**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters or units for two of 12 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the 300 Hall. The deficient practice had the potential to place residents residing in the rooms at risk of living in an unsanitary living environment, and a potential for a diminished quality of life. Findings include: Observations on 6/2/2025 at 11:52 am and 6/4/2025 at 9:15 am in room R304 revealed that the PTAC unit filter displayed a thick gray substance. Observations on 6/2/2025 at 11:48 am and 6/4/2025 at 9:15 am in room R303 revealed that the PTAC unit had black substance with debris inside the unit. During a concurrent observation and interview on 6/4/2025 at 9:23 am, the Maintenance Director confirmed that the PTAC unit filter in room [ROOM NUMBER] had a thick gray substance, and the PTAC unit in room [ROOM NUMBER] had a black and gray substance inside the unit. The Maintenance Director stated the units were cleaned monthly. During an interview on 6/4/2025 at 10:25 am, the Administrator stated the maintenance department should check the PTAC filters and units once a month and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility policy titled A Comprehensive Patients' Rights Program, the facility failed to ensure one of 33 sampled residents (R) (R82) choices of care were honored. This deficient practice had the potential to place R82 at risk of unmet needs and a diminished quality of life. Findings include: Review of the facility policy titled A Comprehensive Patients' Rights Program, reviewed date 12/27/2024, revealed the Intent section stated, This intent of this center to have an effective Patients' Rights program that recognizes that meaningful support of Patient's Rights. We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' rights to make personal choices. We also believe that such a program should include patient, family, and all Associates of the nursing home. Review of R82's electronic medical record (EMR) revealed R82 was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, epilepsy, unspecified, intractable, with status epilepticus, delirium due to known physiological condition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R82's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section E (Behaviors) documented no behaviors were exhibited. Review of R82's Physician Orders revealed no orders for medications to aid with sleep. In an interview on 6/2/2025 at 11:45 am, R82 stated he felt he needed a medication to help him sleep at night. He stated he had informed staff, but had not received a sleep aid medication. In an interview on 6/4/2025 at 9:12 am, R82 stated he had not slept well during the previous night. In an interview on 6/4/2025 at 9:39 am, Licensed Practical Nurse (LPN) GG stated that she was familiar with R82's request for a medication to help him sleep. She stated R82 had asked her about obtaining a medication for sleep a few days prior. She confirmed that the provider was not notified because she got busy and forgot. In an interview on 6/4/2025 at 12:08 am, the Assistant Director of Nursing (ADON) stated that she expected the staff to address a resident's request at the time of the request. She further stated that the nurse should have notified the physician of R82's request for a sleep aid medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure a respiratory therapy mask was properly stored in a manner to prevent contamination for one of 18 residents (R) (R40) receiving respiratory services. This deficient practice had the potential to increase the risks of spreading microorganisms and place R40 at risk for respiratory infections and a diminished quality of life. Findings include: Review of R40's electronic medical record (EMR) revealed diagnoses including, but not limited to, heart failure, unspecified, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow). Review of R40's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R40 was dependent for activities of daily living (ADLs). Section O (Special Treatments, Procedures, and Programs) documented that R40 received oxygen therapy while a resident. Review of R40's Care Plan revealed a care area dated 2/25/2025 of altered breathing patters and included the use of a BiPAP as ordered. Review of R40's Resident Consolidated Order revealed an order dated 3/26/2025 for a Bilevel Positive Airway Pressure (BiPAP) [a non-invasive ventilation used to help with breathing] to be applied at bedtime. Observations on 6/2/2025 at 11:53 am and 6/3/2025 at 9:43 am, in R40's room, revealed R40's BiPAP mask lying on top of the machine on the bedside table and not stored in a protective bag. During a concurrent interview and observation on 6/4/2025 at 9:26 am, Registered Nurse (RN) AA confirmed R40's BiPAP mask was not stored in a protective bag and stated the respiratory masks were typically stored in a protective bag. During an interview on 6/4/2025 at 10:22 am, the Director of Nursing (DON) stated that she expected respiratory masks to be stored in a protective bag when not in use.

