Based on interviews, record review, and review of the facility policies titled, Notification of Change and Resident's Right Regarding Treatment and Advanced Directive, the facility failed to obtain consent/permission from the responsible party (RP) to change insurance provider for one of 51 sampled residents (R) (R7). Findings include:Review of facility's policy titled Notification of Change dated November 2022 and revised August 2024, indicated under Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Under Additional considerations.Review of facility's policy titled Resident's right regarding treatment and advanced directive dated March 2022 and revised October 2024 indicated under Policy Explanation and Compliance Guidelines: .5. The facility will identify or arrange for an appropriate a representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relative health care decisions. 6. The facility would define and clarify medical issues and present them to the residents or legal representatives as appropriate.Review of electronic medical record (EMR) revealed that there were no documented conversations between staff and the RP for R7 regarding a change to Medicare.Review of R7's EMR revealed that there was a copy of the guardianship order uploaded to the record.Interview on 7/17/2025 with the Business Office Manager (BOM) revealed that she was familiar with the situation regarding R7 insurance enrollment with Medicare and admitted that his legal guardian was not notified. She revealed that the admission assistant made the change without notifying or obtaining permission from R7's legal guardian/RP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's policies titled Abuse, Neglect, Exploitation and Fall Prevention, the facility failed to ensure that injuries of unknown source were reported timely to the State Survey Agency (SSA) for one sampled resident (R) (R41).Findings include:Review of the facility policy titled Abuse, Neglect, and Exploitation with an implementation date of 6/1/2021 and a reviewed/revised date of 10/1/2023 documented under Policy: It is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Under Definitions: Serious Bodily Injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse. Under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: . c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention.Under VII. Reporting/Response, A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.Review of the facility policy titled Fall Prevention Program with an implementation date of October 2022 documented under Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. A near miss which is also considered a fall, is when a resident would have fallen if someone else had not caught the resident from doing so.Review of the electronic medical record (EMR) revealed R41 was admitted to the facility with pertinent diagnoses including but not limited to hip fracture, anemia, coronary artery disease (CAD), hypertension, diabetes mellites, anxiety disorder, and depression.Review of R41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R41 is cognitively intact. Section GG, functional status, revealed R41 revealed he benefits from the use of a walker and wheelchair and required substantial/maximal assistance for toileting hygiene, putting on/taking off footwear and lower body dressing. R41 requires partial/moderate assistance with shower/bath and upper body dressing. R41 requires setup/clean up assistance with eating and oral hygiene.Review of R41's care plan dated 6/10/2025 indicated a problem of ADL self-care performance deficit r/t (related to) decreased mobility. Goals included but not limited to R41 will improve current level of function in through the next review date. Interventions included but not limited to Encourage R41 to use bell to call for assistance, PERSONAL HYGIENE: R41requires staff assistance with personal hygiene, TOILET USE: R41 requires staff assistance with toileting, TRANSFER: R41 requires staff assistance with transferrin [sic]. R41 has a focus of R41 is at risk for falls r/t Hx (history) of falls. Goal includes R41 will not sustain serious injury through the next review date. Intervention includes Assist with transfers as needed.Review of the Physician's Orders for R41 included but not limited to:Order dated 6/2/2025 to Assess resident for pain every shift for PainOrder dated 7/3/2025 for OT (occupational therapy) clarification order: OT to tx (treat) 3-5 times a week for 6 weeks to address functional transfers, dynamic standing balance, UE (upper extremity) strengthening and ADL (activities of daily living) performanceOrder dated 7/3/2025 for PT (physical therapy) Clarification Order: PT 3-5 x (times) week x 6 weeks to include ther ex (therapeutic exercises), ther act (activities), neuro re-ed (neurological re-education), gait training, group therapy one time only for 6 WeeksObservation and interview on 7/15/2025 at 10:19 am with R41 revealed he had a roommate who sometimes fell asleep on the toilet for up to an hour or an hour and a half wait. R41 revealed when he complained to the facility, they accommodated him by bringing in a portable commode which was directly in front of his bed, at the foot of the bed, under the television. R41 further revealed he recently received a new hip and was unable to get to the toilet but was not supposed to get out of bed because he could fall.Interview on 7/16/2025 at 4:39 pm with Physical Therapist (PT) KK revealed R41 was admitted into therapy on 6/3/2025. PT KK revealed if a R did not receive therapy, it was logged in their system whether it was a missed visit and the reason for the missed visit. PT KK revealed R41 completed his PT session today but did not do much because he had a fall yesterday. She further stated she was unaware of the fall until R41 reported it to the therapy dept. Interview on 7/16/2025 at 5:30 pm with R41 revealed him in bed stating he was not doing good because he had a fall the previous night. He further revealed he was attempting to go to the bathroom on the bedside commode and fell. He stated he was in pain in his leg. When asked if anyone was in the room and was able to help him, he revealed no one was in the room but he was able to get up and got back to bed.Interview on 7/18/2025 at 12:21 pm with Licensed Practical Nurse (LPN) LL revealed she was not present when R41 fell but heard of the fall. She further revealed she would report to the Unit Manager LPN. LPN LL revealed Registered Nurse/Skilled Coordinator (RN) MM documented the fall in the system, but she was unable to see any documentation in the EMR of the fall. Interview on 7/18/2025 at 12:43 pm with RN MM revealed she heard about the fall but stated R41 did not report it to her. RN MM further stated while she was rounding, she checked in with R41 who let her know he had fallen earlier in the week. RN MM continued to reveal she thought R41 may have had an x-ray for that fall.Interview on 7/18/2025 at 12:56 with the Director of Nursing (DON) revealed the pain doctor examined R41 who had reported he had fallen and but it was not witnessed. R41 reported to the therapist but she was unsure of which therapist however, she felt he was speaking to one therapist and the other overheard. The DON stated at that time, the therapist should have reported the fall to the nursing department so that the nursing department could complete the needed assessments. The DON revealed the Nurse Practitioner (NP) went to see R41 and was able to assess what happened via a demonstration. At that time R41 agreed that was what happened. The DON continued to describe the fall in the form of a near miss. She further revealed when he was assessed there were no skin tears or any other signs of a fall.Interview on 7/18/2025 at 2:07 pm with the Administrator revealed her expectations for staff when it came to reporting was staff should contact her as soon as possible if there was a state reportable. When asked about the negative effect on residents, the Administrator revealed that they wanted to make sure they were safe and taken care of and the incidents would not continue.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled, Care Planning-Resident Participation, the facility failed to implement the care plan for one of 51 sampled residents (R) (R26) related to oxygen (O2) administration and Bi-pap (bilevel positive airway pressure device). Specifically, the resident returned from the hospital with new orders for O2 which were not addressed in the new five-day care plan. Findings include:Review of the facility policy titled Care Planning-Resident Participation with a revised date of March 2023 revealed under Policy Explanation and Compliance Guidelines: .6. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.Review of the electronic medical record (EMR) revealed R26 returned from the hospital on 7/9/2025 with new physician orders including Oxygen at 2 liters (liters per minute-LPM) per nasal cannula (NC) continuous.Review of the EMR revealed R26 had been admitted to the hospital with a diagnosis including but not limited to pneumonia. Observation on 7/15/2025 at 9:00 am revealed R26 had O2 on via NC and a Bi-pap machine at bedside.Interview with resident R26 on 7/16/2025 at 9:45 am revealed that he used his Bi-pap machine every night and his O2 administration was new from the hospital.Interview on 7/16/2025 at 11:11 am with the MDS (Minimum Data Set) Coordinator revealed that upon performing R26's five-day MDS assessment and care plan she confirmed she had neglected to include the respiratory components for the resident on his existing care plan. She stated that she would immediately prepare a modification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to maintain a safe, clean, comfortable, homelike environment by not making needed repairs in three of five hallways (100 hallway, 400 hallway, and 600 hallway) observed in the facility. There were seven resident rooms needing repair on the 100 hallway (room [ROOM NUMBER], 102, 105, 110, 111, 114, 116, and 118), two resident rooms on the 400 hallway (room [ROOM NUMBER] and 403), and one resident room on the 600 hallway (room [ROOM NUMBER]). Additionally, the therapy room had gouged areas in the door exposing rough wood, the main dining room had cracked and loose tiles, and the Beauty Salon's shampoo chair for the residents to sit in to have their hair done was missing one front leg and was being held up by a brick. Findings include: Review of the facility's policy titled: Safe and Homelike Environment dated 4/01/2023 revealed .The facility will provide a safe, clean, comfortable and homelike environment . During a tour on 2/21/2024 at 9:23 am, with the Maintenance Director (MD) revealed the following: In room [ROOM NUMBER], 110,102, 401, and 403, the drywall behind the residents' headboards was gouged. In room [ROOM NUMBER], the area around the base of the toilet had a dark substance. Also, in the corners of the bathroom were areas of a dark substance. The MD stated that it was a buildup of dirt and wax. The wall in the hallway outside of room [ROOM NUMBER] had a large area approximately two feet by two feet that had a white patch. Also, on the wall was an area that had been painted dark brown that was different that the brown color of the wall. In room [ROOM NUMBER], the resident's vinyl on the right arm of