**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled Incontinence Management, the facility failed to ensure a urinary catheter privacy bag was provided for one of one resident (R) R2 with a urinary catheter. This failure had the potential to diminish the resident's quality of life.Findings include:Review of the facility's policies titled Incontinence Management dated January 2025 documented Other Options Catheterizations: Not Appropriate for Rehabilitation; If the resident is not appropriate for a Program, the care plan will identify other interventions to maintain skin integrity, prevent urinary tract infection and provide dignity for the resident.Review of the facility's Electronic Medical Records (EMR) revealed R2 was re-admitted to the facility on [DATE] with a diagnosis that included but not limited to neuromuscular dysfunction of bladder and presence of urogenital implants.Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview of Mental Status (BIMS) of 14, which indicated R2 had intact cognition and Section H (Bowel and Bladder) R2 had a urinary catheter.Review of care plan dated 7/8/2025 documented included but not limited to Focus: R2 has an indwelling suprapubic catheter in place related to neuromuscular dysfunction of bladder. Goal: R2 will be/remain free from catheter-related trauma through the review date. Intervention: Check tubing for kinks, enhanced barrier precautions in place, provide catheter care as indicated, suprapubic catheter 18 French per 10 milliliters (FR / 10mL) Balloon to drainage bag. Use strap/securement device to stabilize tubing (as requested/needed).Review of Physician's Orders dated 7/10/2025 documented included but not limited to Suprapubic Catheter _16___FR / __10__mL Balloon to Drainage Bag. Use trap/Securement Device to stabilize tubing (as requested/needed). Label Bag with Date. For: ____neurogenic bladder_____ (Specify Reason/diagnosis [Dx]) every day shift every 30 day(s) for catheter maintenance.Observation on 7/21/2025 at 11:54 am, 4:50 pm, and 7/22/2025 at 10:04 am revealed R2 in his room, lying in bed with an uncovered urinary catheter bag hanging on the bed rail that could be viewed by residents, staff, and visitors ambulating in the hallway.Interview on 7/22/2025 at 10:18 am with Licensed Practical Nurse (LPN) DD confirmed R2's urinary catheter bag was not covered, and it was visible from the hallway. She stated it should be covered with a privacy bag to provide privacy for R2. She further stated that when the urinary catheter bag was not covered, it would cause low self-worth and embarrassment for R2.Interview on 7/22/2025 at 10:49 am with Certified Nursing Assistant (CNA) EE confirmed R2's urinary catheter bag was not covered, and it was visible from the hallway. She stated it should be covered with a privacy bag because it was a dignity issue and also to provide privacy for the resident. She further stated that when the urinary catheter bag was not covered, it could cause R2 to be uncomfortable. She stated the bag had not been covered for about one week because she thought the facility was out of privacy bags.Interview on 7/23/2025 at 12:30 pm with the Director of Nursing (DON) revealed that her expectations were for urinary catheter bags to be covered at all times except when they were being emptied. She stated that when the foley bags were not covered, it was a dignity issue and it could affect the resident emotionally and psychologically.

