**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record reviews, the facility failed to ensure that three of nine residents (R) (R1, R2, R3) reviewed for ADL (Activities of Daily Living) received care and services according to their needs and preferences. Specifically, the facility failed to ensure shower/baths were given as scheduled for (R1, R2, and R3). Findings include: Record review for R1 revealed resident was admitted to the facility on [DATE], and had diagnoses of but not limited to aphasia, dysphagia, muscle weakness, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and contracture of right wrist. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Review of the care plan, with a target date of 11/26/2024, revealed R1 had a self-care deficit r/t (related to) right wrist contracture, history of CVA (cerebral vascular accident-stroke), hemiplegia/hemiparesis (paralysis on one side or partial weakness), and seizures. The care plan also revealed he will refuse baths/showers at times. Interventions on 9/12/2024 included assisting with ADLs as needed and shower or bath per resident preference. A review of the grievances from June 2024 through December 2024 revealed a grievance filed on behalf of R1 on 9/2/2024 revealed resident complains he has only had bed baths, wants showers, and that he would prefer showers on days. Action to resolve documented that resident shower days were changed to Mondays, Wednesdays, and Fridays and he would be taken to the shower. Review of East Wing Baths list revealed that R1 was scheduled for baths on Mondays, Wednesdays, and Fridays. Review of the shower/bath sheets for September 2024 revealed R1 received five baths in September, on 9/2/2024, 9/11/2024, 9/16/2024, 9/18/2024, and 9/20/2024 (bed bath). Continued review revealed R1 refused a bath on 9/9/2024 and on 9/13/2024. Review of the shower/bath sheets for October 2024 revealed R1 received six shower/baths, on 10/2/2024, 10/11/2024, 10/16/2024, 10/21/2024, 10/27/2024, and 10/30/2024. The bath sheet for 10/7/2024 documented, refused, hip is hurting. Review of the shower/bath sheets for November 2024 revealed R1 received four shower/baths, on 11/8/2024, 11/13/2024, 11/21/2024, and 11/27/2024. Review of the shower/bath sheets for December 2024 revealed R1 received three shower/baths, on 12/6/2024, 12/11/2024, and 12/16/2024. During an interview on 12/19/2024 at 10:51 am, with family member of R1 revealed that she visited around Thanksgiving, R1 had not had a bath and was dirty. Family member stated that she filed a grievance with the facility. Review of the admission record for R2 revealed an admission date of 10/3/2024 and had diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), type 2 diabetes with diabetic polyneuropathy, morbid (severe) obesity, hemiplegia/hemiparesis following cerebral infarction, chronic pain, bipolar disorder, and major depressive disorder. Review of the admission MDS assessment dated [DATE] assessed R2 with a BIMS score of 15 indicating little to no cognitive impairment. Review of the care plan with a target date of 10/22/2024 revealed that R2 had a self-care/mobility deficit r/t COPD, obesity, heart failure, hemiplegia/hemiparesis, muscle weakness, difficulty in walking, chronic pain syndrome, spinal stenosis, and lumbar fractures. Interventions included assisting with ADLs as needed and shower or bath per resident's preference. A review of East Wing Bath list revealed that R2 was scheduled for baths on Tuesdays, Thursdays, and Saturdays. Review of the October 2024 grievances showed a grievance for R2 dated 10/9/2024 reporting he had not received a shower in a week. The resolution included the resident received a shower on 10/10/2024 and his shower days were moved to Tuesdays, Thursdays, and Saturdays. Review of the shower/bath sheets for October 2024 revealed R2 received a shower/bath on 10/10/2024 and 10/17/2024. Review of the shower/bath sheets for November 2024 revealed R2 received a shower/bath on 11/9/2024, 11/13/2024, 11/16/2024. On 11/19/2024 R2 refused, and on 11/23/2024 and 11/28/2024 R2 was out of facility. Review of the shower/bath sheets for December 2024 revealed R2 received a shower/bath on 12/3/2024 and 12/11/2024. An interview was attempted with R2 twice, but he was out of the facility. Review of the admission record revealed that R3 admitted to the facility on [DATE] with diagnoses of but not limited to cerebral infarction, muscle weakness, need for assistance with personal care, schizophrenia, bipolar disorder, chronic pain, fusion of spine, and repeated falls. Review of the admission MDS assessment dated [DATE] for R3 assessed a BIMS score of 15 indicating little to no cognitive impairment. Review of the care plan with a target date of 10/23/2024 revealed R3 had a self-care/mobility deficit r/t CVA, weakness, and pain. She will refuse baths/showers. Interventions included assist with ADL's as needed and shower or bath per R3's preference. Review of the October 2024 grievances revealed that a grievance was filed by R3 on 10/29/2024 reporting a concern that she did not receive her shower/bath on the assigned days. The resolution was that residents' showers were moved to days from nights as it was her preference to receive her shower/bath during the day. A review of East Wing Bath list revealed R3 was scheduled for baths on Mondays, Wednesdays, and Fridays. Review of the shower/bath sheets for October 2024 for R3 revealed R3 received a shower/bath on 10/14/2024, 10/29/2024. On 10/24/2024 no shower/bath given due to no towels or rags, and on 10/31/2024, resident refused. Review of the shower/bath sheets for November 2024 revealed R3 received a shower/bath on 11/8/2024, 11/13/2024, and 11/18/2024. On 11/4/2024 and 11/27/2024 the resident refused. Review of the shower/bath sheets for December 2024 revealed R3 received a shower/bath on 12/11/2024 and 12/16/2024. On 12/6/2024 the resident refused. During an interview on 12/19/2024 at 1:33 pm with R3 revealed that staff would document that she refused her baths, but they could not give her a bath because they did not have towels, and she had not had a shower since Monday. During an interview on 12/19/2024 at 2:45 pm with Certified Nursing Assistant (CNA) AA revealed that there are times that baths cannot be given due to not having linens, sometimes we do not get linen until 3:00 pm, but we still try to get them done that shift. CNA AA stated that baths are not being able to be given because of linens happened as recent as last week or week before. During an interview 12/23/2024 at 3:23 pm with the Administrator revealed that if a resident wanted more showers than what was scheduled, then staff were expected to honor that. If resident wanted a shower at a different time than scheduled, staff were expected to update preference. Administrator revealed that there had not been any grievances for residents not receiving their baths due to no cloths available, and there was one complaint when she first started, and it was addressed right away with the family. During an interview on 12/26/2024 at 2:10 pm with the Director of Nursing (DON) revealed that staff were aware of how shower/baths were scheduled/preferences for residents by a list of the residents for the rooms, at the nurse's stations. She revealed that if the residents wanted something else, they could have it. The showers are listed in Point-Click -Care (PCC) and on the shower sheets. DON revealed that the shower sheets were accurate. She revealed that if showers were not documented, then they did not occur. The DON revealed that there had been an issue with no cloths for baths, and the last time was three weeks ago, which was the first week she worked at the facility. DON stated that housekeeping was responsible for ordering new linens and they have made a purchase for linens in the past month. During an interview on 12/26/2024 at 2:25 pm with the District Manager (DM), revealed that he was not aware of an issue with the facility not having clean linens, and there was an emergency supply in a nearby city. He revealed that he did not have any knowledge of laundry not being done timely. DM further revealed that wash cloths were ordered last month, linens are ordered once a month, and a stock load was put out on Christmas Eve. During an interview on 12/26/2024 at 4:39 pm with CNA KK revealed that sometimes residents were not able to be given a bath due to not having clean linens. CNA KK also revealed that clean linens come from laundry once a day. During a follow up interview on 12/26/2024 at 4:56 pm R3 revealed that it was three weeks before she received a shower after she was admitted to the facility. Resident revealed that the issue was still occurring and that she only gets a shower once a week and she has told staff that she would like a bath daily.