the wheelchair was cracked exposing white material. In room [ROOM NUMBER], the bathroom vanity top was cracked across the entire length of the vanity. The door to room [ROOM NUMBER] had a gouged area that exposed rough wood. In room [ROOM NUMBER], the door to bedroom had gouged areas with exposed rough wood. The hub nurses station facing the side entrance door revealed large areas of laminate missing, exposing brown wood. The backside of the hub nurses station revealed a large area of laminate missing, exposing brown wood. One set of doors to the hub nursing would not close and there was a hole in each of the doors. The therapy room door had several gouged areas exposing rough wood. The main dining room near the conference room had a one cracked tile with the corner missing. Near the piano in the main dining room was a tile that was loose and would move when touched. Interview on 2/21/2024 at 9:50 am, the MD stated that he was not aware of the issues observed during the facility tour. Observation on 2/22/2024 at 9:06 am revealed the right arm rest of the wheelchair in room [ROOM NUMBER] was cracked and there was a buildup of a dark substance behind the bedroom door along the wall and in the corners of room [ROOM NUMBER]. In room [ROOM NUMBER], a wheelchair back strap was cracked and exposed the white material underneath. In room [ROOM NUMBER] and room [ROOM NUMBER], the right arm rest of the wheelchair in each room was cracked, exposing the white material underneath. During an interview on 2/22/2024 at 10:14 am, the MD stated that every Wednesday maintenance washed the wheelchairs with the pressure washer and that they did not have any documentation of wheelchairs that needed to be repaired. Observation and interview on 2/22/2024 at 10:00 am, the facility's Beauty Shop was observed with the Administrator and revealed that the shampoo chair, (a chair residents sit in and that goes back to have their hair washed) had one of the front chair legs missing and in its place was a large gray cement brick with a red brick on top of it to hold the corner of the chair up in a level position. Interview at the time of the observation with the Beautician (BTN) revealed that the chair was fixed this way last Thursday by maintenance. Interview on 2/22/2024 at 10:31 am, the MD stated that he reviewed the work order book at the nurses' station and did not find documentation of the beauty shop chair leg missing. The MD stated that he spoke to the Maintenance Worker (MW) and was told about the beauty shop chair when he was leaving the facility last Friday and that he put the bricks underneath the chair. The MD also stated that the other environmental concerns observed were not in the work order book either.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of a Quarterly MDS, dated [DATE], indicated R#38 had no cognitive impairment, with a BIMS score of 14 out of 15. The resident had no mood or behavior issues. A further review of the MDS revealed the resident required minimal assistance for transfers and extensive assistance for toilet use and personal hygiene. The MDS indicated the resident was occasionally incontinent of urine and always continent of bowel. Observations on 6/28/22 at 12:43 p.m., 6/29/22 at 9:33 a.m., 6/30/22 at 2:46 p.m., and 7/1/22 at 12:37 p.m., revealed a tube of Preparation H hemorrhoidal cream lying on top of a package of wipes on the bathroom counter in R#38's room. During an interview on 7/1/22 at 12:37 p.m., R#38 stated he/she used the restroom independently and applied the Preparation H him/herself for hemorrhoids. A review of the Care Plan, last revised 4/24/21, revealed R#38 was not care planned to self-administer medications, including creams. A review of the June 2022 Physician's Orders revealed R#38 had diagnoses which included multiple compression fractures of the spine, right hip fracture, chronic pain, and constipation. The resident did not have a diagnosis of hemorrhoids. There was no physician's order for the Preparation H hemorrhoid cream, nor for the resident to self-administer medication. A review of the resident's medical records revealed there was no assessment for the resident to self-administer medication. An interview on 7/1/22 at 10:55 a.m. with Certified Nurse Aide (CNA) OO, revealed she did not know if residents were allowed to self-administer medications. During an interview on 7/2/22 at 9:11 a.m., CNA SS revealed she was unsure if residents were allowed to self-administer medications and she did not know of anyone on the 200 Hall that did. During an interview on 07/02/2022 at 9:23 AM, Registered Nurse (RN) TT revealed residents could self-administer medications if they had a physician's order to do so. She stated they did not do any type of formal assessment, just observations of the resident's ability to perform the task. RN TT stated R#38 would be able to self-administer medications, but she was not aware that the resident was using the Preparation H cream. During an interview on 7/2/22 at 11:03 a.m., the DON revealed she was working on putting a policy together for residents self-administering medications. The DON stated there needed to be an assessment and a physician's order for a resident to be able to self-administer medications. She stated she was not aware R#38 was self-administering medications. During an interview on 7/2/22 at 1:07 p.m., the Administrator stated residents were allowed to self-administer medication if they had a physician's order, it was care planned, and there was nursing oversight. The Administrator stated he was not aware R#38 had medication in his/her room. Based on observations, interviews, and record reviews, the facility failed to ensure assessments were completed to determine residents' ability to self-administer medications safely and accurately for two of two residents (R) (R#59 and R#38) reviewed for medication self-administration. Findings include: During an interview on 6/30/22 at 3:58 p.m., the Director of Nursing (DON) stated the facility did not have a policy on self-administration of medications. 1. A review of a Resident Face Sheet revealed the facility admitted R#59 on 5/30/22 with diagnoses that included Parkinson's disease, epilepsy, and muscle spasms. A review of an admission Minimum Data Set (MDS), dated [DATE], revealed R#59 scored 15 on a Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The resident required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Per the MDS, R#59 had unsteady balance, was able to stabilize only with staff assistance, and used a walker and manual wheelchair for mobility. During an observation and interview on 6/28/22 at 11:14 a.m., there were medication capsules and tablets on the bedside table in R#59's room. There was no staff in the room administering the medications. R#59 stated the capsules and tablets on the bedside table were there so the resident could take them. R#59 stated he/she had been diagnosed with Parkinson's disease for 10 years. During an observation on 6/30/22 at 9:41 a.m., R#59 was sitting on the bed in his/her room. There were multiple white colored capsules and tan tablets on the bedside table, as well as in bottles. A review of R#59's Care Plan, dated 5/30/22, revealed self-administration of medications was not addressed. A review of Physician's Telephone Orders, dated 5/31/22, revealed the resident may keep at bedside and self-administer the following medications: - Suntheanine (an amino acid used for relaxation) one tablet orally at hour of sleep for insomnia - Digest Gold (a digestive enzyme) one capsule orally as needed for digestive issues - Methyl Blue (a thiazine dye) for Parkinson's tremors - B6 Niacin (a B vitamin) one tablet orally every day for supplement - Mucuna 40% (a herbal substance used for the nervous system) one tablet every hour for Parkinson's - Super Omega 3 (fatty acids used to reduce the risk of heart disease and promote healthy skin) one capsule every day for vitamin supplement The Physician's Telephone Orders, dated 5/31/22 also indicated, Order clarification: per resident and family, resident believes in natural and supernatural healing and primarily uses herbal supplements at very regimented times. The order indicated the resident/family/friends were to administer the following: - Bromocriptine (a medication used to treat Parkinson's disease) 2.5 milligrams (mg) three times a day - Ibuprofen 200 mg one tablet orally every two hours - Blue Poppy (a supplement used for sedative and muscle relaxant effects) as needed for insomnia - Liposome two drops orally as needed for nausea - Liniment topically as needed for muscle spasms - Daily Vitamin one tablet daily for supplement The 5/31/22 orders also indicated to discontinue all oral medications and refer to previously written orders for medication. A review of the current Physician's Orders sheet, dated 6/1/22 through 6/30/22 and signed by the physician on 6/11/22, did not include the above orders from 5/31/22. Review of the resident's medical record revealed there was no documented assessment to ensure R#59 was safe to self-administer medications and to keep medications at his/her bedside. During an interview on 6/30/22 at 12:56 p.m., Medical Director JJJ stated the facility did not complete an assessment for R#59 to self-administer medication and for medication to be kept at bedside safely. Medical Director JJJ stated the medication was not being monitored for efficacy. He acknowledged R#59 did not have the medication in a secure area or lock box. Medical Director JJJ stated he would make recommendations to the facility for a policy, assessment and safety for residents who would like to self-administer medications. During an interview on 6/30/22 at 2:42 p.m., Licensed Practical Nurse (LPN) BBB indicated the facility did not have a process or procedure to ensure residents were able to self-administer medication safely. LPN BBB stated R#59 had the bottles in his/her room and they were not locked up. She stated R#59 would tell the nurse when he/she took the medications. She stated R#59 would not allow the nurses to remove the medications from the room. LPN BBB stated the medications were not being monitored. She stated there were numerous potential negative outcomes, to include death, if the resident took too many medications. During an interview on 6/30/22 at 3:58 p.m., the DON revealed she was working on a policy and procedure for residents to self-administer medications. She stated R#59 had a BIMS score that indicated the resident was able to make decisions, but no other assessment was completed to ensure the resident was safe to self-administer medication. She stated R#59 did not have a lock box in the room and would be unable to open the lock box if there was one. The DON stated she did not know what medications R#59 had in the room or when the medication arrived at the facility, possibly within a couple of days from admission. During an interview on 7/1/22 at 2:04 p.m., the Administrator indicated the residents had the right to self-administer medication, but the facility had to ensure safety and have oversight. He stated there should be an assessment or evaluation involved. The Administrator's expectation was that residents self-administered medication properly with the involvement of the physician. He stated a negative outcome would be a resident misused the medication.