Based on observations, staff interviews, and review of the facility's policies titled Medication Administration, the facility failed to remove expired medications from one of four medication carts and failed to remove expired medication and medical supplies from one of two medication rooms. The facility's census was 73.Findings include:Review of the facility's policy titled Medication Administration dated January 2025 documented Medications are to be stored appropriately as per manufacturer instructions. All expired medications or medications to be destroyed are to be taken off the medication cart and properly destroyed by the Environmental Protection Pharmacy guidelines.1. Observation on 7/22/2025 at 5:10 pm during review of the 400 Hall medication cart revealed there was one bottle of melatonin 1 mg tablets with an expiration date of 3/2025.Interview on 7/22/2025 at 5:11 pm with Licensed Practical Nurse (LPN) BB, who confirmed the bottle of melatonin 1 mg tablets was expired and should not be on the medication cart. She stated that if the residents received this expired medication, they would get sick, and the medication would not be effective for the residents.Interview on 7/22/2025 at 5:12 pm with Unit Manager (UM) AA, confirmed the bottle of melatonin 1 mg tablets had an expiration date of 3/2025 and should not be on the medication cart. She stated that no expired medications should be on the medication cart. She further stated her expectations were for the nurses to remove expired medications from the carts, and the expired medications were not administered to the residents. The UM stated that if the expired medication was administered to the residents, it would not be good for the residents and it would not be effective.Interview on 7/22/2025 at 5:14 pm with LPN DD, confirmed the bottle of melatonin 1 mg tablets was in the medication cart and had an expiration date of 3/2025. She stated that if the residents received the medication, there could be negative outcomes, and the medication would not be effective. 2. Observation on 7/22/2025 at 5:18 pm of the Back Hall medication room revealed one bottle of aspirin 325 mg tablets with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with expiration dates of 2/2023. Unpackaged gauze rolls and one open pack of gauze were on the surface of a cupboard in the medication room.Interview on 7/22/2025 at 5:20 pm with LPN CC confirmed there was one bottle of aspirin 325 mg tablets with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with expiration dates of 2/2023 in the medication room. LPN CC stated that the nurses should do a daily audit and were responsible for removing expired medications and expired medical supplies from the medication room. She further stated that if the expired medication were administered to the residents, they could get sick. She also stated that if the expired medical supplies were used on the residents, they may not be useful due to the expiration. Interview on 7/22/2025 at 5:22 pm with LPN DD revealed that if the residents received the expired medication, it could cause the residents' conditions to worsen, and the medication should not be in the medication room.Interview on 7/22/2025 at 5:25 pm with UM AA confirmed there was one bottle of aspirin 325 mg tablets with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with expiration dates of 2/2023 in the medication room. She stated her expectations were for the nurses to remove the expired medications and medical supplies from the medication rooms. The UM further stated that it was a collaborative effort with the nurses to remove the expired items. If this effort was not made, the residents would receive the expired medications and become sick. Interview on 7/23/2025 at 12:35 pm with the Director of Nursing (DON) revealed that her expectations were for expired medications and medical supplies to be removed immediately from the medication carts and rooms. She stated that the nurses were responsible for removing expired medications. If residents received expired medications, they could experience negative side effects, and the medication would also be ineffective for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident representative (RR) interview, and staff interviews, the facility failed to provide a sanitary and comfortable environment for one of 53 sampled residents (R) (R58). This deficient practice had the potential to place R58 at risk of living in an uncomfortable environment. Findings include:Review of the medical record for R58 revealed an admission date of 8/2/2023. Diagnoses included, but not limited to, cerebrovascular accident.Review of R58's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 6 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R58 required assistance with all ADLs. In a concurrent observation and interview on 7/21/2025 at 1:15 pm, observation R58 lying in bed watching television and eating lunch, with the RR at the bedside. In an interview, the RR stated the sewage smell in the resident's bathroom was an ongoing problem and was bad. The RR stated the resident's daughter had reported it