Based on observations, Staff interviews, record review, and review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to report an injury of unknown origin for one of six residents (R) (R6) to the State Agency within the allotted time frame. Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated October 2023, under section labeled, Reporting revealed, - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation of suspicion of resident abuse, mistreatment, or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly, - Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review revealed R6 was admitted to the facility with diagnoses of but not limited to intellectual disabilities, Alzheimer's disease, dementia moderate with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and need for assistance with personal care. Review of R6's progress notes revealed that on 12/11/2024 and 12/18/2024 a bruise to the left eye of R6 was identified and it had not been evaluated. Observation on 12/19/2024 at 1:05 pm in the dining room, R6 was observed to have a bruise that was circular in shape that was on the top and bottom of her left eye. The bruise was at least three inches in diameter and was black. During an interview on 12/19/2024 at 1:06 pm with Certified Nursing Assistant (CNA) AA revealed that she was unsure of what happened to R6. Interview further revealed that R6's eye was like that when she came back off her cycle of days off. During an interview on 12/19/2024 at 1:07 pm with Licensed Practical Nurse (LPN) LL revealed she believed R6 had fallen. LPN LL looked in the computer to confirm statement but revealed that she could not find any information to confirm. During an interview on 12/23/2024 at 3:23 pm with the Administrator revealed she completed a report to the state the same day (12/19/2024) that writer inquired about R6. Administrator revealed that she was not sure of how the bruising happened and confirmed that no report of the injury had been completed.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to investigate an injury of unknown origin for one of six residents (R) (R6). Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated October 2023, under section labeled Reporting revealed, All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation of suspicion of resident abuse, mistreatment, or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly, - While it may be necessary for a facility to make an initial evaluation as to whether on incident potentially meets one or more of the reporting criteria, a thorough investigation should be completed after reporting the allegation. For example, upon discovery of an injury, the facility must immediately take steps to evaluate whether the injury is an injury of unknown source, and if the injury meets the defined criteria, an immediate report is required. Record review revealed R6 was admitted to the facility with diagnoses of but not limited to intellectual disabilities, Alzheimer's disease, dementia moderate with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and need for assistance with personal care. Review of R6's progress notes revealed that on 12/11/2024 and 12/18/2024 a bruise to the left eye of R6 was identified and it had not been evaluated Review of the Facility Reported Incidents revealed no reports for the left eye bruising of R6. A request was made for incident report on 12/19/2024 for the incident involving the injury observed on R6, but none was given. During an interview on 12/19/2024 at 1:07 pm with Licensed Practical Nurse (LPN) LL revealed she believed R6 had fallen. LPN LL looked in the computer to confirm statement but revealed that she could not find any information to confirm. During an interview on 12/23/2024 at 3:23 pm with the Administrator revealed she was not sure of how the bruising happened and confirmed that no report of the injury had been completed. Administrator further stated that her expectations for when residents fall, nursing staff's reports are done and are completed according to procedures. Staff should have put everything in the incident report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Medication Administration Guidelines, the facility failed to ensure four of 20 residents (R) (R3, R10, R22, and R27) did not have unsecured unauthorized medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. Finding include: Review of the facility policy titled, Medication Administration Guidelines (undated) under Purpose: The purpose of these guidelines is to promote the health and safety of the residents we serve by ensuring the safe assistance and administration of medications and treatments. Self-Administration: There may be occasions where a resident has been assessed to safely self-administer medications. In this case, the licensed nurse will assist the resident in maintaining the medications in a secure area and will be available for resource if the resident has questions regarding medication dosages side effects or effectiveness. 1. Record review of R3's clinical record revealed the following diagnoses but not limited to Type 2 diabetes mellitus, schizophrenia, Alzheimer, and hypertension, The Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status Score (BIMS) of 12 indicating resident had little to no cognitive impairment. Observation on 4/23/2024 at 9:01 am of R3's room revealed the following medicated cream Remedy Phyloplex (Antifungal and 'treatment ointment) and Remedy (Prevent Silicone Cream with zinc oxide) positioned on the bedside table within view. At the time of observation, R3 reported using the medicated cream (Remedy Prevent Silicone Cream with zinc oxide) daily on her sacral area. She stated that the nurse left the cream in the room. Review of R3's Self-Administration assessment dated [DATE] revealed that resident was not assessed to self-administer medications. 2. Record review of R10 's clinical record revealed the following diagnoses but not limited to gastro-esophageal reflux disease, mild cognitive impairment, and hypertension, The Annual MDS assessment dated [DATE] assessed a BIMS of 15 indicating resident had little to no cognitive impairment. Observation on 4/23/2024 at 10:56 am of R10's bathroom revealed peroxide and mupirocin 2% ointment cream in bathroom positioned on the sink. Resident stated that her wound nurse gave her the mupirocin ointment cream medication for her to self-apply to her vaginal area daily. Record review of R10's Physician Orders revealed an order for Mupirocin External Ointment 2 % (Mupirocin) Apply to skin boil on labia topically two times a day for skin boil start date 4/14/2024. Review of R10's Self-Administration assessment dated [DATE] revealed that resident was not assessed to self-administer medications. 3. Record review of R22 's clinical record revealed the following diagnoses but not limited to chronic obstructive pulmonary disease, mild cognitive impairment, and hypertension, The Annual MDS assessment dated [DATE] assessed a BIMS of 15 indicating resident had little to no cognitive impairment. Observation of R22 's room on 4/23/2024 at 10:51 am revealed a small bottle of oral tooth gel on resident 's bedside nightstand within view. Interview at the time of the observation, R22 reported that he uses tooth gel for pain in his mouth every now and then. He reported that his family helped him purchase the gel. Review of R22's Self Administration assessment dated [DATE] revealed that resident has not been assessed to self-administer medications. 