Based on observation, staff interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene F880 and Administering Medication F760, the facility failed to ensure infection control processes were followed during medication pass observation for one of three nurses observed. This deficient practice had the potential to place residents at risk for infections due to cross-contamination. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene F880, effective 10/2024, revealed the Policy section stated, The facility considers hand hygiene the primary means to prevent the spread of germs. Review of the facility policy titled Administering Medication F760, effective 10/2024, revealed the Guidelines section included, . 15. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. Observation on 5/7/2025 at 8:42 am of medication pass with Licensed Practical Nurse (LPN) AA revealed she removed a medication tablet from a container into her ungloved hand, and used her fingernail to move medication tablets around in the medication cup to count them. In an interview on 5/7/2025 at 9:00 am, LPN AA stated that she didn't always wear gloves during medication pass. She confirmed that she touched the medication tablets with her bare hands and should have had gloves on before touching the tablets. In an interview on 5/8/2025 at 8:01 am, Registered Nurse/Unit Manager (RN/UM) CC stated nurses should wear gloves when preparing medications and should not touch pills that are administered.

Based on observations, staff interviews, record review, and review of the facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, the facility failed to ensure timely repair of a wheelchair for one of 33 residents (R) (R54), who utilized a wheelchair. The facility also failed to ensure a homelike environment in R54's room and bathroom, on one of four hallways (Unit Two Hall), and in the facility entrance area. The failures had the potential to place residents at risk for the use of unsafe equipment, unsanitary conditions, and a potential for diminished quality of life. The census was 70 residents. Findings include: Review of the facility policy titled Safe, Clean, Comfortable, Home-like Environment F584, with an effective date of 9/2023, revealed the policy statement of: Residents have the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Observation on 12/20/2023 at 8:13 am of R54's wheelchair revealed the arm tray on the right side was loose and hanging to the side of the wheelchair and was movable back and forth. Further observation revealed the wheelchair frame had an unprotected hole in it. The wheelchair wheels had a buildup of brown substance and there was dust all over the chair. Observation on 12/20/2023 at 12:00 pm of R54's room revealed the top of the wooden nightstand was protruding, had a gap across the front and the right side, and the plastic framing around the top was not in place. Observation of the bathroom for R54's room revealed rust colored areas that were rough to the touch on the grab bar, the sink faucet had white colored areas on it with a rough texture, the toilet flushing button on top of the tank had rust colored areas on it, the over the toilet seat had chipped paint and rust colored areas on it, there was a 1 inch hole in the adjoining bathroom door, and chipped paint on the ceiling over the hand towel dispenser. Observation on 12/20/2023 at 12:21 pm of Unit Two Hall near the boiler room door revealed the ceiling had a darkened area and the ceiling around the light fixture had an opening where the sheetrock met the light fixture on each side. The floor of Unit Two Hall had torn and soft areas in the flooring and missing pieces of the flooring. Observation on 12/20/2023 at 12:30 pm revealed a fluorescent light in the front hallway by the offices and near the front door had a cover that was hanging down from one side. Walking rounds on 12/21/2023 at 8:24 am with the Maintenance Director (MD) confirmed the findings in R54's room, restroom, and the findings of R54's wheelchair. The MD further confirmed the findings on Unit Two Hall. He revealed they were aware of all the problems, and they were trying to get things repaired. An interview on 12/21/2023 at 12:06 pm with Certified Nursing Assistant (CNA) FF revealed if she saw equipment in disrepair, she reported it to the nurse and to maintenance. She stated staff documented maintenance concerns in a reporting system on the computer. An interview on 12/21/2023 at 12:09 pm with CNA GG revealed equipment repair needs were documented by staff in a notebook that maintenance staff checked. She further stated she documented R54's wheelchair disrepair in the notebook three or four weeks ago. An interview on 12/21/2023 at 12:29 pm with Licensed Practical Nurse (LPN) BB revealed she was unable to locate the maintenance book at the nurse's station and that she used the facility's electronic system to report maintenance concerns. An interview on 12/21/2023 at 12:41 pm with LPN AA revealed if she found equipment in need of repair, she would report it to maintenance and report it using the facility's electronic reporting system. An interview on 12/21/2023 at 1:13 pm with the Maintenance Director revealed the Work Order Report, dated 10/01/2023 through 