Based on interviews, document review, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the facility Administrator and the State Survey Agency for one of two sampled residents (R) (R#4) reviewed for abuse and for one of one staff member (Licensed Practical Nurse BBB) reported as having abusive behaviors towards unidentified residents. Findings include: A review of the facility policy, titled, Alleged Offenses Towards Residents Policy, dated 6/30/18, revealed, Policy: This facility will not tolerate any form of mistreatment, neglect, abuse, or misappropriation of resident property. Definitions: A. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain and/or mental anguish. Investigation, conducting a Thorough Investigation: A. Federal regulation requires that a facility must have evidence that all allegations of abuse, neglect, and exploitation/misappropriation, including injuries of unknown source, are thoroughly investigated. In addition, the facility must take action to prevent further potential abuse while the investigation is in progress. Reporting/Response: A. The facility must ensure that ALL allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property, are reporting immediately to the administrator of the facility, the State Survey Agency and, to other officials in accordance with state law. When Reports Must Be Made: A. All allegations of abuse, neglect, and exploitation/misappropriation, including injuries of unknow source, must be reported. B. If the events that cause reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion. 1. A review of the Resident Face Sheet revealed the facility admitted R#4 with diagnoses which included dementia, anxiety, and congestive heart failure (CHF). A review of the Quarterly Minimum Data Set (MDS) for R#4, dated 3/22/22, revealed a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. R#4 required extensive assistance from staff for transfers and toilet use. The MDS indicated R#4 used a wheelchair as a mobility device. A review of the Care Plan, with last review date of 4/12/22, revealed R#4 was at risk for behavioral symptoms such as being resistant to care. Interventions initiated on 7/5/21 included to allow resident to choose options, avoid power struggles, maintain a calm environment and approach to the resident, and when resident begins to resist care, stop and try the task later. Do not force the resident to do the task. A Complaint or Grievance report, dated 6/3/22, revealed a complaint was filed by the Family of R#4 for an incident that occurred on 6/1/22 at approximately 5:30 p.m. The report indicated the Family of R#4 approached R#4's door and heard R#4 say, Get out of my room. The Family of R#4 opened the door to the resident's room and witnessed a Certified Nursing Assistant (CNA) with their arms up and fist in a ball as if like getting ready to box or hit (R#4). The report indicated the CNAs were told to leave the resident alone as R#4 was not feeling well, per a conversation with the charge nurse. The report indicated the Family of R#4 wanted to know why the CNA was in R#4's room provoking the resident after the CNA was instructed to leave the resident alone. The Family of R#4 also wanted to know what disciplinary action the CNA would receive as This is unacceptable. A statement attached to the Complaint or Grievance report, dated 6//8/22, revealed CNA GGG stated she went into R#4's room to pick up the resident's food tray. She stated R#4 had not eaten so CNA GGG tried to feed the resident and the resident grabbed a hold of the CNA's arm and the CNA was trying to pull away from R#4 when the Family of R#4 entered the room. On 6/29/22 at 8:58 p.m., during an interview with the Family of R#4, they stated on 6/1/22 they witnessed CNA GGG alone in R#4's room with the door closed. The Family of R#4 stated as they reached for the door handle, they heard R#4 say, Get out of here. The Family of R#4 stated R#4 was sitting in their recliner with a food tray in front of them. CNA GGG had their back to the door and had not heard the door open. The Family of R#4 stated when they opened the door CNA GGG was standing in a boxing pose with her fist balled up over R#4 in their recliner saying, come on, come on. The Family of R#4 stated before they could say anything CNA GGG stated she was just playing with R#4 trying to get them to eat. The Family of R#4 stated they immediately asked for a nursing supervisor. The Family of R#4 stated the nursing supervisor Licensed Practical Nurse (LPN) FFF told them the resident had a difficult afternoon and was not in a good mood. R#4 had not wanted to go to the dining room and the nursing supervisor told CNA staff to allow R#4 to dine in their room and leave R#4 alone. The Family of R#4 stated they had wondered why CNA GGG went back into the room when she was told to leave the resident alone. The Family of R#4 stated they felt like R#4 was being provoked and aggravated. The Family of R#4 stated the nursing supervisor indicated they would investigate the concern. The Family of R#4 stated on Friday afternoon (6/3/22) when he came back to the facility to visit again, he asked what had been done about the incident. Social Services VV stated she did not know anything about the incident. The Family of R#4 stated Social Services VV had asked him to fill out a statement about the incident. The Family of R#4 stated they had not gotten any feedback on the incident until the 6/17/22 after threatening to go to the police. The Family of R#4 stated they felt like R#4 was verbally threatened and intimidated. During an interview on 6/30/22 at 2:06 p.m., Social Services Director VV stated the Family of R#4 came to her and stated some days ago he had talked to the nurse about an incident and wanted to know the results of the investigation. Social Services Director VV stated she had not heard about the incident, and she needed to write up the complaint. She stated she went straight to the Director of Nursing (DON) office and turned the complaint into the DON. On 7/1/22 at 7:36 a.m., during an interview with LPN FFF, she stated R#4 had increased agitation that day (6/1/22). LPN FFF stated the Family of R#4 stated CNA GGG was doing something with her elbows bent and fist motioning as if they were boxing. LPN FFF stated she explained to the Family of R#4 the CNA staff had tried to take R#4 to the dining room and the resident had not wanted to go. LPN FFF told staff to leave R#4 alone because the resident was agitated. LPN FFF stated she had not reported the incident to anyone because she thought the Family of R#4 realized things were okay. LPN FFF stated she did not feel like the family was reporting abuse. On 7/1/22 at 7:56 a.m., during an interview with the DON, she stated the Family of R#4 thought CNA GGG was threatening R#4. She stated she spoke to CAN GGG and told her to let R#4 alone when the resident was upset. She stated she moved CAN GGG to a different hall, and CNA GGG did not work with R#4 anymore. She stated CNA GGG told her she was just dancing trying to make R#4 laugh. She stated a complaint form was filled out. She stated if the incident looked like abuse, they reported it to the state. She stated she really did not think it was abuse. During an interview on 7/1/22 at 8:43 a.m., the Administrator stated he did not know about the incident. On 7/1/22 at 9:44 a.m., during an interview with the DON, she stated they reported to the state if the incident was a case of abuse. She stated this incident was not reported to the state. 2. On 6/28/22 at 8:40 p.m., during an interview with Licensed Practical Nurse (LPN) TTT, she stated she had reported having observed LPN BBB have abusive behaviors toward residents. She thought the facility had done their own investigation, but nothing happened. She stated Human Resources Director MMM did not want to report LPN BBB to anyone. An interview was attempted with former DON XXX, but the DON did not return the call. On 6/30/22 at 2:58 p.m., during an interview with Human Resources Director MMM, he stated he was ill in April 2021. He stated Human Resources LLL had done some of the interviews for an abuse investigation. He stated she had some of the interviews, but human resources could not find any other documentation. On 7/1/22 at 9:37 a.m., Human Resources LLL stated LPN TTT came to her with an abuse complaint. She stated she told LPN TTT to write up the complaint and she would give it to the DON. She stated she gave it to the DON. Typed statements from six facility staff (including LPN TTT and LPN BBB) were provided by the facility. The statements were not signed and there was no indication of who obtained the statements. LPN TTT provided a statement on 3/16/21 regarding LPN BBB and her concerns about the way LPN BBB spoke to residents; making degrading and disrespectful comments. A statement from LPN BBB, dated 3/16/21, indicated she denied ever making disparaging remarks about or to a resident. On 7/1/22 at 9:44 a.m., during an interview with the DON, she stated she was unsure if the complaint was investigated. She stated she was not the DON at the time. She was unable to provide documentation that the report of abuse was reported to the state. She stated the facility reported to the state if it was a case of abuse.