Based on observations, staff interviews, and review of the facility's policy titled Labeling and Dating, the facility failed to ensure that expired foods were not available for use. This deficient practice had the potential to place 85 residents who received an oral diet from the kitchen at risk of foodborne illness. Findings include: Review of the facility's policy titled Labeling and Dating, dated April 2024, included, Upon receipt, all items should be inspected and marked with the date it was received into your facility and the date it should be discarded or expired. If the item has a use-by or discard date already printed on it, then you may use this date. During a tour of the kitchen on 6/2/2025 at 9:30 am with the Dietary Manager (DM), the following items were identified: Two jars of grape jelly with an expiration date of 9/25/2024. Two bags of pecan pieces with an expiration date of 4/18/2025. Two bags of chunk light tuna with an expiration date of 5/16/2025. One box of hot cocoa mix with an expiration date of 11/5/2024. Four bags of raspberry gelatin with an expiration date of 4/24/2025. Three bags of cherry gelatin with an expiration date of 4/24/2025. Three bags of strawberry gelatin with an expiration date of 4/24/2025. In an interview on 6/2/2025 at 10:00 am, the Dietary Manager (DM) confirmed the expired food items and stated that expired food items should be discarded on or before the expiration date. In an interview on 6/3/2025 at 11:45 am, Dietary Aide (DA) JJ stated that when staff conducted inventory, they should discard any expired items in storage. In an interview on 6/5/2025 at 8:54 am, the Administrator stated her expectation was for dietary staff to discard food items on or before the expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to ensure a homelike environment as evidenced by slow draining sinks, missing paint from walls and bathrooms, holes in walls, dust buildup in vents, loose sink, brown staining in ceiling, staining on floors, stained privacy curtain, rust on base of overbed table, and missing privacy curtain on one (200 hall) of four halls. Findings include: Observations on 9/15/2023 revealed the following: 1. At 9:26 am in the bathroom of room [ROOM NUMBER] there was a loose sink, panel behind toilet loose with hole showing, dust buildup in vents, and stains in ceiling upon walking in the room. 2. At 9:39 am in room [ROOM NUMBER] behind bed A there was a hole in the wall, staining on privacy curtain for Bed B, and staining on floor at head of bed B. 3. At 11:33 am in room [ROOM NUMBER] there was no privacy curtain for bed A, missing paint from walls in bathroom, dust buildup in vent in bathroom, and buildup on floor at head of bed A. 4. At 12:12 pm in room [ROOM NUMBER] there was missing paint from wall in bathroom, scuff marks throughout the room and bathroom, rusty on over toilet frame, stained privacy curtain for Bed A, and a slow draining sink in the bathroom. 5. At 12:19 pm in room [ROOM NUMBER] the over bed table had rust on the base, slow draining sink in the bathroom, missing paint on wall in bathroom, and buildup on floor in corners of room. During an interview and observation on 9/17/2023 at 9:33 am with Certified Nursing Assistant (CNA) CC and CNA DD, CNA DD confirmed that she was assigned to resident in room [ROOM NUMBER] A. CNA CC and CNA DD both acknowledged the missing privacy curtain for Bed A and reported that the issue should be reported to Maintenance. An environmental tour was conducted on 9/17/2023 at 9:37 am with the Administrator and the Maintenance Director and the following was confirmed: 1. In room [ROOM NUMBER] the over bed table had rust on the base, slow draining sink, missing paint on wall in bathroom, staining on floor in corners of room. 2. In room [ROOM NUMBER] there was missing paint from wall in bathroom, scuff marks throughout room and bathroom, rust on over toilet frame, stained privacy curtain Bed A, and slow draining sink in bathroom. 3. In room [ROOM NUMBER] behind bed A hole in the wall. staining on privacy curtain bed B, staining on floor at head of bed B. 4. In room [ROOM NUMBER], there was no privacy curtain for bed A, missing paint from walls in bathroom, dust buildup in vent in bathroom, and buildup on floor at head of bed A. 5. In the bathroom of room [ROOM NUMBER], loose sink, panel behind toilet loose with hole showing, dust buildup in vents, and stains in ceiling upon entry into room. Patient care was being provided and unable to confirm staining on privacy curtain and staining on floor at the head of Bed A and Bed B. During an interview with the Administrator and Maintenance Director at end of the environmental tour on 9/17/2023 at 9:55 am revealed the Floor tech is responsible for replacing privacy curtains. It was explained that whoever finds a missing or stained privacy curtain should notify the Floor Tech. The Administrator reported that she is acting as the Housekeeping Supervisor due to not having one staffed at this time. There is not a log of tasks for the changing of privacy curtains by the Floor Tech. The Maintenance Director reported that he has been aware of the sink in room [ROOM NUMBER] for about a week. He further reported that he was made aware of the hole in the wall in room [ROOM NUMBER] yesterday. The Administrator reported that the overall environment was in QAPI and on 5/31/2023 developed a plan to address findings at that time. However, the items identified during the environmental tour were not a part of their areas identified to be addressed. Both the Maintenance Director and the Administrator reported that they were not aware of the staining in room [ROOM NUMBER] until the tour today. The Maintenance Director reported that the items identified during the tour are not a part of his monthly tasks but everyone in the building has access to work orders so that they can be addressed. The Administrator reported that everyone can place a work order in the system when an issue has been identified.

