 1/8/2023 at 9:38 a.m., she stated that the nurses is responsible for reviewing the bedrail assessments, triggering residents for the use of bedrails, and putting the order for the bedrail into the electronic record. DON also stated that she was not aware that R#9 had bedrails on her bed at this time because resident had declined and should not have bedrails because she cannot use them. DON stated that residents in the facility should not have three bedrails up and she does not have an explanation for that other than maybe her bed had been changed to accommodate the air mattress. DON verified R#9 does not have an order or consent on the record for the use of the bedrails and resident had3 bedrails up on her bed. During an interview with CNA CC on 1/8/2023 at 9:47 a.m., she stated that R#9 can reach the bed rail with her hand only when she guides her hand to the bedrail, but R#9 does not help with turning over in bed. CNA CC further stated R#39 is a total dependent on staff. During an interview with Maintenance Director on 1/8/2023 at 9:56 a.m., he revealed the therapy department informs him when a resident needs bed rails, and the bed rails are place after the nurse updates the care plan. He stated that he has not placed bedrails on R#9's bed nor has he switched her bed with another bed in the facility. During an interview with the Regional Nurse Consultant on 1/8/2023 at 12:08 p.m., she revealed that she worked in the facility 6 months ago and at that time R#9 could functionally use the bedrails, but she would have to assess the resident to see if she could use the bedrails at this time. She stated that resident is able to pick up her cup and reach for things, but she has not witness her doing that lately. The Regional Nurse Consultant stated that the Therapy department evaluates residents and determine if the resident is able to use the siderails. No one from the therapy department was available for interview during this survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident interviews, review of facility policy titled, Food Temperatures, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance and provide meals that were palatable, attractive, and at a safe and appetizing temperature. Specifically, the facility failed to ensure that food items served for lunch were at 135 degrees Fahrenheit (F) when being served to residents on one of three halls (Hall C). Findings Include: Review of facility undated policy titled, Food Temperatures number eight Proper Hot Holding: Internal temperature of food should be checked every two hours to ensure temperature is kept above 140 F. Interview on 1/6/2023 at 8:59 a.m. with Resident (R)#18 revealed that most meals that are served from the kitchen come to her room cold. Review of resident Quarterly Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15 indicating resident is cognitively intact and able to answer questions appropriately. Interview on 1/6/2023 at 9:30 a.m. with R#41 revealed that food at the facility is terrible and is barley warm when the food gets to his room. Further interview also revealed that the food being cold is an ongoing issue for all meals. Review of resident Quarterly MDS assessment dated [DATE] revealed a BIMS score 15 indicating resident is cognitively intact and able to answer questions appropriately. Review of sampled test lunch tray on 1/7/2023 at 12:40 p.m. revealed test tray that was retrieved from C hall cart food temperatures were not within professional guidelines as evidenced by the following: Liver temperature was 127 degrees F and rice with gravy temperature was 131 degrees F. All temperatures were taken by dietary staff and confirmed at time of observation. Interview on 1/7/2023 at 12:40 p.m. with the Dietary Manager revealed the temperature of the meat should have been at a holding temperature of 135 degrees F as well as the rice with gravy. Further interview also revealed that the food temperatures are taken before the meal trays are prepared and not at any other time during meal service to ensure the temperature is holding. Dietary Manager also confirmed that the food temps were not at regulatory level. Interview on 1/8/2023 at 12:35 p.m. interview with the Administrator revealed that he was not aware that there had been any complaints from the residents concerning the food being cold. Further interview also revealed that he would expect for the residents' meals to served hot when delivered to their rooms and when served in the dining room.