Based on interviews, document review, and review of the facility policy, the facility failed to ensure allegations of abuse were thoroughly investigated for one of two sampled residents (R) (R#4) reviewed for abuse and for one of one staff member (Licensed Practical Nurse [LPN] BBB) reported as having abusive behaviors towards unidentified residents. Findings include: 1. A review of the facility policy, titled, Alleged Offenses Towards Residents Policy, dated 6/30/18, revealed, Policy: This facility will not tolerate any form of mistreatment, neglect, abuse, or misappropriation of resident property. Definitions: A. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain and/or mental anguish. Investigation, conducting a Thorough Investigation: A. Federal regulation requires that a facility must have evidence that all allegations of abuse, neglect, and exploitation/misappropriation, including injuries of unknown source, are thoroughly investigated. In addition, the facility must take action to prevent further potential abuse while the investigation is in progress. 2. Document the details of the incident. 3. Document the description of the injury. 4. Develop a list of known and possible witnesses to the alleged incident. Interview and obtain signed statements from staff, residents, and/or visitors or anyone who has, or might have, knowledge of the incident that is being investigated. Interview staff who cared for the resident(s) at the time of the alleged incident. Interview staff on other shifts who might have seen or heard anything. 8. Describe any action(s) taken by the facility to protect resident(s) and to prevent a possible reoccurrence during the investigation. 1. A review of the Resident Face Sheet revealed the facility admitted R#4 with diagnoses which included dementia, anxiety, and congestive heart failure (CHF). A review of the Quarterly Minimum Data Set (MDS) for R#4, dated 3/22/22, revealed a Brief Interview for Mental Status (BIMS) score of t,wo indicating severely impaired cognition. R#4 required extensive assistance from staff for transfers and toilet use. The MDS indicated R#4 used a wheelchair as a mobility device. A review of the Care Plan, reviewed 4/12/22, revealed R#4 was at risk for behavioral symptoms such as being resistant to care. Interventions initiated on 7/5/21 included to allow resident to choose options, avoid power struggles, maintain a calm environment and approach to the resident, and when resident begins to resist care, stop and try the task later. Do not force the resident to do the task. A Complaint or Grievance report, dated 6/3/22, revealed a complaint was filed by the Family of R#4 for an incident that occurred on 6/1/22 at approximately 5:30 p.m. The report indicated the Family of R#4 approached R#4's door and heard R#4 say, get out of my room. The Family of R#4 opened the door to the resident's room and witnessed a certified nursing assistant (CNA) with their arms up and fist in a ball as if like getting ready to box or hit (R#4). The report indicated the CNAs were told to leave the resident alone as R#4 was not feeling well, per a conversation with the charge nurse. The report indicated the Family of R#4 wanted to know why the CNA was in R#4's room provoking the resident after the CNA was instructed to leave the resident alone. The Family of R#4 also wanted to know what disciplinary action the CNA would receive as This is unacceptable. A statement attached to the Complaint or Grievance report, dated 6//8/22, revealed CNA GGG stated she went into R#4's room to pick up the resident's food tray. She stated R#4 had not eaten so CNA GGG tried to feed the resident and the resident grabbed a hold of the CNA's arm and the CNA was trying to pull away from R#4 when the Family of R#4 entered the room. On 6/29/2022 at 8:58 p.m., during an interview with the Family of R#4, they stated on 6/1/22 they witnessed CNA GGG alone in R#4's room with the door closed. The Family of R#4 stated as they reached for the door handle, they heard R#4 say, Get out of here. The Family of R#4 stated R#4 was sitting in their recliner with a food tray in front of them. CNA GGG had their back to the door and had not heard the door open. The Family of R#4 stated when they opened the door CNA GGG was standing in a boxing pose with her fist balled up over R#4 in their recliner saying, come on, come on. The Family of R#4 stated before they could say anything CNA GGG stated she was just playing with R#4 trying to get them to eat. The Family of R#4 stated they immediately asked for a nursing supervisor. The Family of R#4 stated the nursing supervisor told them the resident had a difficult afternoon and was not in a good mood. R#4 had not wanted to go to the dining room and the nursing supervisor told CNA staff to allow R#4 to dine in their room and leave R#4 alone. The Family of R#4 stated they had wondered why CNA GGG went back into the room when she was told to leave the resident alone. The Family of R#4 stated they felt like R#4 was being provoked and aggravated. The Family of R#4 stated the nursing supervisor indicated they would investigate the concern. The Family of R#4 stated on Friday afternoon (6/3/22) when he came back to the facility to visit again, he asked what had been done about the incident. Social Services VV stated she did not know anything about the incident. The Family of R#4 stated Social Services VV had asked him to fill out a statement about the incident. The Family of R#4 stated they had not gotten any feedback on the incident until the 17th of June after threatening to go to the police. The Family of R#4 stated they felt like R#4 was verbally threatened and intimidated. During an interview on 6/30/22 at 2:06 p.m., Social Services Director VV stated the Family of R#4 came to her and stated some days ago he had talked to the nurse about an incident and wanted to know the results of the investigation. Social Services Director VV stated she had not heard about the incident, and she needed to write up the complaint. She stated she went straight to the Director of Nursing (DON) office and turned the complaint into the DON. On 7/1/22 at 7:36 a.m., during an interview with LPN FFF, she stated R#4 had increased agitation that day (6/1/22). LPN FFF stated the Family of R#4 stated CNA GGG was doing something with her elbows bent and fist motioning as if they were boxing. LPN FFF stated she explained to the Family of R#4 the CNA staff had tried to take R#4 to the dining room and the resident had not wanted to go. LPN FFF told staff to leave R#4 alone because the resident was agitated. LPN FFF stated she had not reported the incident to anyone because she thought the Family of R#4 realized things were okay. LPN FFF stated she did not feel like the family was reporting abuse. On 7/1/22 at 7:56 a.m., during an interview with the DON, she stated the Family of R#4 thought CNA GGG was threatening R#4. She stated she spoke to the aide and told her to let R#4 alone when the resident was upset. She stated she moved the aide to a different hall, and CNA GGG did not work with R#4 anymore. She stated CNA GGG told her she was just dancing trying to make R#4 laugh. She stated a complaint form was filled out. She stated if the incident looked like abuse, they reported it to the state. She stated she really did not think it was abuse. She stated the complaint was investigated by the facility. She stated the facility's investigation included speaking with the Family of R#4, interviewing the CNA, and speaking with the hospice nurse. She stated there were no other residents interviewed nor any other staff. On 7/1/22 at 8:43 a.m., the Administrator was notified of the findings, and he stated he did not know about the incident. On 7/1/22 at 9:44 a.m., during an interview with the DON, she stated they investigated if the incident was a case of abuse. 2. On 6/28/22 at 8:40 p.m., during an interview with Licensed Practical Nurse (LPN) TTT, she stated she had reported having observed LPN BBB have abusive behaviors toward residents. She thought the facility had done their own investigation, but nothing happened. She stated Human Resources Director MMM did not want to report LPN BBB to anyone. On 6/30/22 at 8:58 a.m., during an interview with the Administrator, he stated back in March or April 2021 there were two nurses going back and forth arguing. The argument was between LPN BBB and another nurse. He stated he could not recall the specific details on that incident. He stated the former Director of Nursing (DON) had done an investigation on that incident. An interview was attempted with former DON XXX, but the DON did not return the call. On 6/30/22 at 2:58 p.m., during an interview with Human Resources Director MMM, he stated he was ill in April 2021. He stated Human Resources LLL had done some of the interviews for an abuse investigation. He stated she had some of the interviews, but human resources could not find any other documentation. On 7/1/22 at 9:37 a.m., Human Resources LLL stated LPN TTT came to her with an abuse complaint. She stated she told LPN TTT to write up the complaint and she would give it to the DON. She stated she gave it to the DON. Typed statements from six facility staff (including LPN TTT and LPN BBB) were provided by the facility. The statements were not signed and there was no indication of who obtained the statements. LPN TTT provided a statement on 3/16/21 regarding LPN BBB and her concerns about the way LPN BBB spoke to residents; making degrading and disrespectful comments. A statement from LPN BBB, dated 3/16/21, indicated she denied ever making disparaging remarks about or to a resident. There were no statements from residents or any other documentation indicating an abuse investigation was completed. On 7/1/22 at 9:44 a.m., during an interview with the DON, she stated she was unsure if the complaint was investigated. She stated she was not the DON at the time. She was unable to provide documentation that the report of abuse was investigated. She stated the facility investigated if it was a case of abuse. During a follow up interview with the Administrator on 7/1/22 at 10:08 a.m., he stated he knew an investigation was completed, but he was unable to provide the documentation for the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for two of two sampled residents (R) (R#11 and R#23) reviewed for PASRR. Findings include: The facility did not have a policy for the PASRR process but provided a copy of the PASRR User Manual as their policy. 1. Review of a Resident Face Sheet revealed the facility admitted R#11 on 3/27/20 and readmitted the resident 9/9/20 with diagnoses that included major depressive disorder and paranoid personality disorder. A review of the Annual Minimum Data Set (MDS), dated [DATE], revealed R#11 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The resident required extensive assistance for all activities of daily living (ADLs) except eating, for which the resident required set-up help only. A review of R#11's PASRR revealed the Level 1 screening was requested 11/4/11. The facility was unable to provide an updated PASRR Level 1 prior to the resident's admission to the facility on 3/27/20 or readmission on [DATE]. The PASRR Level 1 did not reflect the diagnoses of major depressive disorder and paranoid personality disorder. During an interview on 7/1/22 at 11:58 a.m., Social Worker VV stated she did not know the process for PASRR because she did not do anything with that. She stated the admission Coordinator might know about the PASRR Level 1. During an interview on 7/1/22 at 12:59 p.m., the Director of Nursing (DON) stated she thought the admission Coordinators completed the PASRR Level 1. She stated the PASRR Level 1 was completed prior to admission to the facility because the date was 2011. The DON stated the PASRR was important to get the care the residents needed to stay safe. During an interview on 7/1/22 at 1:27 p.m., admission Coordinator QQQ stated the PASRR Level 1 was to be completed prior to discharge from the hospital. She stated if the resident was admitted from the hospital without a PASRR Level 1, the admissions staff would submit the PASRR Level 1. She stated the date of R#11's PASRR Level 1 did not correspond with the admission date. During an interview on 7/1/22 at 1:41 p.m., Registered Nurse (RN) admission Coordinator RRR stated the initial PASRR Level 1 information was entered into the state website by the discharging facility. She stated that once the resident was admitted to the facility, the PASRR Level 1 was reentered with updated information and a pending number was provided. If the resident was already in the system, then an update had to be completed within 30 days of admission to use the same number. RN RRR stated the PASRR Level 1 for R#11 was an old one and a new PASRR Level 1 should have been completed. During an interview on 7/1/22 at 2:00 p.m., the Administrator stated a PASRR Level 1 had to be completed within 30 days of admission. He stated the admissions team should have reviewed the information. The Administrator stated a potential negative outcome could be the residents' needs might not be met. 2. Review of a Resident Face Sheet revealed the facility admitted R#23 on 10/31/19 and readmitted the resident 11/11/21 with diagnoses that included major depressive disorder, anxiety disorder, and schizoaffective disorder - bipolar type. A review of the Quarterly MDS, dated [DATE], revealed R#23 had active diagnoses of anxiety disorder, bipolar, and schizoaffective disorder. According to the MDS, the resident had a BIMS score of 12, indicating that the resident had moderately impaired cognition. A review of R#23's PASRR Level 1 form dated 10/30/19 revealed there were no mental illnesses addressed on the application. During an interview on 7/2/22 at 10:48 a.m., the DON indicated it was her expectation that the resident's mental illness (MI) diagnoses be listed on the PASRR Level 1 application. The DON indicated that moving forward, she would be working closely with the hospital, reviewing residents' charts and medications to make sure the mental illness diagnoses were listed on the PASRR applications. During an interview on 7/2/22 at 11:26 a.m., the Administrator indicated it was his expectation that the resident's PASRR was done timely and accurately.