Based on observations, interviews, record review, and review of facility policy titled Abuse Prohibition the facility failed to ensure two residents (R57 and R41) of 81 residents were free from verbal abuse by staff. Findings include: Review of policy titled Abuse Prohibition, with a review date of 12/20/2022 revealed the following: Intent: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and/or their property. The procedures herein established standards of practice for protection of patients and for identification and prevention of abuse. 1. Review of the electronic medical record (EMR) for R57 revealed diagnosis that included but not limited to Malignant neoplasm of colon, unspecified hearing loss, unspecified ear, difficulty in walking, not elsewhere classified, and unspecified lack of coordination, Review of Facility documents revealed: Facility Incident Report Form dated 5/24/2023 submitted for staff to resident abuse and the alleged perpetrator being a Dietary Aide (II). The Dietary Aide was suspended pending the investigation. Review of a written statement (not signed or dated) revealed R57 was sitting near double doors near kitchen when the Dietary Aide came out of the kitchen with the food cart yelling at resident. It is reported that the staff member grabbed R57 by the arm causing skin tears and bruising to his left arm. R57 notified Administrator to call police but she had already called. Once present R57 gave a statement to press charges against the Dietary Aide. Witness statement dated 5/24/2023 at 6 pm by Licensed Practical Nurse (LPN) HH revealed R#57 was sitting in the hallway and the Dietary Aide was trying to get around the resident but resident would not move. Dietary Aide attempted to move the resident and R#57 became argumentative and combative (Swinging his arms in a hitting way). The Dietary Aide then grabbed the resident's arms and held them both down towards the resident and he then grabbed his cart and proceeded to move the cart. The cart then bumped R#57's arm, R#57 was continuing to swing his arms in the air, and this resulted in his skin tear and bruises to arms. Review of another undated witness statement revealed that Dietary Aide was heard cursing at R57 and R57 was cursing back. Review of undated statement from Dietary Aide who reported that he asked R57 to move out of hallway, but he did not move. Dietary Aide then reported that R57 became combative, but he did not touch the resident. He reported that the resident began to yell out and the nurse came up the hallway to get R57 and he continued down the hall to deliver the trays. Review of an Initial Note dated 5/24/2023 revealed that R57 received a skin tear after having an altercation with a Food Service Worker. The document continued to reveal that R57 was fighting with a worker as the food cart was passing him in the hallway. The writer reported that she only heard the commotion but did not see the events leading up to the time in which she arrived. During an interview on 9/15/2023 at 12:12 pm with R57, resident presented hard of hearing but had a notepad at bedside for people to write out their questions. The interview was conducted with R57 responding to typed questions. R57 denied having any problems with staff or other residents and he denied being fearful of anyone. R57 did not voice any concerns regarding the care he is currently receiving. 2. Review of the EMR for R41 revealed diagnosis that included but not limited to Type 2 diabetes mellitus with unspecified complications, Major depressive disorder, recurrent, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, complete traumatic amputation at knee level, and right lower leg, sequela. Review of Facility Incident Report Form - dated 7/2/2023 for staff to resident abuse - Agency Nurse name not listed on this document. There were multiple witness statements that included hearing R41 and the Agency Registered Nurse (JJ) involved in a verbal altercation. During an interview on 9/15/2023 at 9:33 am R41 reported that nurses at the facility talk bad to her, and she specifically reported that she had an incident in which an Agency Nurse cursed me out. During a subsequent interview with R41 on 9/16/2023 