Based on observations, interviews, and review of policy titled Operations: Description of Steps in the Laundry Process, the facility failed to maintain an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced appropriate techniques when folding clean laundry; storing clean mop heads; housekeeping carts stored in the area in direct contact with a clean linen cart; lint trap of dryers with large accumulation of lint buildup; chipped white paint and personal items on folding table; laundry aide siting with feet on the folding table; an accumulation of lint, dust and debris in the laundry room. The census was 73. Findings include: Review of Operations: Description of Steps in the Laundry Process, revision date of 1/2016, revealed the following: C. Lint Screens - These lint screens must be brushed and cleaned after every load or every hour. A review of the facility's Dryer Lint Clean Out Schedule revealed that for the months of July 2022 through November 2022 there was missing documentation for multiple months. Specifically, there were seven days in August 2022 that did not have documentation; no documentation noted September 24 through September 31, 2022; no documentation noted October 6 through October 31, 2022; and no documentation for November 2022. There also was no documentation for lint cleaning for January 2023. During an observation on 1/7/2023 at 12:19 p.m. during tour of the laundry revealed Laundry Aide (LA) FF sitting on the clean folding table with her feet on the table. The clean folding table had chipped white paint. There was also a drinking cup and a small portable heater on the folding table. The shelf above the folding table had a buildup of dust. There was a plastic bag of clean linen on the shelf. Observation behind the washers revealed an accumulation of chemical residue on the back and along the sides of both washers. There was rust along the lateral side of one of the washers. There were gloves, trash, and an accumulation of dust and other debris on the floor behind both washers. Observation of the lint traps on both industrial dryers had a large accumulation of lint. Observation also revealed a plastic bag of clean linen on the pipe on the floor behind the dryer. There was a large accumulation of lint and dust on the back of both dryers and on the floor behind the dryers. LA FF revealed that she has only worked at the facility for nine days. She further reported that she cleaned the lint traps every 1 ½ to 2 hours but no one informed her that she was required to document the cleaning of the lint trap. Observation of the breezeway leading to the laundry revealed 3 housekeeping carts containing trash and a soiled linen container pushed directly against the clean cart containing clean mop heads. In addition, there were clean mopheads hanging directly above a mop pail of dirty water. During an interview on 1/7/2023 at 12:32 p.m. with the Maintenance Director he stated that he is only required to check the lint traps weekly for compliance to ensure that the laundry girls are cleaning them. He further stated that he is not required to document these weekly checks. The Maintenance Director further stated that he honestly has to clean the lint traps whenever he checks them because they are not clean. Maintenance Director verified the lint traps were not clean, the debris behind the washers, the issues in the breezeway and the personal belongings on the folding table. During an interview on 1/7/2023 at 12:58 p.m. with Housekeeping /Laundry Supervisor who revealed that staff is not allowed to sit or have personal items on the clean folding table. She further stated that the Laundry Aide is responsible for cleaning and documenting the cleaning of the dryer lint trap every 2 hours. She verified the findings and stated that the laundry room and breezeway should not ever look this way. Laundry/Housekeeping Supervisor located the facility's Dryer Lint Clean Out Schedule, a review of the log revealed the log for January 2023 was without documentation of the lint traps of the dryer being cleaned. She stated that it is her responsibility to ensure compliance with infection control practices in the laundry and cleaning of the dryer lint traps. She further stated that she has no clue as to why it is not being done. She stated that there have been recent staffing issues in the laundry which may have contributed to the noncompliance. During an observation and interview on 1/8/2023 at 8:24 a.m. in the breezeway with Laundry/Housekeeping Manager revealed a housekeeping cart containing trash bag positioned directly against the clean linen cart containing clean mop heads. Laundry manager stated, I swear that must have just happened, that cart was not there a minute ago. Someone must have parked that housekeeping cart and it rolled down the breezeway coming to a resting place directly onto the clean cart. During an observation and interview with LA FF and Floor Tech (FT) HH on 1/8/2023 at 8:31 a.m. revealed both were at the folding table folding linen with the linen being held against their clothing. FT HH observed folding a white blanket that touched the floor twice while being folded and placed on the clean folding table. LA FF and FT HH both acknowledge that the linen should not be on the floor or against their clothing. During an interview with the Administrator on 1/8/2023 at 10:11 a.m. He stated that he expected the facility staff to follow CMS guidelines.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage Guidance the facility failed to ensure disposal of expired medications by the appropriate expiration date, the facility also failed to ensure that insulin stored in the refrigerator in one of one medication room was properly dated with open and expiration dates for three of 13 residents (R#3, R#10, and R#24) receiving insulin coverage resident. Findings Include: Observation on 5/4/21 at 3:50 p.m. of the facility medication storage room revealed the area was located to the right of the centralized nursing station. The refrigerator was clean, and insulin was stored in individual plastic bins. There was one 3ml (milliliters) bottle of Novolin R that was open with no open date noted for resident (R) R#10, one 3ml bottle of Humalog with no open date for R#3, one 3ml bottle Novolog with no open date for R#24, one 16oz bottle of Milk of Magnesia with an expiration date of December 2020, Liquid Pain Relief 16 fl. Oz (fluid ounces) with an expiration date of September 2020. All expired medications were confirmed by the DON at the time of observation. Interview on 5/4/2021 at 3:55 pm. with the DON who was present at time of observations revealed that the expectation is that staff would discard any expired medications that were in the medication room. Further interview also revealed that all insulins should be dated with an open and expiration date after the seal has been removed and the insulin has been used. Interview on 5/4/2021 at 4:15 p.m. with RN FF revealed that all insulins should have an open and expiration date on the label after it is opened.