Based on record review and interviews, the facility failed to provide care according to professional nursing standards for two of four sampled residents (R) (R#133 and R#287) reviewed for falls. Specifically, the facility failed to assess R#133 and R#287 for neurological changes after the residents experienced unwitnessed falls. Findings included: An interview with the Director of Nursing (DON) on 6/30/22 at 1:58 p.m. revealed neurological assessments should be completed for a resident who experienced an unwitnessed fall. 1. A review of R#287's Resident Face Sheet revealed the resident had diagnoses that included vascular dementia and altered mental status (AMS). A review of R#287's 6/22/22 admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severely impaired cognition. Per the MDS, R#287 required extensive staff assistance for transfers, bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated R#287 used a wheelchair as a mobility device. According to the MDS, R#287 had not sustained any falls in the six months prior to admission and had sustained one fall with no injury since admission to the facility. A review of R#287's Care Plan, dated 6/10/22, revealed the facility identified the resident was at risk for falls and developed interventions that included treatment for orthostatic hypotension, implementing an exercise program that targeted gait and balance, increasing staff supervision with intensity based on resident need, and providing individualized toileting interventions based on needs/patterns. A review of a facility report dated 6/25/22, revealed staff found R#287 sitting beside the foot of the resident's bed. The report revealed no one observed the resident fall and the resident was assessed to have no apparent injuries. A review of Skilled Daily Nurses Notes dated 6/25/22 revealed staff documented R#287 had no neurological/muscular problems on the day shift. There was no documented evidence staff assessed the resident's neurological status on the evening or night shift on 6/25/22. During an interview on 7/1/22 at 3:21 p.m., Registered Nurse (RN) KKK stated staff were required to assess residents for 72 hours after a fall. RN KKK stated if a resident had an unwitnessed fall, staff should conduct a neurological assessment and repeat neurological checks every 15 minutes for one hour, every 30 minutes for one hour, and every four hours until neurological checks were completed. On 6/30/22 at 10:22 a.m., an interview with Licensed Practical Nurse (LPN) III, revealed the protocol after a fall was to initiate an incident report, assess the resident, notify the family and physicians, and determine if the resident was hurt or needed to go to a hospital. LPN III stated if the fall was not witnessed, staff tried to determine the cause of the fall and completed a neurological check form. Further interview with the DON on 7/2/22 at 1:58 p.m., revealed there were no documented neurological assessments completed for R#287 following the fall on 6/25/22. During an interview with the Administrator on 7/2/22 at 1:59 p.m., the Administrator confirmed nurses should conduct neurological assessments of a resident after an unwitnessed fall. 2. A review of a Resident Face Sheet revealed the facility admitted R#133 on 9/3/21. A review of a MDS assessment, dated 9/10/21, indicated R#133 had moderate cognitive impairment as evidenced by a BIMS score of 10. A further review of the MDS indicated the resident required limited assistance of one person for their activities of daily living (ADLs), including transfers, ambulation, toileting, and personal hygiene. The MDS indicated the resident had one fall in the month prior to admission, one fall in the 2-4 months prior to admission, and one fall since admission to the facility that resulted in a non-major injury. A review of a Nurse's Note dated 9/5/21 indicated that, around 10:30 p.m., R#133 attempted to get up to use the bathroom and wrapped the sheet off the bed around them, causing them to fall while ambulating. The note indicated the resident hit the right side of their head but wanted to go to the hospital for a scan the following morning instead of that night. The note indicated a head-to-toe assessment was completed with no apparent injury found. The note revealed the resident was considered to be in stable condition. There was no documentation of neurological checks being initiated or completed for a fall with a possible head injury. A further review of Nurses Notes and Skilled Daily Nurses Notes for 72 hours after R#133's fall, from 9/5/21 through 9/8/21, revealed there was no documentation of neurological checks being completed. A copy of R#133's neurological checks for the fall on 9/5/21 was requested from the DON on 7/1/22 but was not provided by the end of the survey. During an interview with RN TT on 7/2/22 at 9:23 a.m., she stated if a resident's fall was unwitnessed then neurological checks should be completed. She stated the neurological checks were documented on a separate form that had specific times when they should be done. RN TT stated neurological checks were important to do to monitor a change in the resident's level of consciousness that could indicate a major problem. During an interview with the DON on 7/2/22 at 11:03 a.m., she stated if a resident had a witnessed fall and hit their head or had an unwitnessed fall, then neurological checks should be completed for 72 hours to monitor for head injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility policy, the facility failed to monitor and maintain hot water at a safe temperature for six of 68 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). Findings include: A copy of the facility's policy on monitoring hot water temperatures was requested from Maintenance CC on 6/29/21 at 11:28 a.m. Maintenance CC returned at 12:01 p.m. and stated the facility did not have a policy on monitoring hot water temperatures. The facility document, Hot Water Temps, dated 4/19/22, May 2022, and June 2022 were reviewed. The review of the Hall Temps log for April 2022, May 2022, and June 2022 indicated the acceptable range was 95-105 degrees F. Further review of the log revealed no temperatures over 108.1 degrees F were recorded. Observations done on 6/28/22 revealed the following hot water temperatures: - At 9:38 a.m. the temperature of the sink water in the adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] was 121.2 degrees Fahrenheit (F). - At 10:02 a.m. the temperature of the sink water in the bathroom for room [ROOM NUMBER] was 130.2 degrees F. - At 10:03 a.m. the temperature of the sink water in the bathroom for room [ROOM NUMBER] was 120.9 degrees F. During an interview on 6/28/22 at 10:04 a.m. with R#37, the resident complained of the water temperature being too hot sometimes but denied any burns. A review of the Quarterly MDS dated [DATE] revealed R#37 had a BIMS score of 15 out of 15. During an interview with Maintenance Director (MD) BB on 6/28/22 at 1:50 p.m., he stated they had to adjust the water heaters monthly based on the readings. MD BB stated there were waterless tanks for every two rooms that were turned on by pressure, so if one side had the hot water on and the other room turned theirs on, they would get automatic hot water that could be hotter than normal, depending on which side the tank system was on. He stated he had been at the facility for over 15 years and the facility had had trouble with the water temperatures for years. He stated he previously had to do frequent water checks on the same rooms identified above because of the same issues. MD BB had a thermometer that was checked for accuracy by placing it in a cup of ice water. The temperature read 31.1 to 33.7 degrees F after holding for 20 seconds. MD BB then used the thermometer to verify each of the temperature readings above, each time allowing the temperature to hold for 20 seconds. MD BB adjusted each water heater after the temperature was verified and he set them to temperatures less than 105 degrees F. During a second interview with MD BB on 6/29/22 at 9:20 a.m., he stated the water must be on in both rooms at the same time to equal out the pressure to regulate the temperature of the water. He stated this had been an on-going problem for 10 years. He stated they used to have two-gallon tanks for two rooms to service four residents. He stated they only had a few of those left. He stated, As soon as you turn the water on those tanks they run out of hot water. He stated it made it hard to keep an endless supply at the right temperature. MD BB could not state what the regulatory temperature was. He said he thought it was 118-120 degrees F. Observations of Maintenance CC taking water temperatures in resident bathrooms with MD BB on 6/29/22 revealed the following: - At 9:29 a.m. the temperature of the sink water in the bathroom of room [ROOM NUMBER] was 138.1 degrees F. It took 20 minutes for the temperature to be adjusted to less than 105 degrees F. - At 9:50 a.m. the temperature of the sink water in the bathroom of room [ROOM NUMBER] was 124.1 degrees F. Maintenance CC adjusted the temperature to below 105 degrees F. During another interview with Maintenance CC on 6/29/22 at 4:30 p.m., he stated he was responsible for checking the water temperatures once a month. He stated he did not know what the regulatory temperature was supposed to be but stated he just tried to keep it between 95-105 degrees F. He stated when he was filling out the temperature logs, if a water temperature were out of range, he would adjust the water heater until the temperature was in an acceptable range and then document what the reading was after it had been adjusted. He stated he did not log the high temperatures. During an interview with Registered Nurse (RN) TT on 7/2/22 at 9:23 a.m., she stated she was not aware of any issues with hot water. She stated there had been no complaints and no burns. She stated the hot water tanks were adjusted by maintenance and was unsure how often the water temperatures were being checked. During an interview with Licensed Practical Nurse (LPN) UU on 7/2/22 at 10:06 a.m., she stated she had noticed hot water in some of the sinks but had never been burned or knew of any residents that had gotten burned. She stated she was unsure how it was adjusted but that it was probably done by maintenance. She stated she was unsure how often the water temperatures were checked. The LPN did not state if she had reported this to maintenance. During an interview with the Director of Nursing (DON) on 7/2/22 at 11:03 a.m., she stated she was made aware of the hot water temperatures after they were identified during the survey but stated she did not know there was an issue. She stated they usually got complaints about cold water. She stated she was unsure if anything was being done about the hot water readings. During an interview with the Administrator on 7/2/22 at 1:07 p.m., he stated he was made aware of the hot water temperatures identified during the survey. He stated it had not been an issue in the past and could not explain why the high temperatures were found during the survey. He stated surveillance gaps had been noted, but they talked about hot water in QA (quality assurance) meetings and no issues had been identified. He stated the maintenance staff were supposed to check the temperatures throughout the facility, but he had not followed up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for two of three residents (R) (R#7 and R#37) reviewed for beneficiary protection notification review. Findings include: A policy related to SNF ABN was requested from the facility, but the facility did not have a policy. 1. A review of the Resident Face Sheet revealed the facility admitted R#7 on 3/28/22 with diagnoses which included dysphagia, oropharyngeal phase, slurred speech, and epilepsy. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed R#7 had a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating severe cognitive impairment. A review of the Notice of Medicare Non-Coverage (NOMNC) revealed skilled nursing and rehabilitation services ended 4/28/22 and the resident would continue living in the facility. The SNF ABN for R#7 was requested from the facility and the facility was unable to locate the form, which indicated the facility did not present the SNF ABN to R#7's representative. Therefore, the resident and representative were not notified of the charges or financial responsibility had they chosen to continue receiving therapy. 