4. Record review of R27 's clinical record revealed the following diagnoses but not limited to heart disease of native coronary artery, type 2 diabetes, hypertension, The Quarterly MDS assessment dated [DATE] assessed a BIMS of 15 indicating resident had little to no cognitive impairment. Observation on 4/2320/24 at 11:22 AM revealed the following items on the sink in R27 's bathroom a bottle of mouthwash with alcohol and a bottle of rubbing alcohol bottle within view. Resident shares the bathroom with two other residents in an adjoining room. Also, on the resident rolling bedside table was a small bottle of artificial tears within view. R27 reported that she uses the items alcohol and mouthwash without supervision for her own personal use but that the nurse will assist her with the artificial tears' meds. She stated that nurse left artificial tears in her room for her use. During an observation of rounds of R3, R10, R22, and R27's rooms on 4/23/2024 beginning at 1:11 pm and ending at 1:30 pm with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) BB all medications and antiseptic products were confirmed in the residents' room. Both staff reported being unaware of the medications and products. LPN BB reported that resident was not assigned to them but assigned to LPN AA who was at lunch. The DON reported that none of the residents were care planned or assessed to self-administered medications or antiseptic products. The DON removed the medication from the resident 's room. She reported that the R22 was receiving antibiotics for his gums. She thinks that the R22 's family brought the medication to him. R27 eyedrops should be kept at the nurse station. R3 using the antibiotic vaginal cream could be an infection control issue if the resident were applying it. She confirmed the muciprion was an on the residents' Electronic Medical record (EMR) but could not confirmed if the nurse left or gave the med to the resident. R10 's zinc ointment should have been placed in the bedside drawer and not in the opening. She stated that zinc ointment was okay to leave in the room as long as secured in the drawer. She reported that the facility has Angels Guardian Rounds, and this is to monitor and inspect rooms for any identified concerns and this should include unauthorized items in the resident 's room. DON reported that she had not been in the resident room lately and that she has other guardian angels monitoring these rooms, every day. Interview on 4/23/2024 at 1: 30 am, with LPN AA confirmed that the eyedrops were in R27 's room. She denied leaving eye drops in the room. She reported that R3 's zinc ointment should have been placed in a secure place and not left at the bedside. She stated that she and certified nursing assistant were educated to place the zinc ointment or any incontinent cream items in a secure place. She stated that her expectation is for the CNA to bring the zinc ointment to her after use so she can place it in a cabinet near the nurse station. She reported being unaware of R27 using the vaginal cream independently without supervision from a nurse. She stated that nurses would apply the vaginal cream with a Q-Tip for infection control and wash the perineal area before applying. She reported being unaware of R10 's oral gel.

Based on observations and staff interviews, the facility failed to ensure a safe/clean/comfortable/homelike environment for one of three hallways (100 Hall), four of 34 bedrooms and two of 17 bathrooms on the100 Hall. Specifically, the hallways had a loose handrail along the interior corridor, the frame on the exit door was jagged with rough edges at the bottom of the door, an old rusty inoperable heater was attached to the wall there were chips and scratches on the floor as residents entered the dining area. Additionally, residents' rooms and bathrooms contained black and sticky substances on the floors, basins uncovered, scraped and jagged closet doors, broken tiles, tiles pulled away from the wall, tiles with stains and dark brown sticky substance covering the floor and peeling paint. The facility census was 67 residents. Findings included: 1. Observation on 4/23/2024 at 8:49 am revealed a loose handrail along the interior corridor on unit 100 hallway. Observation on 4/24/2024 at 9:49 am revealed a loose handrail along interior corridor on unit 100 hallway. Observation dated 4/25/2024 at 11:00 am revealed a loose handrail along interior corridor on unit 100 hallway. Interview walking rounds on 4/25/2024 at 11:13 am with Administrator and the Maintenance Director (MD) confirmed that the handrail along interior corridor on 100 hallway needed repair. MD stated that the handrail was a quick fix. Observation dated 4/23/2024 at 11:45 am revealed the flooring on unit 100 by the dining room was noted to have chips and scratches. Observation dated 4/24/2024 at 10:10 am flooring on unit 100 by the dining room was noted to have chips and scratches. Observation dated 4/25/2024 at 1:30 pm revealed the flooring on unit 100 by the dining room was noted to have chips and scratches. An Interview walking rounds on 4/25/2024 at 1:45 pm with Maintenance Director confirmed that the flooring needs repairs. He stated that a rug was covering that area but when the rug was pulled up the repairs needed were noticed. He stated that this could be a quick fix, but approval needs to go through the corporate office. 2. Observations were conducted daily on 100 Hall during the survey time period of 4/23/2024 through 4/25/2024 during hours of 8:00 AM through 5:00PM. The following environmental concerns were identified, confirmed, and addressed with the Administrator, Housekeeping Supervisor, and Maintenance Director on 4/25/2024 at 11:00 AM. 1. Observation of Room-13 missing peeling paint on floor exposing dirty tiles, scraped closet door and bathroom doors. 2. Observation of Room-10 's bathroom floor tiles stained with a dark brown sticky substance at the base of the toilet and bathroom door damaged that prevented closure. 3. Observation of Room-4 scraped closet doors and frame edge of one closet door with protruding sharp jagged edges. 4. Observation of Exit door frame edge damage with missing frame at the bottom causing jagged sharp edges. 