12/20/2023, revealed R54's room had no history for any type of repairs. He revealed he had thrown the maintenance logbook away two years ago. An interview on 12/21/2023 at 1:38 pm with the Administrator revealed if a wheelchair required repairs, the maintenance department should be able to fix it. An interview on 12/21/2023 at 1:49 pm with the MD revealed he had weekly and monthly task lists. He stated he and his assistant took care of issues as they came to them. He further stated wheelchairs were cleaned monthly by housekeeping, and he recently ordered wheelchair armrests. He reported that he did not have anything documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident guardian interviews, record review, and review of the facility policy titled F625 Bed Hold, the facility failed to ensure one resident (R) (R225), or their guardian, was provided notification of the facility's bed-hold policy upon transfer to a hospital. The facility census was 70 residents. Findings include: Review of the facility's policy titled F 625 Bed Hold, last revised June 2023, revealed the policy was: The community staff shall inform residents upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed-hold policy. The Guidelines section line numbered 1 stated: Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. Review of the Physician's Orders revealed an order dated 9/22/2023 of: May transfer to (the local psychiatric hospital) for evaluation and treatment. Review of the Progress Notes revealed a nursing progress note dated 9/23/2023 that R225 left with transport emergency medical services (EMS) and the local psychiatric hospital received report. Interview on 12/20/2023 at 12:50 pm with Business Office Manager (BOM) revealed R225 was a private pay resident and was admitted on [DATE]. She stated R225 had a conservator and a guardian handling business affair. She stated she spoke with the conservator about the bed hold policy and the conservator understood R225 did not have to pay anything until 10/01/2023. She stated R225 had already paid for the month of September on the day of admission. She stated that she was not in the office with the Social Services Director (SSD) on 9/19/2023 when the bed hold was issued but remembered being told they gave it to the guardian before R225 was transferred to the hospital. Interview on 12/20/2023 at 1:00 pm with the Administrator revealed when R225 was scheduled to be transferred to the psychiatric hospital, the unit nurse gave the bed hold paperwork to R225's guardian. She confirmed the facility did not make a copy of R225's bed hold documents when they were transferred to the hospital. The Administrator stated education was provided when she realized the staff were not honoring the bed hold policy for the residents. A telephone interview on 12/21/2023 at 11:20 am with R225's guardian confirmed she did not receive a bed hold policy from the facility.

Based on observations, staff interviews, and review of the Quality Assessment and Performance Improvement (QAPI) Plan 2023, the facility failed to have an effective Quality Assurance (QA) program that developed and implemented actions to repair and/or replace the flooring throughout the facility in a timely manner. This failure had the potential to affect 70 residents. Findings include: Observation of Hall Two on 12/20/2023 at 12:21 pm revealed the flooring had soft areas and breaks/missing tiles down the entire hallway. During observations with the Maintenance Director on 12/21/2023 beginning at 10:42 am, he confirmed the soft/spongy flooring and missing tiles on Hall Two and throughout the common areas of the facility. Interview on 12/21/2023 at 10:42 am with the Maintenance Director revealed the flooring project was already in progress for over a year when he was hired in January 2022. He stated he will continue to repair the flooring until they can secure a qualified contractor. Review of the Environmental Performance Improvement Plan (PIP) 2022 revealed the status was in progress and no records were found. The Root Cause Summary, in which audits were conducted, related to floors. The target end date was June 2, 2022, and the PIP status was unsuccessful. Review of the Environmental PIP 2023 QAPI Goal revealed the PIP status was in progress with a target end date of December 31, 2023, with floors in need of repair. Review of the email correspondence between the National Director of Plant Operations and the Regional Maintenance Director, the Administrator, and others, revealed ongoing discussions related to securing contractors. In an interview with the Regional Nurse Consultant (RNC) on 12/21/2023 at 11:29 am, she stated the flooring in the facility was a huge priority for corporate office and they speak about it weekly. She stated they were reviewing current bids for a contractor, and they would like to start in the first quarter of 2024. In an interview with the Administrator on 12/21/2023 at 11:45 am, she stated she started a PIP related to the flooring when she was hired in November 2021, but the flooring replacement project was already underway. She stated it had been a challenge to find a licensed, bonded contractor who was able or willing to take on this massive project in this region.