2. A review of the Resident Face Sheet revealed the facility admitted R#37 to the facility on 4/25/22 with diagnoses which included chronic pain, unspecified heart failure, generalized osteo arthritis, and transient ischemic attack (TIA). The resident still resided in the facility. A review of the Quarterly MDS, dated [DATE], revealed R#37 had a BIMS score of 15, indicating intact cognition. A review of the NOMNC revealed skilled nursing and rehabilitation services ended 5/13/22. The SNF ABN for R#37 was requested from the facility and the facility was unable to locate the form, which indicated the facility did not present the SNF ABN to R#37. Therefore, the resident was not notified of the charges or financial responsibility had they chosen to continue receiving therapy. During an interview with R#37 on 7/01/22 at 11:35 a.m., the resident stated they could not recall discussing the SNF ABN form. During an interview on 6/29/22 at 4:10 p.m. with MDS Nurse and Medicare Manager HHH, she stated the Business Office Manager (BOM) was responsible for presenting the SNF ABN to the residents. She said the BOM had passed away recently, and she did not know where to look for the SNF ABN in order to determine if they had been presented. During an interview on 7/1/22 at 1:20 p.m., the Director of Nursing (DON) stated she was unaware that the SNF ABN had to be signed. She stated she would ask MDS Nurse and Medicare Manager HHH to discuss and ask for signatures in the future. The DON stated it was important for the residents to receive the SNF ABN, so they knew the cost of the services if they chose to continue receiving services. The form also informed residents that services were ending and assisted with finalizing discharge planning. During an interview on 7/1/22 at 2:09 p.m., the Administrator stated the BOM had passed away and he did not have information about the SNF ABN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to have an effective infection control program and failed to implement measures to prevent the potential spread of COVID-19 throughout the facility, in accordance with guidance from the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS). Specifically, the facility failed to: - Ensure visitors entering the facility were screened for signs and symptoms of COVID-19 prior to entering the facility. - Ensure proper personal protective equipment (PPE) was used during an outbreak of COVID-19. - Ensure there was proper social distancing during communal activities and dining. This had the potential to affect all residents and staff in the facility. As of 6/28/22, the facility census was 82 and there were 98 staff members. Findings include: 1. A review of the facility's policy titled Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, indicated 13. Visitors will be screened for international travel within the last 14 days to restricted countries, signs or symptoms of a respiratory infection such as fever, cough and sore throat, and contact with someone with confirmed or under investigation for COVID-19. 14. Visitors with known or suspected COVID-19 will be restricted from entering the facility. 15. The facility will educate visitors to follow respiratory hygiene and cough etiquette precautions. On 6/28/22 at 11:32 a.m., visitors were observed entering the building and screening themselves. The visitors were observed checking their temperatures and completing the screening questions. No facility staff was in the screening area. A review of the Family Symptom Screening COVID-19 forms from 6/30/22 through 7/2/22 revealed 10 visitors were allowed to enter the facility without either taking and documenting their temperature or documenting a review of symptoms for COVID-19. During an interview on 6/30/22 at 8:06 a.m. with the Director of Nursing (DON), she stated visitors and staff screened themselves most of the time because they were not able to hire someone to screen everyone and they did not have the staff to do it. During an interview on 7/2/22 at 9:23 a.m. with Registered Nurse (RN) TT, she stated the nursing supervisors monitored the visitors' screening every time someone came in the door. She stated the screening sheets should not have any blanks. She stated if she noticed the visitor left a blank, she would get them to answer the question. She stated she did not know of any visitors that refused to screen when they came in. She stated she was not always at the desk though or would get busy with something else, so the screening was not perfect. On 7/2/22 at 10:20 a.m. a visitor was observed screening themselves into the facility. During an interview on 7/2/22 at 11:03 a.m. with the DON, she stated screening was monitored by the charge nurse and the day supervisor as much as they were able. She stated there should not be holes in the documentation, but she stated they could not make the visitor fill them in. She stated they tried to make people follow the rules but when they asked them the screening questions, they would get upset. She stated the only other option would be to close the building, so they just did the best they could. During an interview on 7/2/22 at 1:07 p.m. with the Administrator, he stated nursing was supposed to be monitoring the screening and it should be monitored at all times. He stated if there was an issue such as the visitor not taking their temperature, the staff should stop them, and it should be addressed right away. He stated there should be no blanks on the screening forms. 2. A review of the facility's policy titled Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, indicated, Personal Protective Equipment (PPE) includes: Gloves, Gown, Respiratory Protection and Eye protection that covers both the front and sides of the face. The facility's policy did not address source control measures to be implemented for unvaccinated staff, such as the need to wear an N-95 mask. The policy did not address what PPE should be worn throughout the facility during an outbreak. Upon entrance to the facility on 6/28/22 at 8:45 a.m. the Director of Nursing (DON) stated the facility had one positive COVID-19 resident (R) (R#234) that was in isolation on the 600 Hall. During an interview with the DON on 6/30/22 at 8:06 a.m., she stated the facility had another resident (R#50) test positive for COVID-19 on the evening of 6/29/22. During an interview with the DON on 6/30/22 at 3:11 p.m., she stated R#50's family called the facility because they had tested positive for COVID-19, and they wanted the resident tested. She stated the resident's roommate was also tested and was negative. She stated they tested all residents and some of the staff for COVID-19 that day in response to the positive case they identified the previous evening and had another resident test positive, R#42. During an interview on 7/1/22 at 8:34 a.m. with Licensed Practical Nurse (LPN) KK, she was wearing a surgical mask and no eye protection. LPN KK stated she was not aware she had to wear an N-95 or eye protection. A review of the COVID-19 Staff Vaccination Status for Providers indicated LPN KK was not vaccinated, and a review of the COVID-19 testing logs revealed she was not up to date with her testing. On 7/1/22 at 8:39 a.m., Activity Director (AD) LL was observed pulling down her mask in the hallway to talk to the resident in room [ROOM NUMBER]. AD LL pulled the mask up, walked into room [ROOM NUMBER], and pulled it down again when she approached the resident who was sitting in their recliner. On 7/1/22 at 8:43 a.m., signage on room [ROOM NUMBER], a room of a positive COVID-19 resident, indicated the resident was on contact isolation. The sign indicated masks should be worn if splashing of bodily fluid (urine) might occur. This same signage was posted on the door to room [ROOM NUMBER], another isolation room. The signage on both rooms did not indicate the resident was on droplet precautions as needed for COVID-19 positive patients. On 7/1/22 at 8:45 a.m., R#6 was observed not wearing a mask and propelling themself down the hallway past an isolation room. The resident passed by multiple staff members, and no one tried to get the resident to put on a mask. On 7/1/22 at 8:47 a.m., the resident from room [ROOM NUMBER] was sitting in the hallway in their wheelchair with their mask under their chin talking to an unidentified staff member, and they did not ask the resident to pull up their mask. On 7/1/22 at 9:02 a.m., Certified Nurse Aide (CNA) MM approached room [ROOM NUMBER] (an isolation room) and put a gown on and then gloves and walked into the room without putting on any eye protection. There was a pair of goggles hanging on the wall outside the door in the hallway above the personal protective equipment (PPE) cart. There was also a pair of safety glasses on top of the PPE cart. Observations revealed none of the staff were wearing eye protection. On 7/1/22 at 9:09 a.m., CNA NN pushed an unidentified resident down the 300 Hall past the COVID-19 positive room. The CNA was wearing a surgical mask and was not wearing eye protection, and the resident had their mask below their chin. During an interview with CNA OO on 7/1/22 at 10:55 a.m., she stated they did not have to wear eye protection if they were not in a COVID-19 room. She stated she was fit tested for an N-95 mask but did not wear it because she did not provide care for any COVID-19 positive residents. She stated they were notified about COVID-19 updates about two weeks ago. On 7/1/22 at 12:04 p.m., LPN KK was observed in the dining room wearing a surgical mask with no eye protection. During an interaction with the Administrator on 7/1/22 at 3:02 p.m., he was wearing a surgical mask and no eye protection. During an interview on 7/2/22 at 8:55 a.m. with Physical Therapy Assistant (PTA) RR, she was wearing a surgical mask and no eye protection. During an interview on 7/2/22 at 9:11 a.m. with CNA SS, she was wearing a surgical mask and no eye protection. She stated she did not care for any COVID-19 residents, so she did not have to wear the N-95 mask or eye protection. She stated they got some kind of training every two weeks on payday, but it was not anything new. During an interview on 7/2/22 at 9:23 a.m. with RN TT, she was wearing a surgical mask and no eye protection. RN TT stated they were not considered to be in outbreak unless they had four positive residents. She stated when they were in outbreak, they all wore N-95 masks and goggles, and they kept the door to the facility locked, so anytime anyone came to the door, the staff had to personally screen them and let them it. She stated the last training they had on COVID-19 was during their massive outbreak, but she could not remember when that was. During an interview on 7/2/22 at 10:06 a.m. with LPN UU, she was wearing a surgical mask and no eye protection. LPN UU stated she worked night shift and did not deal with visitors or screening. She stated the facility was not in an outbreak. She stated an outbreak was when more than 10% of the residents on the hall were sick. She said if they were in an outbreak, they used to put them in a particular area of the facility, called the bubble, to isolate them. She stated now they just isolated the resident in a private room. She stated they should wear an N-95 mask, gown, and eye protection when they were in the rooms. She stated they were trained on COVID-19 updates about two weeks ago, but the training was nothing new. During an interview on 7/2/22 at 10:40 a.m. with CNA MM, she stated she wore a shield, gown, gloves, and N-95 mask when entering a COVID-19 isolation room. She stated she wore the N-95 mask yesterday because she was caring for COVID-19 positive residents but was not wearing one that day because she was not assigned to those rooms. She stated they got training whenever they got their paychecks. She stated she was not fit tested for the N-95 mask but was required to wear it. During an interview on 7/2/22 at 11:03 a.m. with the DON, she stated they got updated information about COVID-19 from the Centers for Disease Control (CDC) and the health department. She stated the last contact with the local health department was months ago, probably January of this year. She stated the Administrator was the one that contacted them with any new cases, and she had not had any contact with them recently. The DON stated training on COVID-19 was done with every infection control in-service every three months. She stated it contained the updated information and guidelines. She stated they also discussed updates in the monthly infection control meeting and then each member was to update their staff. She stated since they were in outbreak status, the residents that were isolated had their trash collected and bagged to take out through the back, signs were put up, and the staff should use gowns, gloves, N-95 mask, and goggles. She stated anyone working on the halls with isolation rooms should be wearing N-95 masks also. During an interview on 7/2/22 at 1:07 p.m. with the Administrator, he stated he was unsure when the local health department had last been updated. He stated the DON did it. The Administrator stated he was not aware they were supposed to be wearing eye protection throughout the facility or N-95 masks. 