Based on observations, staff interviews and review of the facility policy titled, Infection Control Manual the facility failed to store patient care equipment (wash basins and a specimen collector pan) in a sanitary manner to prevent the spread of infection in four of 10 bathrooms on the B hall. Findings Include: Review of the facility policy titled, Infection Control Manual dated 2/2016, revealed: The facility will appropriately care for resident care equipment and supplies to prevent them from becoming sources of infection. The facility must establish and maintain 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. An observation made on 5/03/21 at 11:00 a.m. revealed: Room B6/B8's shared bathroom had one unlabeled washbasin on the floor and one unlabeled wash basin on the back of the commode. Neither were stored in a bag. Room B10/B12's shared bathroom had one unlabeled washbasin on the floor and not stored in a bag. Room B14/B16's shared bathroom had three unlabeled washbasins on the floor, and all were not stored in a bag. Room B13/B15's shared bathroom had one unlabeled wash basin and one specimen collector pan on the floor, and neither were in a bag. An observation made on 5/04/21 at 10:43 a.m. revealed: Room B6/B8's shared bathroom had one unlabeled washbasin on the floor and one unlabeled wash basin on the back of the commode. Neither were stored in a bag. Room B10/B12's shared bathroom had 1 unlabeled washbasin on the floor and not stored in a bag. Room B14/B16's shared bathroom had three unlabeled washbasins on the floor, and all were not stored in a bag. Room B13/B15's shared bathroom had one unlabeled wash basin and one specimen collector pan on the floor, and neither were in a bag. During observation rounds made on 5/04/21 at 11:00 a.m. made of rooms 208-216 with the Administrator, Director of Nursing (DON), and Regional [NAME] President of Operations verified the improper storage of resident wash basins and a specimen collector pan on the B hall. They agreed the wash basins and specimen collector pan should be labeled with a resident's name, placed in a bag, and stored off the floor. An interview on 5/06/21 at 9:29 a.m. with a Certified Nursing Assistant (CNA) CNA AA revealed wash basins should be rinsed out after use, let it dry, put the basin in a bag, make sure it is labeled with the resident's name and store it in the closet or on hook in the bathroom. An interview on 5/06/21 at 9:40 a.m. a Licensed Practical Nurse (LPN) LPN BB, a night shift nurse, revealed the resident's wash basins should be stored in a bag, labeled with the resident's name and stored in the resident's closet or hanging up in the bathroom. An interview on 5/06/21 at 9:58 a.m. with the DON revealed her expectations are to store the resident's wash basins in a sanitary manner and to make sure the basins are labeled with the resident's name. An interview on 5/06/21 at 3:40 p.m. with the Administrator revealed he would expect the facility to follow the infection control policies related to storage of the resident's wash basins and specimen collector pans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility document entitled Deep clean checkoff List revealed under check off the following areas when completed 25. Inspect curtains for spills or damage and alert management so they get replaced. Observation on 5/3/21 at 11:09 a.m. revealed the privacy curtain between bed A and C have noted brown stains at the base, privacy curtain for bed A had dark to black stains noted to the base of the curtain as well. Floor in room [ROOM NUMBER] had black streaks noted on the floor leading out of the door. (217-B) B-Hall Observation on 5/3/21 at 11:51 a.m. of room [ROOM NUMBER]-B on the C Hall revealed the plastic stripping on the foot board is loose and hanging on the floor, paint is peeling off of the wall between two closets by the door hinge there was also noted paint peeling in corner of the room by the air conditioning unit, curtains that are by Bed A was noted to have multiple brown stains and a chunk of brown matter to curtain hem, curtain was also noted to have dirty spots front and back. Observation on 5/3/21 at 11:57 p.m. for room [ROOM NUMBER]-B on the C Hall revealed the privacy curtain for B Bed revealed