5. Observation of a wall mounted heater near the exit door covered with brown rust-colored substances. The Maintenance Director identified substances as rust. 6.Observation of Room-8 bathroom revealed two basins on the floor uncovered with dirt and debris. Dark wet coffee colored stain substances observed coating the tiles near the commode. Interview on 4/25/2024 at 11:15 am, the Maintenance Director, Administrator, and Housekeeping Supervisor confirmed the environmental issues identified with each room. The Housekeeping Supervisor reported that her staff cleans the rooms daily and was unaware of the floor tile conditions in the bathrooms. The Administrator confirmed that the basin should not be on the floor and that the certified nursing assistant is responsible for sanitation of the basin. The Administrator reported that she was aware of the issues and the plan was to fix the identified items. She reported that the wall heater was not operable and can be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, RAI/Care Planning Management, the facility failed to implement the care plan for one of five residents (R) R17. Specifically, the facility failed to ensure the plan of care was followed for R17 related to oxygen administration. Findings: Review of the facilities policy titled, RAI/ Care Planning Management, dated October 2023 revealed in the section Process for completing the MDS, CAAs, and Care plans, under Standard: It is the practice of this facility to conduct a comprehensive, accurate, state standardized, reproducible assessment of each resident's functional capacity. Under Objective number 1. To identify residents' individual needs and care requirements. Under section titled The Care Plan revealed care plans are to be accessible for clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change. Review of the medical record for R17 revealed resident was admitted to the facility with a diagnosis of but not limited to chronic obstructive pulmonary disease (COPD) and shortness of breath. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed under section O (Special Treatments and Programs) indicated oxygen use for the assessment look back period. Review of R17 care plan revealed under focus: resident has COPD and requires supplemental oxygen, Goal: Resident will be free of signs and symptoms of respiratory infections through review date, Interventions: oxygen settings as ordered. During initial screening on 4/23/2024 at 9:50 am, Surveyor observed resident in bed with the oxygen on and the oxygen was set at 4.5 L/M. Second Observation on 4/23/2024 at 11:30 am revealed R17 oxygen level was still set at 4.5 L/M. Interview on 4/24/2024 at 4:15 pm with Director of Nursing (DON) revealed her expectations for nurses was to monitor and make sure the oxygen is set at the correct level per physician order for residents receiving oxygen therapy and for the staff to follow the residents plan of care. Interview on 4/25/2024 at 9:10 am with MDS Coordinator revealed that the care plan for R17 indicates her oxygen should be administered as ordered by the physician. Further interview also revealed that she expects the nurses to follow the physicians' orders and the residents plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen, Administration-Delivery Device , the facility failed to ensure oxygen was administered as ordered by the physician for one of five residents (R), R17. Findings include: Review of the facility policy titled, Oxygen, Administration-Delivery Device, dated August 2021 revealed under Purpose: To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident. Further review under Guidelines number 3(a) Excessive levels of oxygen over a period may result in disorders associated with hyper-oxygenation. Review of the clinical record revealed R17 was admitted to the facility with the diagnoses of but not limited to chronic obstructive pulmonary disease, and shortness of breath. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R17 had a Brief Interview for Mental Status (BIMS) score of 13, indicating little to no cognitive impairment. Review of Section O (Special Treatments and Programs) indicated oxygen use. Review of the Physician's Orders dated 4/11/2024 revealed O2 (oxygen) at 2 liters per minute (L/M) continuously via nasal canula every shift, change 02 tubing and water bottle weekly every night shift every Sun. During initial screening on 4/23/2024 at 9:50 am, Surveyor observed resident in bed with the oxygen on and the oxygen was set at 4.5 L/M. Second Observation on 4/23/2024 at 11:30 am revealed R17 oxygen level was still set at 4.5 L/M. Interview on 4/23/2024 at 11:39 with Licensed Practical Nurse (LPN) AA confirmed that the oxygen was set at 4.5 L/M. Surveyor asked what the ordered amount of oxygen for R17 was, she stated that she was not sure but will look at the physician order. After reviewing the physicians' orders for R17, LPN AA confirmed that the order is for oxygen at 2 L/M. Interview on 4/23/2024 at 11:50 am with LPN BB regarding residents' oxygen that is set at 4.5 L/M revealed that physician order was for oxygen at 2 L/M. She stated that she continues to check on R17 and did not know whether the resident changed the oxygen or not. Interview on 4/24/2024 at 11:30 am R17 stated that she is not a nurse and did not touch the oxygen tank to change the setting, and that she only puts the nasal canula in her nose. Interview on 4/24/2024 at 4:15 pm with Director of Nursing (DON) revealed her expectations for nurses was to monitor and make sure the oxygen is set at the correct level per physician order for residents receiving oxygen therapy. The surveyor asked if a resident will be at risk of adverse reaction when the oxygen level is higher than what the order says. DON revealed that the resident would be at risk of adverse reaction especially if the resident has COPD. Interview on 4/25/2024 at 9:10 am with MDS Coordinator revealed that the care plan for R17 indicates her oxygen should be administered as ordered by the physician. Further interview also revealed that she expects the nurses to follow the physicians' orders and the residents plan of care.

Based on staff interviews, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for the First Quarter (Q1) of Fiscal Year 2024, the facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 67 residents. Findings include: A review of the PBJ [NAME] Report for Q1 2024, October 1 through December 31, revealed the Staffing Data Report triggered for excessively low weekend staffing and a one-star staffing rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation for, or failure to pass a CMS audit designed to discover discrepancies in PBJ data). A review of the facility's documents titled Daily Staff Posting, and PBJ Time, from October 2023 through December 2023, revealed discrepancies between the total number of hours nursing staff worked on the weekends and the total number of nursing hours worked reported to CMS. Interview with the Director of Nursing (DON) on 4/24/2024 at 2:30 pm, she reported being unable to explain the discrepancy. She has had to work weekends to ensure coverage and during the weekdays as a nurse on the floor to ensure coverage. She also reported her nursing staff and certified nursing assistant have worked hours over to ensure coverage. The discrepancy would have to have come from the prior DON and Administrator. Interview with the Administrator and Regional [NAME] President on 4/24/2024 at 10:42 am, the Administrator could not offer any explanation. She reported her hire date was after that period. Interview on 4/23/2024 at 3:00 pm, the Regional [NAME] President reported that the current Administrator is newly hired, and the former leadership (Administrator and DON) are no longer working. This would be hard to determine what happened in reference to the low staffing, and the accuracy of the PBJ reports submitted. It would be hard to determine the baseline and to determine the shortage of staff. She stated that the facility was currently in compliance with RN coverage and staffing. She acknowledged the one-star staffing rating and said that everyone was working hard to get staff into the facility.