3. A review of the facility's policy titled Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, indicated, In the event of a facility outbreak, institute outbreak management protocols: Group activities will cease on the unit including dining, activities, and therapy. On 7/1/22 at 11:07 a.m., eight residents were in the day room, some only three to four feet apart. Six of the residents were not wearing masks or were wearing them inappropriately. On 7/1/22 at 12:05 p.m., 24 residents were sitting in the dining room, not social distancing, less than two feet apart from each other. They were in groups of five to six. There were seven residents on the assistance side of the dining room. Two of the residents were sitting side by side; the other residents were social distanced. On 7/2/22 at 8:53 a.m., nine residents were sitting in the Rose day room in front of the nurse's station. Some of the residents were less than four feet apart from each other, and four of the residents were not wearing masks or were wearing them inappropriately. A review of the Activities Resident Roster Form, dated 6/28/22, revealed there were three unvaccinated residents or residents with unknown vaccination status with 17 other residents during the first activity listed. Three unvaccinated/unknown vaccination status residents attended the second activity listed with five other residents. Three unvaccinated residents attended the third activity listed with eight other residents. A review of the Activities Resident Roster Form, dated 6/29/22, revealed there were two unvaccinated residents with nine other residents during the first activity listed. Two unvaccinated residents attended the second activity listed with nine other residents. During an interview on 7/1/22 at 12:11 p.m. with Activity Director (AD) LL, she stated she was told they could have activities if the residents wore their masks. On 7/2/22 at 10:20 a.m., nine residents were sitting in the day room. Five of the residents were not wearing masks or were wearing them inappropriately. A staff member did apply a mask to one of the residents not wearing one.

Based on interviews and facility document and policy review, the facility failed to inform residents, resident representatives, and/or families of confirmed COVID-19 cases in the facility, along with mitigating actions, in a timely manner. This had the potential to affect all residents in the facility. The facility census was 82. Findings include: A review of an undated policy titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), revealed no policies or procedures related to COVID-19 notifications being made to residents, representatives, and/or families. A copy of the facility's policy for COVID-19 notifications was requested from the Director of Nursing (DON) on 7/1/22 at 12:00 p.m. but was not provided by the end of the survey. During an interview with the DON on 6/29/22 at 8:36 a.m., she stated sometimes the facility notified family members of the facility's COVID-19 status by letter or during visitation. She stated she was not aware that residents, resident representatives, and/or families had to be informed by 5:00 p.m. the following day. On 6/30/22 at 2:30 p.m., the Administrator provided a handwritten list indicating the list contained the names of the facility's positive COVID-19 cases in the last 30 days. The list included the date, resident name and room number, or staff position. The list indicated positive cases of COVID-19 were identified on 5/20/22, 5/22/22, 5/25/22, and 6/22/22, totaling four cases. Proof of notification for these positive cases was requested from the facility on 7/1/22 at 8:30 a.m. but was not provided by the end of the survey. During an interview with the DON on 6/30/22 at 8:06 a.m., she stated the facility had another resident test positive for COVID-19 on the evening of 6/29/22. During another interview with the DON on 6/30/22 at 3:11 p.m., she stated staff tested all residents for COVID-19 that day in response to the positive case they identified the previous evening and identified another positive test result for a resident. Proof of notification for these positive cases was requested from the facility on 7/1/22 at 8:30 a.m. The facility provided a resident census indicating COVID-19 notifications were done on 6/30/22 and 7/1/22 to residents' representatives and/or families with the name of the person contacted. There was no indication the residents had been notified of the COVID-19 status in the facility. During an interview on 7/1/22 at 8:51 a.m. with a family member of Resident (R) #287, the family member stated he/she was not aware of the COVID status in the facility. The family member stated he/she was at the facility every day, and no one had said anything. The family member stated he/she had not received any type of notification of the COVID-19 status of residents or staff. During an interview on 7/1/22 at 10:58 a.m. with a family member of R#10, the family member stated he/she was notified by phone the previous day that the facility had one positive case in the facility. The family member stated he/she thought it was really strange that they received a phone call when they never had before. During an interview on 7/1/22 at 11:17 a.m. with R#45, they stated no one had told them about the COVID status in the facility. R#45 stated one of their family members told them they were notified that there were two positive COVID-19 cases in the building. During an interview on 7/1/22 at 12:11 p.m. with Activity Director (AD) LL, she stated that nursing staff should be notifying the residents and their families of the COVID-19 status in the facility. She stated she was not part of that task. During an interview on 7/1/22 at 3:02 p.m. with the Administrator, he stated he was unsure if notifications were done in May 2022 and would have to check on it. During an interview on 7/2/22 at 9:23 a.m. with Registered Nurse (RN) TT, she stated the facility notified the family of the residents who tested positive for COVID-19, but not anyone else. She stated such notifications should be documented on nursing notes. She stated the facility did not inform the residents. RN TT stated she was put in charge of notifying all the residents' families of the current COVID cases in the facility and was not able to get them all done on 6/30/22, so she finished on 7/1/22. She stated she tried to document the notifications in the charts, but she may have missed some since she also had to participate in four admissions. During an interview on 7/2/22 at 11:03 a.m. with the DON, she stated that notifications were occurring but were not documented. She stated the nurses called and gave reports to the families of the COVID positive residents, but not other resident families. During an interview on 7/2/22 at 1:07 p.m. with the Administrator, he stated residents had not been notified of the positive COVID-19 cases because they would get really paranoid. The Administrator stated staff had been calling the families to notify them of the current COVID-19 cases, but they were not previously doing the notifications, and visitors were not being notified at that time.

Based on record review, policy review, and interviews, the facility failed to ensure all facility staff, including contract staff, were vaccinated for COVID-19 or had an exemption in place. Specifically, the facility's vaccination rate was 98.5%. The facility also failed to have policies and procedures in place for the COVID-19 vaccine. This had the potential to affect 82 residents and 98 staff. Findings include: A review of the facility's policy titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, revealed no policies or procedures related to the COVID-19 vaccine or its requirements. A copy of the facility's policy for COVID-19 vaccinations for residents and staff was requested from the Director of Nursing (DON) on 7/1/22 at 12:00 p.m. and was not provided by the end of the survey. A review of the facility's COVID-19 Staff Vaccination Status for Providers revealed the facility had a total of 132 staff, including contract staff, and 119 were completely vaccinated, 11 had exemptions, and two staff members were only partially vaccinated. These two staff members were Certified Nurse Aide (CNA) WW and CNA XX (agency). A review of the proof of vaccination from the pharmacy for Certified Nurse Aide (CNA) WW indicated they received their first dose of a two dose vaccine series on 1/5/21. No second dose was recorded. A review of the COVID-19 Vaccination Record Card for CNA XX indicated they received their first dose of a two dose vaccine series on 2/1/22. No second dose or boosters were recorded. During an interview with the DON on 7/1/22 at 10:40 a.m., she stated the facility did not really have any policies regarding COVID-19. They just reviewed the current guidelines during their monthly infection control meeting and did updates that way. The DON was interviewed again on 7/2/22 at 11:03 a.m. and stated they did not have a policy on the COVID-19 vaccination; it was dictated by the president. The DON stated CNA WW received their first vaccination and had an appointment to get their second dose, but the DON did not know when it was scheduled. During an interview with the Administrator on 7/2/22 at 1:07 p.m., he stated they could not find their policies on COVID-19 vaccinations. The Administrator stated he was not aware there were staff that were only partially vaccinated. He stated it was each department heads responsibility to ensure their staff were vaccinated.

Based on staff interviews and document review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the resident population during day-to-day operations and emergencies. Findings included: A review of a Facility Assessment Tool, dated 2/8/22, revealed it did not include the following: -The facility's resident population, the number of residents, and the facility's resident capacity. -The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population. -The staff competencies that were necessary to provide the level and types of care needed for the resident population. -The physical environment, equipment, services, and other physical plant considerations that were necessary to care for this population. -Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. -The facility's resources including, but not limited to, all buildings and/or other physical structures and vehicles. -Equipment (medical and non-medical). -Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies. -All personnel, including managers, staff (both employees and those who provided services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. -Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. -Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. -A facility-based and community-based risk assessment, utilizing an all-hazards approach. During an interview on 7/2/22 at 10:46 a.m., the Administrator and the Director of Nursing (DON) indicated they were not aware the facility was required to conduct and document a facility-wide assessment.