to the nurses. The RR further stated that some days it was so bad, it was difficult to stay in the room. In an interview on 7/22/2025 at 11:08 am, the Director of Nursing (DON) revealed that she was aware of the odor in R58's room. She stated she was told the bathroom smelled bad because it was rarely used and the toilet was not flushed often. In a concurrent observation and interview on 7/22/2025 at 11:12 am, the Corporate Maintenance confirmed the smell in R58's bathroom. He stated that the P-trap on the sink was designed to hold water, and if no one used the sink in a long time, the water would evaporate, which would cause a smell. In an interview on 7/22/2025 at 11:22 am, the Administrator stated she had not received a complaint regarding the smell in R58's room. She stated that when she had smelled an odor in the hall, she always assumed it was the resident with a colostomy bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Infection Control Manual, the facility failed to ensure three of five sampled residents (R) (R1, R29, and R13) for vaccinations had a completed consent, declination and/or proof of education for the pneumococcal and/or influenza vaccine. This deficient practice had the potential to place R1, R29, and R13 at risk of unmet needs. Findings include:Review of the facility policy titled, Infection Control Manual, revised date 9/2023, revealed the Immunizations: Standing Orders, section included, . 3. Counsel resident and/or family/responsible party on the benefits and adverse effects of each vaccine prior to administration of the vaccines. 4. Complete the Pneumococcal and Influenza Vaccine-Information and Consent with the resident or family at the time of admission and each time offered. Place in the medical record.1. Review of the admission Record for R1 revealed admission on [DATE]. Review of the Immunization Record for R1 revealed the resident received Prevnar 23 in 2020, at age [AGE]. Review of the clinical record revealed no consent, declination, or education for the pneumococcal vaccine. 2. Review of the Admissions Record for R29 revealed admission on [DATE]. Review of the Immunization Record for R29 revealed the resident received Prevnar 13 on 10/2/2020, at age [AGE], and there were no historical dates for the influenza vaccination. Review of the clinical record revealed no consents, declinations, or education for the influenza or pneumococcal vaccines. 3. Review of the admission Record for R13 revealed admission on [DATE]. Review of the Immunization Record for R13 revealed R13 was administered an influenza vaccine on 11/21/2024 by the Assistant Director of Nursing (ADON) at the facility. Review of the clinical record revealed no consent, declination, or education for the influenza vaccine.In an interview on 7/23/2025 at 1:56 pm, the Director of Nursing (DON) stated that nurses document vaccine administration in the medical record. The DON stated that on admission, consent and education was provided to the residents or resident representative for vaccines. The DON further stated that the influenza vaccine was given to residents during flu season. The DON stated there was no further documentation for the resident's vaccines.

Based on observations, staff interviews, record reviews, and review of the facility policies titled Management of Laundry and Infection Control Manual, the facility failed to ensure that laundry staff followed infection control processes while performing laundry services and failed to ensure the laundry room was maintained in a sanitary condition. In addition, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for one of two residents with a gastrostomy tube (G-Tube) [a tube surgically inserted through the abdomen into the stomach used to deliver nutrition, fluids, and medications]. These deficient practices had the potential to place residents at risk of infections due to cross-contamination. The census was 73 residents. Findings include:Review of the facility policy titled, Management of Laundry, dated 1/2016, revealed the Description of Steps in the Laundry Process section included, Pck-up or Collection of Soiled Linen. B. Transferring Soiled Linen: . all soiled linen must be covered during transportation while being stored on unit or floors. A soiled linen container should be lined with an impervious (waterproof) liner. At designated times, laundry workers are to collect soiled linens from each soiled linen room using a large bin with lid marked - For Soiled Linen Use Only. Laundry workers must always wear the proper protective equipment (PPE) when handling soiled linen. 2). Sorting soiled linen: The laundry room must have a process in place to effectively sort soiled linen without cross contaminating clean linen. As soiled linens are sorted into proper wash classifications, employees must wear the proper personal protective equipment (PPE), which includes gloves and a protective apron.Review of facility policy titled, Infection Control Manual, revised date 9/2023, revealed the section titled Two-Tier Transmission Based precautions: Airborne Precautions included, Enhanced Barrier Precautions expand the use of PPE [personal protection equipment] and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfers of MDROs [Multi-Drug Resistant Organism] to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for EBP include: . Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.1. During observation and interview of the laundry room on 7/22/2025 at 9:40 am, with the District Manager (DM), observation revealed a blanket on the floor in front of an exterior door. The DM confirmed the blanket and stated it was placed there because of heavy rain, and he was unsure how long the door had been leaking. Continued observation and interview on 7/22/2025 at 10:58 am, with the DM revealed that during the observation of Laundry Aide NN separating and washing laundry, the aide's apron was loose, and soiled laundry came in contact with her uniform. Further observation revealed that Laundry Aide NN went into the clean laundry area to wash hands while wearing a protective apron. The DM confirmed the findings. In an interview on 7/22/2025 at 11:05 am, Laundry Aide NN revealed that the protective gown should be fitted. An observation and interview on 7/22/2025 at 11:11 am of the clean linen storage area revealed a towel with dark black stains coming out of a hole in the wall. Further observation revealed that an uncovered basket of clean laundry was against the towel. Laundry Aide NN stated she was unsure how long the towel had been there. She stated that she had not notified the Maintenance Director about the hole in the wall and stated she would need to rewash the laundry in the basket.In an interview on 7/22/2025 at 11:15 am, the Maintenance Director revealed that he was unaware of the hole in the wall and stated he would place a cap over the hole.During an observation and interview on 7/23/2025 at 1:25 pm, in the laundry room, it was observed that a bag of laundry had been placed on top of the soiled linen bin, and not under the bin cover. The DM stated that the staff had hurriedly placed the bag of laundry on top of the bin cover and covered the bag. 2. Review of R1's admission Record revealed diagnoses including, but not limited to, malignant neoplasm of the tongue and anemia. Review of the Annual Minimal Data Set (MDS) assessment for R1, dated 5/12/2025, revealed that Section K (Swallowing/Nutritional Status) documented that R1 had a feeding tube while a resident. Review of the Care Plan Report for R1 revealed a Focus area, revised date 2/6/2025, of the resident was at risk for changes in skin integrity and had a G-tube. Interventions included enhanced barrier precautions in place, dated 5/21/2025. Further review revealed a Focus area, created 2/3/2025 and revised 7/15/2025, of the resident was at risk for impaired immunity related to currently receiving chemotherapy secondary to tongue cancer. Interventions included that the resident was at risk for contracting infections due to impaired immune status, and keeping the environment clean and people with infection away. Observations on 7/21/2025 at 11:09 am and 7/22/2025 at 10:14 am revealed there was no EBP signage or PPE supplies at R1's doorway or in the room. Observation revealed EBP signage on other resident doors in the facility. Observation on 7/23/2025 at 5:09 pm revealed Licensed Practical Nurse (LPN) FF administering bolus tube feeding to R1, wearing gloves and not wearing a gown. In an interview on 7/24/2025 at 10:35 am, LPN FF confirmed she did not wear a gown while administering tube feeding to R1. She stated that R1 should be on EBP and was unsure where the cart of PPE supplies for R1 was. She further stated residents with indwelling devices should be on EBP. In an interview on 7/24/2025 at 11:11 am, the Director of Nursing (DON) stated that residents with catheters, wounds, and feeding tubes were to be on EBP. The DON further stated the expectation was for the nurse to place a sign on the door and a cart outside the room, and stated that the Wound Care Nurse usually handled EBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of facility policy titled Skin Management Standards, the facility failed to provide wound treatment per the physician's order and failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (R67) of three residents reviewed for pressure ulcers. This deficient practice had the potential to place R67 at risk for medical complications and infection. Findings include: A review of the undated facility policy titled Skin Management Standards, revealed the procedure for dressing change: 1. Check the doctors' orders for the type and frequency of dressing and any special instructions required for performing the procedure, including pre-medication for the resident's comfort. 6. Wash/ Sanitize hands, put on clean gloves, remove soiled dressing, and discard immediately in a plastic bag. 7. Remove gloves, and place them in a plastic bag. 8. Wash/ sanitize hands. 9. Put on a pair of clean gloves. 10. Clean the wound from the center of the wound in a circular motion . 11. Discard gloves. 12. Wash/ sanitize hands. 13. Put on a pair of clean gloves. 