white substance in the middle of the curtain black spots on the inner aspect and outer of curtain. Observation on 5/3/21 at 12:00 p.m. of the privacy curtain for C301 C Hall revealed there a brown stain as well as brown substance on the lower portion of the curtain by the hem, there was also a hard brown black crusted over substance at the very bottom of the curtain by the hem line facing the foot of the bed. Observation on 5/3/21 at 2:18 p.m. of room [ROOM NUMBER] on the C Hall revealed the privacy curtain for Bed A has dark stain noted on the lower half of the curtain there was also some missing hooks at the top of curtain track for bed A as well, Bed B curtain had noted brown stains at the bottom of curtain and one black spot on the bottom of the curtain at the hem line. Observation on 5/3/21 at 2:09 p.m. of room [ROOM NUMBER] (on the C Hall) revealed the privacy curtain for Bed B has brown stain on the lower half of the curtain on the outside and inner side. Interview on 5/4/21 at 8:15 a.m. with the Administrator revealed that he was not aware of the current condition of the privacy curtains in rooms 217, 301, 305, and 307. Administrator confirmed that privacy curtains in each of the rooms described were dirty and acknowledged that they needed to be replaced. Further interview also revealed that is the responsibility of the housekeeping staff to ensure that if there is an issue with the privacy curtains rather, they are stained or not retracting properly that they are to be replaced. Administrator also confirmed that in room [ROOM NUMBER] that there was a large black stain on the floor leading from the B bed all the way to the room door exit. Administrator also confirmed the disrepair of the wall between two closets and in the corner of the room by the air conditioner for room [ROOM NUMBER] (C-Hall) in which the paint was actually peeling from the wall and chips of sheet rock was noted on the floor. In the same room (301) Bed B was noted to have the stripping to the foot board of the bed hanging and unattached to the bed foot board. On 5/04/21 at 8:25 a.m. Interview with Housekeeping supervisor revealed that deep cleans are conducted daily one room on each hall. The nursing staff is notified of which rooms are to be deep cleaned that day so that the resident can be removed from the room. Further interview with Supervisor also revealed that there was a privacy curtain audit that was completed on 4/28/2021 and that there are privacy curtains on back order. If there is an issue with the curtains rather, they are stained or not fitting properly then they would report it to her, and she would ensure that the curtains were replaced. No staff member had reported to her the need for curtains in rooms 217,301, 305 or 307 to be replaced to her knowledge. Interview on 5/04/21 at 8:45 a.m. with Housekeeper DD revealed that he is usually assigned to the B-Hall (200) and during the daily cleaning regimen the five- step daily room cleaning process is followed. While cleaning the room the trash is pulled first, the floors are swept, bathroom is cleaned, and the curtains looked at for any stains or missing hooks. If there are any stained curtains or anything wrong with curtain hooks or tracking the curtain is replaced. Continued interview also revealed that staff member did not notice any stains on the curtains in room [ROOM NUMBER]. Interview on 5/4/21 at 9:00 a.m. with CNA EE revealed that she works the B Hall regularly and has noticed that the curtains in room [ROOM NUMBER] did have stains on them as well as the stain in the floor. Continued interview also revealed that Housekeeping Supervisor completed an audit about three weeks ago on all of the privacy curtains and nothing was done. Further interview also revealed that the privacy curtains have been in this condition for a while and management stated they would change them but did not. Continued interview with CNA EE also revealed that when there are any maintenance issues there is a form that is completed and placed in the tray of the maintenance director's door. Interview on 5/4/21 at 9:15 a.m. with the Maintenance Director revealed work orders for repairs are completed daily. The staff has access to maintenance request forms which are stored in a