Based on observations, staff interviews, and review of a job description titled, Laundry Worker, the facility failed to follow infection control practices by not having a clean and sanitary environment in the laundry department and a heavy buildup of dust, dirt, and grime to prevent cross contamination of dirty and clean laundry. The census was 67 residents. Findings Include: Review of undated job description titled, Laundry Worker revealed, Work Area Maintenance: cleans and sanitizes the work area including machines, worktables, and sorting area. Observation during tour of the laundry department on 4/25/2024 beginning at 9:42 am revealed the following: 1. Spider webs and a buildup of dust noted on walls, ceiling tiles and pipes, and behind the washing machines and dryers. 2. A heavy buildup of dust, dirt, and grime on the pipes, electrical cords, and floor behind the washing machines and dryers. 3. Heavily soiled and dusty cloths used as a filler surrounding the air condition unit in the clean sorting and folding area. 4. A pink bath pan under the handwashing sink filled with dark colored liquid (water). Water was leaking from under the sink into the pan and had been there long enough it had run over onto the floor, and unidentifiable black spots on the rim of the pan. Interview on 4/25/2024 at 9:20 am, Licensed Practical Nurse (LPN) KK revealed the facility was currently using agency staff for housekeeping and laundry. Interview on 4/25/2024 at 9:55 am with the Housekeeping Manager (HM) revealed she had been employed with the company for seven years. HM reported staff were to clean the laundry every day at the end of shift; staff were to sweep, clean lint traps, and make sure nothing was on the floor. She confirmed dust was on pipes, ceiling, on cloth/fabric filler around air conditioner (AC), around an old air unit that was sealed off with cardboard and blue tape, and the handwashing sink had been leaking. HM stated maintenance performed deep cleaning and it had been a while since deep cleaning was done. Interview on 4/25/2024 at 10:20 pm with the Maintenance Director (MD), and Corporate Maintenance (CM) revealed that housekeeping staff were responsible for cleaning in the laundry department. He was not aware of any cleaning or maintenance issues in the laundry department. CM and MD reviewed pictures, and confirmed the laundry department were unclean, unsanitary, and they would make immediate corrections as indicated. Interview on 4/25/24 at 12:57 pm the with Administrator revealed that her expectations were for the laundry department to be clean and sanitary. She stated that the folding/sorting room needed a new AC /heat unit and that she had to complete a capital expenditure request to corporate because the expense is over $500. She stated staff, she assumed, put towels and other materials under the window unit in the folding/sorting room, to block cold air from getting in since there have been cool temperatures in the mornings. She revealed her expectations were that staff clean daily and that maintenance clean the high, out of reach ceilings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's housekeeping plan of correction, the facility failed to maintain an environment free from a build-up of dirt, debris, stains, smears, damaged baseboards, peeling/scuffed paint, missing bathroom fixtures, and supplies for three resident bathrooms, two shower rooms, and one dining room on one of three halls (West Hall secured unit). The deficient practice had the potential to affect all residents residing on the secured unit by not providing a clean, sanitary, and homelike environment and living space. Findings include: During an interview on 5/30/2023 at 11:30 a.m., with Project Crew members DD and EE revealed that the previous maintenance person had quit. They stated that they were part of a crew that traveled from facility to facility and had been at this facility for about a week and a half. Interview on 6/1/2023 at 4:30 p.m., with the Director of Nursing (DON) stated that the current Administrator and previous Administrator had identified concerns with housekeeping including the concerns on the secured unit. Interview on 6/1/2023 at 5:00 p.m. with the Administrator revealed that he had identified issues with housekeeping and that it was not up to his expectations. A review of the Client Survey/Facility Assessment-Plan of Correction form, with the contracted housekeeping company, revealed that an onsite visit was completed on 6/1/2023, and the plan of correction was initiated on 6/2/2023.The plan included the concerns of room cleanliness, resident room cleaning, resident rooms, and housekeeping staffing. The plan of correction included the housekeeping staff was provided with in-service education on 6/2/2023. The in-service education included a 5-Step daily patient room cleaning procedure and a 7-step daily washroom cleaning. The following observations were made on the [NAME] Hall secured unit: 1.During an observation on 5/15/2023 at 1:42 p.m. and on 6/5/2023 at 9:50 a.m., in the shared bathroom for rooms two and four, the toilet tank did not have a lid and the toilet seat was loose and askew. There was a stale urine odor. There was no toilet paper or toilet paper holder. During observations on 6/5/2023 at 9:50 a.m. and again on 6/6/2023 during environmental observations with the Administrator between 11:00 a.m. and 11:30 a.m. there was a pile of clothes in the corner near the sink. There were two spots of a thick brown substance on the floor along with two pieces of opened plastic packaging. There was no toilet paper or toilet paper holder, and the toilet tank did not have a lid. During the observation on 6/6/2023 with the Administrator, he stated that he was going to have to talk with housekeeping. 2. During an observation on 5/15/2023 at 1:45 p.m., in the shared bathroom for rooms five and seven, there were spots and smears of a dried brown substance on the wall and baseboard beside the toilet and on the bathroom door frame for the room seven entrance to the bathroom. During an observation on 6/5/2023 at 9:55 a.m., there were dried brown smears and stains on the wall beside the toilet. There was no toilet paper or toilet paper holder. There were no paper towels in the wall-mounted paper towel dispenser. The call light switch was missing the attached string. During environmental observations with the Administrator on 6/6/2023 between 11:00 a.m. to 11:30 a.m., there were dried brown smears and stains on the wall and the baseboard beside the toilet. There was no toilet paper or toilet paper holder. There were no paper towels in the paper towel dispenser, and the call light switch was missing the attached string. The Administrator stated that the cleaning needed to be more thorough. 