14. If ordered, apply medication and topical treatment to the wound. A review of the Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed R67 was not able to complete the Brief Interview for Mental Status (BIMS) score assessment, and had diagnoses including neurological condition, paraplegia, and malnutrition. The resident had one stage 4 pressure ulcer that was not present on admission. A review of the current February 2024 Physician's Orders revealed the following orders: 1. Sacrum: Clean sacrum with Dakin's, apply crushed Flagyl 500 milligrams (mg) (a medication used to treat infections) to the wound bed, then apply Dakins 0.5% (a topical antiseptic used to clean infected wounds and ulcers) moistened gauze to wound bed/undermining, super absorbent, cover dry protective dressing such as superabsorbent adhesive - every day shift for Treatment Plan for Sacrum and as needed for misplaced or soiled dressing. 2. Clean Left Elbow, cleanse wound, pat dry, apply Flagyl directly to the wound bed then apply Dakin's 0.5% moistened gauze to the wound bed, cover with dry protective dressing such as rolled gauze secured with tape or composite. Change Daily/PRN (as needed). Flagyl Oral Tablet 500 mg - Apply to Left Elbow topically every day shift for Treatment to Left Elbow. 3. Left Elbow Medial, cleanse the wound with NS (normal saline) or Dakin's, pat dry, apply Santyl (an ointment used to remove damaged tissue from chronic skin ulcers) nickel thick to the wound bed, cover with calcium alginate for drainage management, then cover with dry protective dressing such as rolled gauze secured with tape or composite, every day shift for Treatment For medial Elbow and as needed for misplaced or soiled dressing. Physician Documentation dated 11/28/2023 revealed pressure ulcers to the sacrum, coccyx, heels, and hips - unavoidable. During observation of wound care on 2/25/2024 at 6:25 am, Licensed Practical Nurse (LPN) BB started treatment to the sacrum. The dressing dated 2/24/2024 was removed. The sacrum wound was cleaned with Dakin's, and crushed the Flagyl was placed on the Dakin's soaked gauze which was then placed on the wound bed. LPN BB did not change gloves or sanitize hands after cleaning the wound and before applying the medication. The Dakin's soaked gauze was not placed into the undermining of the wound. LPN BB completed the treatment, changed gloves, sanitized hands, and moved to the next wound. LPN BB cleaned the left elbow, applied Flagyl to the wound bed, and applied Dakins' soaked gauze and a dry protective dressing. She then cleaned the medial left elbow with Dakin's, applied Santyl to the wound bed, and covered it with calcium alginate and a dry protective dressing. The treatments to the left elbow and medial left elbow was performed according to the physician's order. However, LPN BB failed to change gloves and sanitize hands after cleaning each wound and between each wound treatment. An interview with the LPN BB on 2/25/2024 at 7:30 am revealed that she normally sanitizes hands and changes gloves after cleaning and before placing medication and also, she would normally place the Dakin's soaked gauze into the undermining with a cotton swab. She stated she was nervous.

Based on observations, staff interviews, and review of facility policies titled Procedure for Washing Pots and Pans, and Proper Temperatures For Meal Preparation and Service, and review of the EcoLab Product Specification document for the Multi-Quat Sanitizer, the facility failed to demonstrate the proper usage of the three-compartment sink to sanitize dishware to prevent contamination, failed to allow dishware items to air dry, and failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. These deficient practices had the potential to place residents consuming an oral diet at risk of contracting a foodborne illness. The facility census was 69 with 68 residents receiving an oral diet. Findings include: 1. A review of the undated facility policy titled Procedure for Washing Pots and Pans, revealed the Procedure section line 3: The third sink sanitizes the items by: a. Use of a chemical sanitizer added to water filling the sink with water; or b. Filling the sink with water kept at 180 degrees F and submerging the items for at least one minute. 4. Place pots and pans on the drain sink to air dry. A review of the EcoLab Product Specification document for the Multi-Quat Sanitizer stated to expose all surfaces to the sanitizing solution for not less than 1 minute. Observation on 2/24/2024 at 10:50 am of the Dietary Manager (DM) washing dishware using the three-compartment sink revealed that the sanitizing sink had not been set up for usage. The DM began to set up the sanitizing sink and was having difficulties getting the sink to fill with sanitizing solution. Continued observation of the DM revealed that she washed the dishware in soapy water, rinsed it, and placed it in the sanitizing sink that continued to not fill with sanitizing solution. The DM took the plastic hose in the sink that was dispersing the sanitizing solution and splashed it over the dishware. The DM then handed the dishware items to the dietary cook to use, the items were not placed to air dry. Further observation revealed that the facility was using EcoLab brand quaternary sanitizing solution. During an interview on 2/24/2024 at 10:50 am, the DM confirmed that the dishware was not properly sanitized in the sanitizing solution. The DM confirmed that the facility uses a quaternary sanitizing solution and dishware should be submerged in the solution for at least 60 seconds. The DM was not able to state why the proper procedure was not used and confirmed that she gave the dishware items to the cook to use without air drying. 