Based on document review, policy review, and interviews, the facility failed to designate at least one qualified individual as the infection preventionist (IPs) responsible for the facility's infection prevention and control program (IPCP). The failed practice had the potential to affect all residents who resided in the facility. As of 6/28/22, the facility census was 82. Findings included: A review of the facility's policy titled Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, revealed no information related to the requirement for an IP. A review of the facility's IPCP revealed the facility had not designated at least one qualified individual as the IP. During an interview on 7/2/22 at 3:08 p.m., the Director of Nursing (DON) stated she had not completed any specialized training in infection prevention and control. She stated no one in the facility had been educated or certified to be the IP at the facility. During an interview on 7/2/22 at 3:10 p.m., the Administrator stated he thought the DON was certified as an IP. He indicated he was not aware the facility did not have a qualified IP, and the facility needed to get one as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to perform routine and outbreak COVID-19 testing for all staff and residents as per guidelines from the Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH. Specifically, the facility failed to: - Identify an outbreak of COVID-9 in the facility after a resident tested positive to ensure broad-based outbreak testing or contact tracing was immediately conducted for residents and staff; and - Perform routine COVID-19 testing per current guidelines when the facility was in a county with a high community transmission rate. This had the potential to affect all staff and residents in the facility. As of 6/28/22, the facility census was 82 and there were 98 employees. Findings include: A review of the facility's policy titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), undated, revealed no policies or procedures related to testing residents and staff for COVID-19. A copy of the facility's policy for COVID-19 testing was requested from the Director of Nursing (DON) on 7/1/22 at 12:00 p.m. and was not provided by the end of the survey. 1. Review of the CMS-QSO-20-38-NH memorandum, revised 3/10/22, revealed Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level. Upon entrance to the facility on 6/28/22 at 8:45 a.m., the DON stated the facility had one positive COVID-19 resident (R) (R#234) that was in isolation on the 600 Hall. A review of the facility's COVID-19 testing logs revealed R#234 tested positive for COVID-19 on 6/22/22 during the routine every-other-week testing the facility was conducting at the time for all residents. Further review of the testing logs revealed the facility did not do contact tracing or outbreak testing of all staff after a positive COVID-19 case was identified on 6/22/22 During an interview on 6/29/22 at 8:36 a.m. with the DON, she stated they were testing all residents and staff for COVID-19 every other week. She stated the health department told them not to test anyone that was vaccinated and that if they got two or more cases then they should start testing weekly. During an interview with the DON on 6/30/22 at 8:06 a.m., she stated the facility had another resident (R#50) test positive for COVID-19 on the evening of 6/29/22, indicating they were in outbreak according to the county health department, so they would start testing all unvaccinated staff weekly. She stated the facility had received a call from R#50's family, who visited frequently, to say they had COVID-19 so they tested the resident, and the resident was positive. During another interview with the DON on 6/30/22 at 3:11 p.m., she stated R#50's family called the facility because they had tested positive for COVID-19, and they wanted the resident tested. She stated the resident's roommate was also tested and was negative. She stated they tested all residents and some of the staff for COVID-19 that day in response to the positive case they identified the previous evening and had another resident test positive, R#42. A review of the Daily Staff Assignments for 6/29/22 revealed three unvaccinated staff members (Licensed Practical Nurse [LPN] KK, Certified Nurse Aide [CNA] EEE and CNA WWW) were scheduled to work. A review of the Daily Staff Assignments for 6/30/22 revealed four unvaccinated staff members (LPN KK, CNA WWW, LPN VVV and CNA EEE) and one partially vaccinated staff member (CNA WW) were scheduled to work. 2. A review of the report of COVID-19 level of community transmission available on the CDC COVID-19 Integrated County View site (https://covid.cdc.gov/covid-data-tracker/#countyview) indicated that Cobb County, where the facility was located, was in a red/high transmission rate, indicating that anyone that was not up to date with all COVID-19 vaccine doses was required to test twice a week. The county had been at a red/high transmission rate since 5/9/22. A log of the county transmission rates for the last eight weeks was requested from the facility on 7/1/22 at 8:30 a.m. The Administrator provided a screen shot of the current county positivity rate and not the transmission rate. A review of the Daily Staff Assignments for 6/29/22 revealed out of 39 staff scheduled, 26 staff were not up to date with all COVID-19 vaccination doses and three were unvaccinated. A review of the Daily Staff Assignments for 6/30/22 revealed out of 38 staff scheduled, 23 staff were not up to date with all COVID-19 vaccination doses, four were unvaccinated, and one was partially vaccinated. Observations on 6/28/22 at 2:30 p.m. revealed a red cart behind the wall between the nurses' stations that was the COVID Cart with testing supplies in it which was taken room to room when they were testing. There was a sign on the cart that indicated COVID-19 testing frequency was bi-weekly unless symptomatic, and the next mass test was 7/4/22. All residents and staff needed to test, even if vaccinated, and the exempt staff needed to test weekly. During an interview on 6/30/22 at 8:06 a.m. with the DON, she was not aware of the current county transmission level. She stated she thought it was low. She was not aware that staff that did not have the COVID-19 booster were not considered to be up-to-date and they needed to be testing these staff members twice a week. During an interview on 7/01/22 at 10:55 a.m. with Certified Nurse Aide (CNA) OO, she stated she was being tested every two weeks at the facility. CNA OO stated they did not know what outbreak meant. She stated CNAs tested her, but the nurse would sign off on it. A review of the vaccine matrix revealed CNA OO was not up to date with all COVID-19 vaccine doses. During an interview on 7/1/22 at 12:11 p.m., Activity Director (AD) LL stated one positive resident did not mean they were in outbreak, but since they had three positive residents, they were in an outbreak. She stated the staff and residents were being tested every two weeks. She stated she had last tested on [DATE]. During an interview on 7/2/22 at 9:11 a.m. with CNA SS, she stated they were having to be tested for COVID-19 every two weeks since they had a positive case in the facility. During an interview on 7/2/22 at 9:23 p.m., Registered Nurse (RN) TT stated residents were tested upon admission and then weekly. RN TT stated the facility was not considered to be in outbreak until they had four or more cases. During an interview on 7/2/22 at 10:06 a.m. with Licensed Practical Nurse (LPN) UU, she stated she was tested for COVID-19 every other week. She stated they had dates posted when they were supposed to test on the COVID-19 cart. She stated the facility was not in an outbreak. She stated an outbreak was when more than 10% of the residents on the hall were sick. A review of the vaccine matrix revealed LPN UU was not up to date with all COVID-19 vaccine doses. During an interview on 7/2/22 at 10:40 a.m. with CNA MM, she stated she usually tested every two weeks and was tested the previous day on 7/1/22. She stated she was unsure if the facility was in an outbreak and had not been told about more frequent testing. A review of the vaccine matrix revealed CNA MM was not up to date with all COVID-19 vaccine doses. During an interview on 7/2/22 at 11:03 a.m. with the DON, she stated they were doing weekly testing at that time and stated they tested last week and this week. She stated the Administrator checked the list to ensure people were testing appropriately and stated she should be doing it too. She stated testing of staff was done by the restorative aides on day shift, and the nurses on evening and night shifts tested their staff. She stated everyone knew how to do it because they had been doing it for so long that sometimes the staff tested themselves. The DON stated the Administrator kept a log and monitored it. During an interview on 7/2/22 at 1:07 a.m. with the Administrator, he stated residents were tested upon admission, and it was documented on the chart and the master sheet. He stated the master sheet was what he used to report to NHSN (National Healthcare Safety Network). He stated testing was weekly as of this week. He stated they tested last week and then again this week, and each department head was responsible to ensure their staff was testing. He stated the staff were testing themselves, but it was overseen by nursing. The Administrator stated he was keeping a log of the county positivity rates until February when he stopped getting weekly emails about it and it fell off the radar and he had not kept up with it. He was not aware they were supposed to be monitoring the transmission rate; he thought it was the positivity rate. He was not aware of the testing requirements.

Based on interviews, document review, and policy review, the facility failed to develop and implement policies and procedures to ensure each resident and staff member was offered the COVID-19 vaccination and provided with education regarding the benefits, risks, and potential side effects associated with the vaccine prior to such offering. Additionally, the facility failed to maintain thorough medical record and personnel documentation reflecting such education and offerings or the vaccination status of each resident and staff member. This had the potential to affect 82 residents and 98 staff. Findings include: A review of the facility's undated policy titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), revealed no information related to offering the COVID-19 vaccine to residents and staff, educating residents and staff regarding the COVID-19 vaccine prior to such offerings, or documenting these efforts as well as the vaccination status of each resident and staff member. A copy of the facility's policy regarding COVID-19 vaccinations for residents and staff was requested from the Director of Nursing (DON) on 7/1/22 at 12:00 p.m. but was not provided by the end of the survey. A review of the facility's vaccine matrix for residents revealed seven residents were listed with a question mark next to their name indicating their vaccination status was unknown. A review of the facility's vaccine matrix for staff revealed two staff members were only partially vaccinated and did not have pending or approved exemptions. During an interview with the DON on 7/1/22 at 10:40 a.m., she stated the facility did not really have any policies regarding COVID-19. The DON stated the facility simply reviewed current guidelines during monthly infection control meetings for updates. The DON was interviewed again on 7/2/22 at 11:03 a.m. and stated the facility did not have a policy on COVID-19 vaccinations, noting that COVID-19 vaccinations were dictated by the president. During an interview with the Administrator on 7/2/22 at 1:07 p.m., he stated he could not find the facility's policies regarding COVID-19 vaccinations.