3. During observations on 5/30/2023 at 10:35 a.m. and on 6/1/2023 at 3:10 p.m., in the shared bathroom for rooms [ROOM NUMBERS] the baseboard was partially detached from the wall behind the toilet and near the sink. There was no toilet paper, and the toilet paper holder did not have a spindle. During an observation on 6/5/2023 at 3:50 p.m., there were no paper towels in the wall-mounted paper towel dispenser. There was no toilet paper, and the toilet paper holder did not have a spindle. The baseboard behind the toilet and near the sink remained partially detached from the wall. During environmental observations with the Administrator on 6/6/2023 between 11:00 a.m. to 11:30 a.m., there were no paper towels in the paper towel dispenser. There was no toilet paper, and the toilet paper holder did not have a spindle. The baseboard behind the toilet and near the sink remained partially detached from the wall. 4. During observations on 6/5/2023 at 10:00 a.m., 1:05 p.m., 3:53 p.m., and on 6/6/2023 at 9:12 a.m., in the secured unit dining room, there were multiple dried white stains running down the large windows. There were also multiple random pieces of clear tape attached to the windows. There was a buildup and collection of dirt, debris, dried stains, scuffed and peeling paint to the lower portions of the walls, windowsills, and baseboards that wrapped around the dining room. During environmental observations with the Administrator on 6/6/2023 between 11:00 a.m. and 11:30 a.m., a staff member was cleaning and buffing the floor of the dining room. The build-up of dirt, debris, dried stains , scuffed and peeling paint remained on the lower portions of the walls, windowsills, and baseboards. There were multiple dried white stains and pieces of tape attached to the large windows. The Administrator stated that they were going to do some painting in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of pest control service records, the facility failed to maintain an environment free from flies on two of three halls (East and [NAME] Hall), in one of two dining rooms and for one of 15 resident's resident (R)(A). Findings include: A review of the facility fly control program contract revealed a fly control program has been in place since 6/8/2018. A review of pest control service records for 2023 revealed pest control services, including for flies, had been provided monthly on 1/18/2023, 2/20/2023, 3/20/2023, 4/19/2023, 5/19/2023, and 6/5/2023. However, flies were observed in the facility in the following areas: East Hall A review of the 5/19/2023 pest control service record revealed a notation from the service technician to please keep all ultraviolet light (UVL) fly equipment plugged in. However, during observations on 6/5/2023 at 11:23 a.m. and 2:03 p.m., the UVL mounted on the wall at the end of the East Hall was unplugged. During a medication pass task observation on 6/5/2023 at 11:41 a.m., on the East Hall, two flies were observed in room [ROOM NUMBER] crawling on (R) A's pillow, bed linens, overbed table, and his forehead. RA attempted to swat the flies away. During a subsequent observation on 6/5/2023 at 1:00 p.m., two flies were observed flying around RA while he was in bed eating lunch. The flies were observed crawling on the resident, the bed linens, and overbed table where his lunch tray was set up. RA, when asked if he usually had flies in his room, responded yes, every day. West Hall (secured unit) 1. During an observation of room four, on the [NAME] Hall (secured unit), on 5/15/2023 at 1:42 p.m., flies were observed flying around the room, near the closed bathroom door. When the bathroom door was opened multiple small insects, which were flying around the bathroom, flew out toward the door when it was opened. During an observation of room four on 6/5/2023 at 9:50 a.m., two flies were flying around the room. Flies were also observed flying around the room four bathroom. During environmental observation rounds with the Administrator on 6/6/2023 from 11:00 a.m. to 11:30 a.m., two flies were observed on the privacy curtain in room four, near the open bathroom door. 2. During an observation of room seven, on the [NAME] Hall (secured unit), on 6/5/2023 at 9:55 a.m., two flies were observed crawling on the first bed. During an environmental observation rounds with the Administrator on 6/6/2023 from 11:00 a.m. to 11:30 a.m., a fly was observed crawling on the first bed in room seven. Main Dining Room During observations on 6/5/2023 at 4:39 p.m. and 6/6/2023 at 8:05 a.m., multiple dead flies (more than 27) were observed on the windowsills underneath the line of windows in the main dining room. During environmental observation rounds with the Administrator on 6/6/2023 from 11:00 a.m. to 11:30 a.m., he confirmed that the pest control company was at the facility the day prior, on 6/5/2023, for their monthly service visit. The Administrator stated that he had spoken to the pest control service technician about flies, and they discussed adding additional UVL's in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews the facility failed to follow Physician's Order for one of four residents (R) (R#39) who received nutrition via gastric feeding tube. Findings include: A review of the clinical record revealed that R#39 was admitted to the facility on [DATE] with diagnoses that included End stage renal disease, gastrostomy, aphasia, hypertension, non-traumatic cerebral hemorrhage, gastroesophageal reflux disease, diabetes mellitus, anemia and major depressive disorder. An observation on 7/20/22 9:36 a.m. revealed R#39 lying in bed low bed with head of bed elevated. Feeding pump was connected to G-tube, tube feeding formula Nepro 1.2 infusing at 60 cubic centimeters (cc) per hour (hr). A review of the physicians' order revealed note dated 5/23/22 that reads Nepro 1.2 60cc/hr for 22hrs via peg tube. Order was discontinued 7/21/22. During an Interview with DON on 7/21/22 at 9:20 a.m. it was revealed R#39 had been receiving the TF at 60cc/hr at 24 hours continuously, and the physician order should have reflected that the TF was infusing at 60 cc/hr for 24 hours continuously. During an interview with charge nurse on 7/21/22 at 1:35 p.m. it was revealed that she usually stops the tube feeding around 10:00 a.m. and resumes at 12 noon. Charge nurse confirmed she had no documentation for stopping and starting the tube feeding. A review of the medication administration record, treatment administration record or progress notes revealed no documentation of the tube feeding being stopped at any time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to: maintain a safe, clean, comfortable, homelike environment on two of two Halls (East Hall and [NAME] Hall) free from stained, sagging, and holes in ceiling tiles, dusty, dirty ceiling vents and fans, stained, scratched toilets, missing baseboard, scuffed-up doors, one loose sink that needed caulking, one leaking sink; maintain a comfortable air temperature within range of 71 degrees Fahrenheit (F) to 81 degrees F; maintain a working women's shower free from disrepair, missing floor tiles, musky smell, with equipment stored in it; and ensure the smoking porch was free from dirty ceiling