2. A review of the undated facility policy titled Proper Temperatures for Meal Preparation and Service, revealed the minimum acceptable temperature for meat is 135 degrees F. Steam table temperatures were completed on 2/24/2024 at 12:35 pm with Dietary [NAME] AA using the facility's calibrated thermometer. Continued observation revealed the ground liver had a temperature of 131 degrees F. During an interview on 2/24/2024 at 12:35 pm, Dietary [NAME] AA confirmed that after stirring the pan containing ground liver four times the temperature of the meat was 131 degrees F. The Dietary [NAME] revealed that food items on the steam table should be at least 135 degrees F and the ground liver needed to be re-heated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, the facility failed to promote and facilitate resident self-determination for one (Resident [R] #51) of four sampled residents reviewed for pain management. Specifically, the facility failed to ensure nursing staff honored R#51's choice regarding acceptance or refusal of specific medications. Findings included: A review of the admission Record revealed R#51 had diagnoses including chronic pain, anxiety, spondylosis (arthritis affecting the neck), and spinal stenosis (narrowing or compressing of the nerves) in the neck area/upper back. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R#51 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident received pain medications on an as-needed (PRN) basis and had frequent pain at an intensity level of 7 out of 10 (with zero being no pain and 10 being unbearable pain). According to the MDS, the resident received an opioid (narcotic pain medication) on seven days during the seven-day assessment period. Review of a Care Plan, dated 05/09/2022, revealed R#51 was at risk for pain. A planned intervention was to administer pain medication as ordered. Further review of the care plan revealed an entry dated 06/22/2022, which indicated R#51 refused care and was verbally abusive toward staff. Additionally, a care plan entry dated 08/20/2022 noted that two staff members were to provide all care. Review of the August 2022 Medication Administration Record (MAR) revealed R#51 was to receive oxycodone 10 milligrams (mg) every four hours PRN (as needed) for severe pain, per a physician's order dated 05/06/2022. Review of a Progress Note, dated 08/29/2022 at 6:28 AM, revealed Licensed Practical Nurse (LPN) BB noted that R#51 argued about his/her medications when it was time to take them after having repeatedly requested the medications. Per the note, R#51 stated he/she did not want a sleeping pill and just wanted the pain medication. The note revealed all of the medications had been prepared and placed into two medication cups. The note indicated LPN BB advised the resident to discuss with the physician, any medications about which the resident had questions. The note revealed the resident eventually took the medications. During an interview on 08/30/2022 at 7:25 PM, LPN BB stated on the evening of 08/28/2022, she prepared medications for R#51 and had to wait for a Certified Nursing Assistant (CNA) to go in the room with her. LPN BB stated the resident had made false accusations against the staff, so two staff members had to go in the room during care. LPN BB stated when the CNA was available, she went in to give R#51 the medications. R#51 wanted to argue and only wanted to take the pain pill. LPN BB stated the pills were all mixed together and she could not remember which one was the pain pill, so told R#51 it was all or nothing. LPN BB stated the resident did take the medications later, but she could not recall what time they were given. LPN BB stated she was passing medications on the 100, 200 and 300 Halls and did not take the time to go back to verify which pill was the pain pill. During an interview with the Administrator and the Regional [NAME] President on 09/01/2022 at 2:33 PM, the Administrator stated the resident had the right to refuse medications. The Regional [NAME] President stated the nurse should have identified the pain medication to give the resident and educated the resident on the potential results of not taking the other medications. During an interview on 09/01/2022 at 4:40 PM, the Director of Nursing (DON) stated the nurse should have pulled the bubble pack (medication packet with doses of medication separated into individual bubbles) off the cart to identify the pain medication. The nurse could have given the resident the pain medication and then documented that the resident refused the other medications.