at 9:00 am R41 reported that there was an incident in May in which a nurse cursed at her so the police were called. R41 further reported that she thinks the facility got rid of that nurse because she has not seen her again. During an interview on 9/16/2023 at 4:15 pm with the Administrator and Director of Nursing (DON) confirmed that verbal abuse was substantiated by staff towards R41 and R57. It was reported that after every facility reported incident (FRI) education is provided to staff. DON confirmed that the agency nurse involved in the incident with R41 last day working at the facility was on 7/2/2023. The Administrator provided a separation notice for the Dietary Aide involved in the incident with R57, with 5/24/2023 being the last day of employment. The reason for separation was Company Rule violation Abuse. During an interview with the DON on 9/17/2023 at 7:25 am it was reported that the staffing agency is provided a copy of education related to abuse whenever it is provided to facility staff, and it is the agency's responsibility to educate their staff. She further reported that the facility does not receive any confirmation from the agency that the education was provided. Lastly, the DON reported that abuse education has not been provided to agency staff upon working at the facility because the agency should be providing the education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R8 diagnoses include but not limited to dementia with behaviors, dysphagia, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Cognition: BIMS score of 99 indicating severe cognitive deficit. Section G-Functional Status: Extensive assistance with bed mobility; total dependence with dressing, eating, personal hygiene and bathing. Section K-Nutrition: Weight loss indicated not prescribed by Physician, receives nutrition >51% via feeding tube. Review of R8's Physicians Orders revealed and order for Diabetisource AC at 55 milliliters (ML) every hour, check every shift, feeding may be held during activities of daily living (ADL) care, therapy, and medication administration. The enteral feeding is not periodic, and the duration of infusion is indefinite. Auto feeding tube flush at 48 ML every hour. Resident may have pureed food and nectar thick liquids upon request during the day. Observation on 9/15/2023 at 8:19 am and 1:14 pm revealed R8 gastrostomy tube feeding set infusing at 50 ml per hour and water flush set at 52 ml per hour. Observation on 9/16/2023 at 8:10 am revealed R8 in bed, bed low position and head of bed elevated. Gastrostomy tube feeding set infusing at 50 ml per hour, bag and water flush set at 52 ml per hour. Interview on 9/16/2023 at 8:29 am with Resident Care Coordinator (RCC) BB revealed feeding pump set at the correct settings. She indicated she just checked it and she reset it according to the order. She indicated it should be checked by the nurse every shift and by the nurse who changes the feeding out at night. Interview on 9/16/2023 at 8:35 am with Licensed Practical Nurse (LPN) AA revealed she checks the feeding pump during her shift. Interview on 9/17/2023 at 8:58 am with the Director of Nursing (DON) indicated she would expect the nurses to check the feeding pump settings every shift and when hanging a new bottle and follow the Physician's Orders. She indicated that not following the recommended settings could contribute to weight loss or dehydration. She indicated the resident has had weight loss but currently her weight is stable. The Registered Dietician was unavailable for interview. Based on observation, record review, staff interview, and review of the facility policy 'Enteral Nutrition Management', the facility failed to provide enteral nutrition and hydration according to physician orders for two of four residents (R) (R65 and R8) receiving tube feeding in the facility. Findings include: 1. Review of the facility policy 'Enteral Nutrition Management' with a review date of 12/30/2022 revealed it is the intent of this center to provide nutritionally complete enteral or parenteral feedings, as ordered by the physician, for the nourishment of patients who are unable to meet estimated nutritional needs orally. Review of the 