fans and spider webs. Findings include: Observation on 7/20/22 at 9:55 a.m., and interview at that time with resident (R) R#5 and R#41 revealed stained ceiling tiles and dead bugs in the fluorescent light fixture in resident room on East Hall. R#5 and R#41 reported the air did not work properly in odd numbered rooms on East Hall. Observation on 7/20/22 at 1:39 p.m. in room three on East Hall revealed a dusty box fan set up at the foot of bed b blowing on resident in bed because there was no air coming out of the floor vent. Observation in the bathroom revealed a busted ceiling tile, and dusty vent. Observation on 7/20/22 at 1:45 p.m. with the Maintenance Director, and interview at that time, revealed he was not aware the air was not working properly on East Hall, the unit was new, and he checked random rooms daily to ensure temperatures (temps) was between 72 to 76 degrees. Resident#73 presented with a Brief Interview of Mental status (BIMS) score 99, and R#48 presented with a BIMS of 00, indicating significant cognitive deficits. R#73 was in bed with cover up to his chin. Temperature check on 7/20/22 at 2:04 p.m. verified by the maintenance director using the facility calibrated thermometer, revealed a temp of 69 degrees in their room. Observation on 7/20/22 at 2:15 p.m. of a thermostat mounted on the East Hall, temp was set at 76 degrees. During random temperature checks with the maintenance director, using his calibrated thermometer, air temps in resident rooms on the East Hall were verified between 69 and 72 degrees Fahrenheit. Interview at that time with the maintenance Director revealed the problem is East Hall is very busy because smoke porch and laundry dept. are at the end, constant traffic in and out of the double doors causing warm temps in the hallway. The thermostat that regulates resident rooms was mounted in the hallway where it's warmer, keeps running trying to adjust to the temp set at, although it is much colder inside resident rooms. A temp check on East Hall revealed a temp of 79 degrees. His expectation was that the thermostat be moved from the hallway but that would have to be approved, and he would need help to get it done. Observation of R#40 in their room wearing grey sweatpants, tan long-sleeved pull-over shirt, a grey & white undershirt, grey non-skid socks, and grey hoodie cap. Interview at that time R#40 revealed to surveyor he was cold and said it's always cold. Air temp in the room, verified by the Maintenance Director, was 71 degrees. Temp was checked immediately in hallway outside the room and verified a temp of 79 degrees in hallway. During a walkthrough of the facility with the Maintenance Director on 7/21/22 between 2:00 p.m. and 2:30 p.m. the maintenance director verified the following on East and [NAME] Hall: Women's shower felt cold, damp, had musky smell, missing floor tiles, floor tiles in disrepair, and half of the shower was used for storage of equipment. Men's shower had bad floor and ceiling tiles, a hole in ceiling where sprinkler had been. Missing baseboard and very cold in room [ROOM NUMBER]. Bad ceiling tiles and a hole in ceiling tile in bathroom of room seven. Dusty vent in bathroom, hole in ceiling, holes in bathroom wall tile, and no cable in room eight. Very dusty vent in bathroom of room six. Dusty vent and loose sink that was not caulked in room five. Dusty fan blowing on resident, air not running from vent, and light not working, dusty vent and broken ceiling tile in bathroom of room three. Dusty vent in bathroom, stained ceiling tiles and dead bugs in the ceiling light in room three. Dusty vent in bathroom and bad floor tiles in room two. Dirty ceiling fans and spider webs on smoking porch, one of three ceiling fans not working. Large hole in the wall in the laundry department, and several towels stuffed around another opening in wall. Stained or scratched toilet bowl in bathroom of room [ROOM NUMBER]. Observation at that time the Maintenance Director confirmed large, formed stool in bathroom [ROOM NUMBER] toilet. Interview at that time with the Maintenance Director revealed he has to use the snake tool regularly to unstop the toilet because of the large stool, and he made a motion with his hands as if going in a circle around the toilet bowl. The consensus was that the inside of the toilet bowl was scratched from the tool instead of stained. Dripping faucet under bathroom sink in room two on [NAME] Hall. During an interview on 7/21/22 at 10:30 a.m. with CNA EE revealed she had worked here since 3/22/22. She confirmed orientation and training when she started and confirmed that if staff see something that needs cleaning or repairing, they should report it to housekeeping or maintenance. During an interview on 7/21/22 at 10:35 a.m. with CNA FF revealed she had worked here since 6/27/22. She confirmed receiving orientation and training when she started. Interview revealed if they see needed cleaning, maintenance or repairs they report it to housekeeping or maintenance. During an interview at 2:30 p.m. the Maintenance Director revealed he was the only person in Maintenance, he did not have any help, he did all maintenance and repairs by himself unless corporate comes, cleaning is contracted by Healthcare Services, and they do housekeeping/cleaning jobs. He revealed he did not have a work order log, there is a book at each nurse station that staff are supposed to use to report repairs and maintenance, but they don't use it, and staff inform him by word of mouth. He confirmed he cleaned the vents not long ago and could not believe they were so dusty. During an interview on 7/21/22 at 2:45 p.m. with the Administrator revealed housekeeping was contracted with Healthcare Services, they have a generalized policy for every building related to laundry, housekeeping and cleaning, and have only one maintenance staff, the director. The Administrator confirmed maintenance and repairs were needed, but supply and demand had caused a delay in getting supplies in rural areas. They utilized local retailers as much as possible but there is still a delay in getting what they need to complete repair and maintenance jobs. Her expectation was that the facility is in the best possible condition. Further interview confirmed there was only one door to the laundry department used for entering and exiting with dirty and clean laundry, and the laundry door is open to the smoking porch. The Administrator did not feel this was causing cross contamination because dirty laundry should be contained and transported in a covered container. Her expectation was the laundry door should be closed when residents are smoking on the porch, doors between the dirty and clean side should always be closed, laundry carts should not be parked on the smoking porch and should be stored in the laundry department. She confirmed there was a large hole in the wall, there were steps to get in and out of the laundry department, and that two staff could carry the laundry cart up and down the steps.