tray on the maintenance door. When a request is received depending on what the request is rather it requires immediate attention such as a water leak or missing tile, the request is usually completed within 24-48 hours. Continued interview revealed that maintenance director did confirm that the wall in room [ROOM NUMBER] was in disrepair with peeling paint and the sheet rock chipping and falling away on the floor. There was no documentation to confirm the needed supplies for the wall repair was ordered or received. Observation on 5/6/21 at 4:45 p.m. of the privacy curtains for room [ROOM NUMBER] (B-Hall), 305, and 307 revealed that privacy curtains were still noted with dark stains and missing hooks. Curtains have not been changed out. room [ROOM NUMBER] was locked and could not be observed. Based on observations, an staff interviews the facility failed to ensure the ceiling air vents in resident bathrooms on two of three halls were clean and not heavily covered in dust, failed to ensure that the hall ceiling air vents were clean on two of three halls, failed to ensure that the privacy curtains for four rooms on two of three halls were clean for four resident rooms (217,301, 305 or 307), failed to ensure that the wall between two closets in in the corner of one room (room [ROOM NUMBER]) on one of three halls was in good repair without peeling paint and chipping sheetrock, and failed to ensure that the B bed in room [ROOM NUMBER] had a foot board that didn't have the stripping loose and hanging off. Findings include: 1. Observation on 5/3/21 during tour and screening of residents, revealed there was a heavily coated build-up of dust on the ceiling air vents in the joining bathroom of the following rooms (Rm): 201/203, 202/204, 205/207, 206/208 on the 200 hall. Observation on 5/4/2021 during observation rounds revealed there was a heavily coated build-up of dust on the ceiling air vents in the joining bathroom of 102/104, 105/107, 106/108, 110/112, 109/111; and four hallway ceiling vents on the 100 hall. Observation on 5/4/21 at 3:35 p.m. during walking rounds, and interview at that time with the Maintenance Director, confirmed a heavily coated build-up of dust on bathroom ceiling vents in RM [ROOM NUMBER], 206, 207, 208, 209, 210, 211 on the 100 hall as follows: 5/04/21 at 3:35 p.m. Room (Rm) B2-B4 joining bathroom. 5/04/21 at 3:40 p.m. Rm B5-B7 joining bathroom during a walk thru with the Maintenance Director confirmed heavily coated dusty vents in the bathroom. 5/04/21 at 3:45 p.m. Rm B6-B8 joining bathroom during a walk thru with the Maintenance Director confirmed heavily coated dusty vents in the bathroom. 5/04/21 at 3:50 p.m. Rm A9-A11 joining bathroom during a walk thru with the Maintenance Director confirmed heavily coated dusty vents in the bathroom. 5/04/21 at 3:55 p.m. Rm A113 bathroom during a walk thru with the Maintenance Director confirmed heavily coated dusty vents in the bathroom. 5/04/21 at 4:00 p.m. Interview with the Maintenance Director confirmed the dusty bathroom vents and revealed they had been identified on 4/21/21 and was on his list of maintenance to complete. The Maintenance Director revealed housekeeping should be dusting when they clean the bathroom. Walking rounds on 5/5/2021 at 9:00 a.m. with the Administrator and another state surveyor/Team Coordinator, the Administrator confirmed a heavily coated build-up of dust on the joining bathroom ceiling vent of RM [ROOM NUMBER]/103, 102/104, 105/107, 106/108, 109/111; and four hallway ceiling vents, on 100 hall as follows: A hall, Rm A2-A4 shared bathroom. A hall, Rm A5-A7 shared bathroom. A hall, Rm A6-A8 shared bathroom. A hall, Rm A10-A12 shared bathroom. Four vents in the ceiling of A hall/locked unit Interview on 5/5/2021 at 9:15 a.m. with the Administrator confirmed very dusty ceiling air vents in resident bathrooms and the 100 hallway, and revealed he felt it was the Maintenance Director's responsibility for cleaning vents. He revealed the dusty vents were unacceptable, and most likely got that way due to not staying on top of it and not having a set schedule for cleaning. His expectation was that ceiling air vents should not be heavily coated in dust, should have been cleaned routinely, and should be free of dust.