7/6/2023 Quarterly Minimum Data Set (MDS) Assessment for R65 revealed a BIMS score of 99 indicating severely impaired cognition, no behaviors, is totally dependent upon staff for all Activities of Daily Living (ADL) with two-person physical assist, has active diagnoses of hyponatremia, anxiety, Diabetes Mellitus (DM), is receiving tube feeding, and receives an antipsychotic, antidepressant, antibiotic, and insulin injections 7/7 days. Review of the Physician orders revealed Auto feeding tube flush 38 milliliters (ml) / hour (hr). Diagnosis (Dx): Gastrostomy status modification date: 8/8/2023. Diabetisource AC 55 ml / hr. May be held for ADL (activities of daily living) care, therapy, and medication administration. The enteral feeding is not periodic, and the duration of infusion is indefinite. Dx: Gastrostomy status Start Date: 4/8/2023. Observation on 9/15/2023 at 8:31 am revealed R65 in bed with eyes closed. Bed noted in lowest position. Tube feeding infusing of Diabetisource AC at 55 ml / hr with water flush set at 50 ml every 4 hours. Bag of water is also hanging. Bags are observed labeled using the labels that came with bags and are dated with start time and initials of staff who hung feeding and water. Head of bed is at 35 degrees. Observation on 9/15/2023 at 2:35 pm of R65 resting in bed. Tube feeding continues infusing at 55 ml/hr. Water set on pump continues to infuse at 50 ml every 4 hours. Observation on 9/16/2023 at 7:45 am of R65 revealed she was in bed with eyes closed. Tube feeding infusing at 55 ml per hour and flush infusing at 50 ml every 4 hours. Head of bed up at 30 degrees. R65's mouth was open and appeared moist. Lips were observed to be moist. Observation and interview on 9/16/2023 at 8:05 am with Licensed Practical Nurse (LPN) LPN AA, revealed, upon entrance to the room of R65, she confirmed the feeding pump is infusing the flush at 50 ml every 4 hours. During observation and interview on 9/16/2023 at 8:12 am with LPN AA, and Resident Care Coordinator (RCC) BB, they confirmed the order for the feeding flush for R65 is 38 ml per hour. During this time the RCC stated it is the responsibility of the nurses and herself to ensure feeding pumps are set accurately. Observation and interview on 9/16/2023 at 8:15 am with LPN AA revealed she entered the room of R65 and changed the settings to the correct settings for the feeding flush per the physician order. During this time, she revealed that because the flush was not infusing as ordered R65 was not receiving enough fluid and that R65 had the potential to become dehydrated. Interview on 9/16/2023 at 10:15 am with the DON revealed it is the responsibility of the nurses to ensure the tube feedings are set on the pump accurately per the physician orders. She revealed the orders are on the Medication Administration Record (MAR) and are to be checked and signed off that the rates are correct two times daily, morning and night. She revealed that the settings on the feeding pump being incorrect for R65 put her at risk for dehydration.

Based on observation, interviews, documents, and review of facility policy titled Cleaning and Sanitizing, Storage, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent cross contamination as evidenced by failing to label and date food items, failing to remove expired items from the cooler, failed to ensure all equipment was not in disrepair, and failing to ensure cleanliness of kitchen and dry food storage shelves for 78 of 81 residents receiving an oral diet. Findings include: Policy: Storage - review 12/30/2022 - Intent It is the intent of this center to store food in a manner that maintains quality and safety. Policy: Cleaning and Sanitizing - review 12/30/2022 - Guideline - Cleaning schedules should be implemented and maintained for all areas of the kitchen. Review of the Quality Assurance Event dated 6/27/2023 identified an issue with compliance in the kitchen which included labeling, dating, and cleaning. Staff not taking ownership of tasks was identified as the root cause of the problem and staff education was provided. During the initial kitchen tour on 9/15/2023 at 7:45 am the following was revealed: 1. The eye wash station leaking. 