Based on observations, interviews, and record review of the policy entitled, Management of the Laundry, the facility failed to provide a separate delivery entrance into the Laundry Room to take soiled or dirty linen/clothes, use appropriate PPE including gloves and an apron when sorting linen, and keep soiled or dirty linen/clothes covered; this affected Residents who used the linen at the facility and had their clothes cleaned in the Laundry Room. The census was 75. Findings include: The policy entitled Management of the Laundry has these statements, It is very important to properly transport and store soiled linens to prevent the spread of infection. To do so, all soiled linen and clean linen must be covered during transportation and while being stored on unit or floors. Soiled linens brought down manually must have a separate delivery entrance and must be place into the soiled linen bins. As soiled linens are sorted into the proper wash classifications, employees must wear the proper personal protective equipment (PPE), which includes gloves and a protective apron. During an observation of the Laundry Department on 7/19/22 at 10:00 a.m. it was revealed there was uncovered dirty linen on the floor; there is only one door used to enter and exit the Laundry Department. The door to the clean area was open to the dirty side. During an interview with Laundry Worker (LW) AA, on 7/19/22 at 10:41 a.m. revealed the staff from the units bring dirty laundry in bags to the door of the laundry department and put the laundry on the floor; she uses gloves only to sort through the dirty laundry; clean clothes and linen are taken from the dryer to another room to fold and sort; clean clothes and linen are then put on a blue buggy outside of the laundry room and the laundry staff takes the clean linen and clothes to the unit. During an interview with LW BB on 7/20/22 at 09:00 a.m. revealed that the same door is used to take the dirty linen to the Laundry Department and take the clean linen from the Laundry Department to the units. During an Interview with LW BB on 7/20/22 at 12:15 p.m. revealed the smoking area is adjacent to the Laundry Department; the door to the Laundry Department is open most of the time; the clean clothes cart is kept out on the porch where Resident's smoke but she does not put clean clothes out there while smoking is going on; noted at this time there were three ceiling fans on the porch; all were dusty, one was not working. During an interview with Certified Nurse Assistant (CNA) DD on 7/21/22 at 9:00 a.m. revealed dirty linen is put in the Soiled Utility Room; they use gloves and put it in plastic bags; if leaking will double bag; the staff will take the dirty linen to the Laundry Department. They use gloves when transporting the linen. During interview and tour of Laundry Department with the Administrator on 7/21/22 at 9:30 a.m. revealed she is aware there is only one entrance for the Laundry Department; reviewed Laundry Policy with Administrator, Management of the Laundry which states; Soiled linens brought down manually must have a separate delivery entrance and must be placed into the soiled linen bins. Administrator states there is only one entrance for the Laundry Room. During an interview with LW BB on 7/21/22 at 1:30 p.m. revealed the door to the laundry is open at all times; clean linen is folded and sorted in a separate room; when ready to put linen on the cart she walks through dirty area and puts it on the cart on the porch area; the clean linen is not covered. During an interview on 7/21/22 at 2:45 p.m. with the Administrator it was revealed housekeeping services was contracted through Healthcare Services, and Healthcare Services has a generalized policy for every building related to laundry, housekeeping, and cleaning. The Administrator confirmed maintenance and repairs were needed but that supply and demand had caused a delay in getting supplies in rural areas and thus caused delays. They utilize local retailers as much as possible but there is still a delay in getting what they need to complete repair and maintenance jobs. Her expectation was that the facility is in the best possible condition. Further interview confirmed there was only one door to the laundry department, used for entering and exiting with dirty and clean laundry, and the laundry door is open to the smoking porch. She did not feel this was causing cross contamination because dirty laundry should be contained and transported in a covered container. Her expectation was the laundry door should be closed when residents are smoking on the porch, doors between the dirty and clean side should always be closed, laundry carts should not be parked on the smoking porch and should be stored in the laundry department. She confirmed there were steps to get in and out of the laundry department, and that two staff could carry the laundry cart up and down the steps.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, it was determined the facility failed to ensure that the staff knocked on the door and asked permission prior to entering for two of 38 resident (R) rooms (East hall rooms [ROOM NUMBERS]). Findings include: A record review of the quarterly Minimum Data Set (MDS) (Minimum Data Set (MDS) is the state approved resident assessment instrument which contains a minimum set of data elements with uniform definitions and categories concerning the cost and quality of nursing care) dated 3/22/19 for Resident Z (R Z) revealed a Brief Interview for Mental Status (BIMS) summary score of 15 (A BIMS score of 13-15 indicates cognitively intact). An observation on 4/07/19 at 12:39 p.m. revealed Certified Nursing Assistant (CNA) AA walking into the East hall room one with a meal tray, CNA AA entered the room without knocking or asking permission to enter. An observation on 4/07/19 at 12:40 p.m. revealed CNA AA continued to EAST hall room two with a meal tray, without knocking and entered the room. CNA AA further continued passing meal trays on 04/07/19 at 12:42 p.m. returning to East hall room [ROOM NUMBER] and again without knocking, entered the room. An observation on 4/08/19 at 8:13 a.m. revealed CNA AA entered room EAST hall room one and eight without knocking. An observation on 4/08/19 at 8:14 a.m. CNA AA entered East hall room one without knocking. An interview on 4/09/19 at 4:48 p.m. with R Z revealed sometimes they don't knock; the maintenance man sometimes doesn't knock. I just tell them to their face when they don't, I mean they say they knock sometimes, and I don't hear them, but I heard you when you knocked. An interview on 4/10/19 at 8:48 a.m. with CNA AA revealed in- services are every payday and they have said knock on doors, but if the door is open, I just go on in. If the door is closed, you must knock and announce yourself. An interview on 4/10/19 at 9:29 a.m. with the Director of Nursing (DON) revealed everyone is expected to attend residents' rights inservices, we have it four times a year. We had a staff meeting about knocking on doors. The DON continued by stating, if the door is open, they still need to knock, it was said in that staff meeting. She states her expectations are for all staff to knock even if the door is open. An interview on 4/10/19 at 2:08 p.m. with the Administrator revealed she expected all staff to knock on doors before they enter a resident's room. She further revealed she knows the Maintenance Director knocks, at least when she is looking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policies titled, Administrative Manual: Admissions and Discharge Process and Planning for Home or Continued Care, the facility failed to document a complete discharge summary and recapitulation of the resident's stay for one of three residents (R#64) who was discharged to another skilled nursing facility (SNF). Findings include: Review of an undated facility policy titled, Planning for Home or Continued Care stated, If discharge to home or community is anticipated: your healthcare team will complete a discharge transition plan for you. This plan is a summary of your stay and follow-up plan of care and will be provided to you and those caring for you in the community. Review of a facility policy dated 3/3016, titled Administrative Manual: admission & Discharge Process, did not address the discharge summary or provide guidelines to develop and document the discharge summary. Review of the face sheet for R#64 revealed the resident was originally admitted to the facility on [DATE] (re-admitted on [DATE]) and discharged to another skilled nursing facility (SNF) on 1/10/19 with diagnoses that included but were not limited to disorganized schizophrenia, obsessive-compulsive disorder, hypertension, neurogenic bladder, osteoarthritis-left knee, hypothyroidism, seizures, and diabetes. Review of the Discharge summary dated [DATE], signed by the Director of Nursing (DON) and the attending physician, did not contain a recapitulation of R#64's stay. Review of the Discharge Instructions dated 1/10/19 at 2:00 p.m. documented the discharge, provided a brief transfer report for R#64 but did not include a complete recapitulation of his stay. Review of the clinical record for R#64 revealed the Social Worker's (SW) Progress Note dated 1/10/19 at 17:40 (5:40 p.m.), documented the discharge but did not contain a complete recapitulation of R#64's care and treatment at the facility. In an interview with the Director of Nursing (DON) on 4/10/19 at 2:00 p.m., she confiremed that confirm the current discharge summary was lacking a complete recapitulation of the resident's stay.