2. In the walk-in cooler there was a container of thickened tea that had been opened but there was no open date on the item. Directions: After opening, may be kept up to 7 days under refrigeration. 3. There were at least 5 bags of powdered milk that had a use by date of 7/13/2023. 4. There were seven 16-ounce containers of strawberries with one of the containers having a white substance all over the strawberries. It had a use by date of 9/20/2023. The Dietary Manager was not at the facility at the time of the tour. During an interview and observation with Certified Dietary Manager (CDM) on 9/16/2023 at 7:53 am the following was observed: 1. In the walk-in cooler there was one opened container of thickened tea that was opened as evidenced by the tabs on top of container being broken. The tea was not labeled or dated with an open date. 2. In the dry food storage area there were 10 five-pound bags of Instant Nonfat Dairy Milk. 3. In dry the food storage area the shelf to the right was noted to have black buildup on the shelves. 4. Condensation was noted on the vents throughout the kitchen. It is noted that the food cart that was being prepared at the time was sitting directly under a vent and there was some dripping onto the empty sups that were sitting up top. 5. Dust was noted to be in the ceiling in the kitchen. 6. There was a black buildup on the can opener. 7. The walls throughout the kitchen were noted to have food splatter. Specifically, near the three-compartment sink, dishwashing area, and wall by the dry food storage area. 8. The light fixtures were noted to have dust buildup on the covers. 9. The eye wash station near the handwashing sink was leaking. During the interview with the CDM on 9/16/2023 at 7:53 am it was reported that she tries to check the cooler daily to remove items that need to be removed. She confirmed that the thickened liquid container was open but not labeled. She reported that the shelves should be checked at least monthly and as needed for cleanliness. She reported that there is a cleaning schedule, and she confirmed the buildup on the wall near the microwave. It was reported that there has not been a deep clean of the kitchen due to challenges related to staffing. The Dietary Manager was unsure of the last time that a deep clean was completed in the kitchen. It was further reported that she was not aware of the eyewash station leaking until it was brought to her attention. During an interview on 9/17/2023 at 6:42 am with the Administrator and CDM it was reported that the issues (label and dating and cleaning) in the kitchen were recognized back in June and were placed in QAPI. On 8/31/2023 the Assistant Food Service Manager was demoted due to not performing job tasks to make sure things were in compliance. It was reported that there has been a lot of staff turnover in the kitchen as well and they are working on that too. It was further reported that the condensation and dust were identified in an audit by the Dietitian a few weeks ago. Review of Daily Cleaning Schedule for August 2023 revealed only one sheet with 10 entries indicating a task was completed. The Weekly Deep Cleaning Schedule for the same month had three entries (delime dish machine and range top burners) to indicate deep cleaning tasks were completed. However, none of the other tasks on the form were completed. Review of Daily Cleaning Schedule and Weekly Deep Cleaning Schedule for September 2023 did not indicate that any tasks had been performed by staff. During a subsequent interview on 9/17/2023 at 10:15 am with the Administrator it was reported that the issues had been identified in the kitchen and the plan started back in June. However, upon review on 8/31/2023 there had not been much progress. It was reported that a staff person was identified as not doing his/her part and a demotion was effective 9/7/2023. It was acknowledged that there should be daily cleaning and weekly deep cleaning completed but it is not reflected in the cleaning schedules that were provided. The Administrator acknowledged that cleaning in the kitchen had not been done consistently and a meeting is scheduled (with CDM and Maintenance) on 9/18/2023 to determine their next steps.

Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 35 medication opportunities were observed, and there were three errors for two of four residents (R) (R#54) and (R#72) by two of three certified medication aides (CMA) observed giving medications, for an error rate of 8.57%. Findings include: On 5/25/22 at 7:07 a.m., Certified Medication Aide (CMA) FF was observed giving R#54 her morning medications. Observation revealed that medicines given included Aspirin 81 mg (milligrams) chewable 1 tablet, Cranberry Extract 450 mg 1 tablet, Loratadine 10 mg 1 tablet, Vitamin C 500 mg 1 tablet, Vitamin D3 25 mg 5 tablets, Aripiprazole 5 mg 1 tablet, Losartan Potassium 100 mg 1 tablet, Memantine HCL 10 mg 1 tablet, Metoprolol Succinate 50 mg 1 tablet, and Venlafaxine HCL 37.5 mg 1 tablet. After all of the resident's morning medications had been prepared, CMA FF counted the number of pills in the cup, and verified during interview that what she prepared was all of the medications R#54 received for that time of day. Review of R #54's May Physician's Orders in the electronic medication record revealed an order for Aspirin 81 mg delayed release 1 tablet. During the medication observation with CMA FF on 5/25/22 at 7:07 a.m., CMA FF verified that she administered ASA 81 mg chewable 1 tablet. On 5/25/22 at 7:22 a.m. during medication observation surveyor observed CMA BB administer the following medications to R#72; Clopidogrel 75 mg 1 tablet, Hydrochlorothiazide 12.5 mg 1 tablet, Montelukast Sodium 10 mg 1 tablet, Levetiracetam 25 mg 1 tablet, Potassium Chloride 10 meq 1 tablet and Sertraline HCL 25 mg 1 tablet. Surveyor observed CMA BB remove 2 Flovent Inhalers from the mediation cart for administration for R#72. CMA BB asked resident to rinse her mouth with water before and after the administration of the Flovent Inhaler. CMA BB then attempted to administer the second inhaler (Flovent); surveyor intervened and asked CMA BB to step outside with both inhalers. CMA BB verified that the second inhaler was another Flovent inhaler and not the scheduled Combivent inhaler. CMA BB stated, I got mixed up. Review of R#74's electronic medication record revealed that resident has an order for Multivitamin with Minerals 1 tablet, which was not administered with the morning medications. CMA BB verified she did not administer the scheduled medication. Review of facility's policy titled Pharmacy Services Medication Administration General dated 2019 reads medications are administered as prescribed, in accordance with good nursing principles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy titled Transmission-Based Precautions (TBP), the facility failed to ensure proper disposal of contaminated Personal Protective Equipment (PPE), for one of two residents (R) (#24) on TBP. Specifically, the facility failed to ensure that biohazard container was available for staff use. Findings include: Review of the clinical record revealed R#24 was admitted to the facility on [DATE]. On 5/14/22, R#24 was discovered to have shingles and was started on Valacyclovir 1 gram daily for five days and placed on isolation. Observation on 5/25/22 at 9:56 a.m. revealed Certified Nursing Assistant (CNA) BB exiting R#24's room with used PPE in hand and placed it in soiled trash cart located on the hall. Continued observation on 5/25/22 at 10:06 a.m. revealed no biohazard container in residents' room. Interview with Director of Nursing (DON) on 5/25/22 at 10:08 a.m. confirmed that there was not a biohazard container in the resident's room. The expectation is that if the biohazard container is not available in the residents' room, to place the used PPE in the trash can in the room until a container can be replaced. On 5/25/22 at 10:15 a.m. interview with CNA BB revealed that the PPE was taken off in the room and placed in the container in the hall because there was not a biohazard container in the room and there was not a trash bag in the trash can in the room to use as well. Continued interview also revealed that it is usually housekeeping that would make sure that the containers are in the rooms. Interview with Administrator on 5/25/22 at 12:07 p.m. revealed that there should be a biohazard container in each residents' room that is on infection precautions. It is the responsibility of all that enters that room to ensure that the proper disposal containers are in the room for staff use. Staff should not be taking dirty linen or used PPE from a room on precautions out in the hall and mixing it with other laundry. The expectation is that all infection control precautions be followed. Review of facility policy titled Transmission-Based Precautions dated 12/4/21 under contact precautions revealed to remove gown and observe hygiene before leaving the patient care environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policies review titled Preventive Maintenance Schedules, and Physical Plant Maintenance, the facility failed ensure that the facility was maintained in a clean, safe, and sanitary condition on two of three halls observed. Specifically, the facility failed to ensure that used bath basin were properly labeled and stored in five residents' rooms on 300-Hall (room [ROOM NUMBER], 306, 308, 310, and 312), and one resident room on 200-Hall (room [ROOM NUMBER]). The facility also failed to ensure residents rooms were in good repair for rooms [ROOM NUMBERS] which had water noted on the bathroom floor from a water leak that was not addressed. Findings include: On 5/24/22 at 9:42 a.m. observation of room [ROOM NUMBER] bathroom revealed bath basin on back of toilet unlabeled with unlabeled urinal inside. On 5/25/22 at 8:56 a.m. second observation of room [ROOM NUMBER] bathroom revealed bath basin on back of toilet urinal hanging on towel rack unlabeled. On 5/24/22 at 9:45 a.m. observation of room [ROOM NUMBER] revealed base board in room on the floor, bath basin in bathroom unlabeled sitting on the floor by the toilet. Wall behind sink under vanity mirror has missing paint with dry wall showing, as well as wall on A side of the room. On 5/25/22 at 8:48 a.m. second observation of room [ROOM NUMBER] revealed base board lying on the floor off wall going into bathroom. Wall behind sink under vanity mirror has missing paint with dry wall showing, as well as wall on A side of the room. On 5/24/22 at 10:00 a.m. observation room of room [ROOM NUMBER] revealed water on the floor in front of bathroom door, paint on the bathroom wall is peeling away, bath basin sitting on the back of the toilet unlabeled, urinal hanging on towel rack in the bathroom. On 5/25/22 at 8:53 a.m. second observation room [ROOM NUMBER] revealed water on the floor white towel noted soaking up residual, bath basin on back of toilet unlabeled, paint on bathroom wall by toilet peeling away. Black substance noted on the wall of bathroom in the corner. On 5/24/22 at 10:12 a.m. observation of room [ROOM NUMBER] revealed water on the floor in front of bathroom door. On 5/25/22 at 8:49 a.m. second observation of room [ROOM NUMBER] revealed water on the floor in front of bathroom door, brown smeared substance on wall by the toilet in bathroom paint peeling off the wall to the right of bathroom. On 5/24/22 at 10:26 a.m. observation of base board in room [ROOM NUMBER] revealed bathroom has peeling paint, base board lining under drawers is peeling off and lying on the floor, bath basin in bathroom unlabeled and sitting in the sink and on the back of toilet. On 5/25/22 at 8:58 a.m. second observation of room [ROOM NUMBER] revealed bathroom has peeling paint, base board under drawers is peeling off and lying in the floor, three bath basins noted in bathroom one in the sink, one on the back of the toilet, one on the floor on white stand, all basins were unlabeled. On 5/24/22 at 10:34 a.m. observation of room [ROOM NUMBER] revealed toilet seat sitting on the floor against the wall of the bathroom, bath basin stacked one in another unlabeled. On 5/25/22 at 9:03 a.m. second observation of room [ROOM NUMBER] revealed toilet seat sitting on the floor against the wall of the bathroom, urinal on towel rack unlabeled, bath basin on back of toilet unlabeled. On 5/25/22 at 9:41 a.m. interview with Housekeeper AA revealed that staff member was not aware of a maintenance logbook to log any repairs that need to be addressed, staff member stated that they usually just verbally let the Maintenance Director know of any repairs that are observed. On 5/25/22 at 10:04 a.m., environmental rounds conducted with Administrator and RN Regional Nurse Consultant due to Maintenance Director and Environmental Services Director out on leave. During conducted rounds all previous environmental observations were confirmed during rounding. On 5/25/22 at 11:11 a.m., interview with Administrator revealed there was only one Maintenance staff member for the facility. All maintenance requests are documented in the TELs system that only the administrative staff and the charge nurses have access to. Further interview also revealed that Administrator was not aware of the needed repairs that were observed during environmental rounds. Continued interview also revealed that if there are any needed repairs for the facility the maintenance staff from their sister facility will come over fix any issues that need to be addressed. During interview it was also disclosed that it is the Administrators expectation that the facility be kept clean and in good repair. Review of facility policy titled Physical Plant Maintenance dated 12/4/21 revealed under intent: it is the intent of this center that all areas of the building, grounds, and equipment be maintained and properly serviced. Under guideline: the following functions should be by plant operations but are not limited to: Maintaining the building and equipment in compliance with manufacturer recommendations, current federal, state, and local laws, regulations, and guidelines: Maintaining the building in good repair and free from hazards; providing routinely scheduled maintenance service to areas; and others that may become necessary or appropriate. Review of facility policy titled Preventive Maintenance Schedules dated 12/4/21 revealed under intent: It is the intent of this center that preventive maintenance schedules be developed and implemented to assure that the building and equipment are maintained in a safe and operable manner.