Based on record review, interviews, and facility policy titled Change of Condition/Incident Reporting, the facility failed to notify the responsible party (RP) of a resident's change of condition. The RP was not notified of a hospital transfer or notified when the resident returned from the hospital with a diagnosis of COVID-19. This affected one [Resident (R) #19] of one resident reviewed for notification of changes of condition. Findings included: Review of a policy dated August 2021 and titled Change of Condition/Incident Reporting indicated, If there is an actual change in condition, the resident's physician is notified promptly and validated as to information. Family/Responsible Party notified promptly. A review of an admission Record revealed the facility admitted R#19 with diagnoses which included acute respiratory failure, cerebral infarction, and other speech language deficits. A review of a Minimum Data Set (MDS) assessment, dated 07/04/2022, revealed R#19 had severe cognitive impairment as evidenced by a Staff Assessment for Mental Status (SAMS). Per the MDS, the resident was totally dependent on staff for activities of daily living, had a tracheostomy, and had impaired speech. A review of a progress note, dated 07/09/2022 at 11:23 AM, revealed R#19 was transferred to a hospital for percutaneous endoscopic gastrostomy (PEG; feeding tube) tube replacement. There was no documentation the RP was notified of R#19's hospital transfer. A review of a progress note, dated 07/09/2022 at 11:56 PM, revealed R#19 returned from the hospital with a new gastrostomy tube (G-tube) and was positive for COVID-19. There was no documentation the RP was notified of R#19's return to the facility, G-tube placement, or COVID-19 positive status. During an interview on 08/30/2022 at 11:24 AM, the RP confirmed the facility failed to provide notification on 07/09/2022 that R#19 had been transferred to the hospital for a PEG tube replacement and had not been notified that R#19 had returned from the hospital with a positive COVID-19 diagnosis. During an interview on 09/01/2022 at 10:35 AM, Registered Nurse (RN) QQ reported the decision to send a resident to a hospital involved her discretion and/or notification of family. RN QQ reported she attempted to contact the RP for R#19 once and did not get an answer. RN QQ reported she failed to document the attempt to contact R#19's RP but should have. During an interview on 09/01/2022 at 1:23 PM, Director of Nursing (DON) KK reviewed R#19's chart and reported there was no documented communication with the RP regarding the resident's changes in condition, noting there should have been. On 09/01/2022 at 3:12 PM, the Administrator reported the RP should have been notified of R#19's transfer to the hospital and positive COVID-19 diagnosis upon the resident's return to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of an admission Record revealed R#55 had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular (relating to the brain and its blood vessels) disease affecting the left non-dominant side and end stage renal disease. Review of an annual Minimum Data Set, dated [DATE], revealed R#55 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility and was totally dependent for transfer. During an interview on 08/29/2022 at 8:35 AM, R#55 stated $160.00 cash had been taken from the lockbox in his/her room, which was provided by the facility. The resident stated he/she had reported the missing money to the facility but had not received any response. Review of a Complaint Form, dated 02/28/2022, revealed R#55 reported $160.00 had been taken from a locked box in the resident's room. The resident reported the money had been placed in the lock box, and the key was accidently left inserted in the lock while the resident left the room to visit with family. The resident did not check the contents of the box until the next day, when he/she discovered the money was gone. The section of the form designated for documentation of the steps taken to investigate, summary of pertinent findings or conclusions, and corrective action taken indicated the police were notified and came to the facility, and a report was filed; however, no money was located, and no suspects were identified. The form did not indicate any staff or residents were questioned regarding the missing money. The grievance log entry contained no documentation to indicate the facility conducted any further investigation. The bottom of the form indicated the grievance was resolved and the resident was informed of the outcome. During an interview on 08/30/2022 at 3:35 PM, the surveyor asked the Administrator for a copy of the investigation of R#55's grievance regarding missing money. During an interview on 08/30/2022 at 4:43 PM, the Administrator and the Director of Nursing (DON) stated they had no documented investigation to provide for review. Based on observations, interviews, and record review, the facility failed to ensure prompt efforts were made to resolve residents' grievances and the results of those efforts were communicated to the resident for two (Resident [R] #51 and R#55) of five sampled residents reviewed for grievances related to missing personal property. Specifically, the facility: - Failed to ensure R#51's verbal complaint of missing clothing was documented as a grievance, efforts were promptly made to locate the clothing, and the resident was kept informed of efforts to resolve the grievance. - Failed to ensure R#55's grievance related to missing money was thoroughly investigated. Findings included: 1. Review of an admission Record revealed R#51 had diagnoses which included generalized anxiety disorder, essential hypertension, and spondylosis (arthritis affecting the neck). Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#51 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During an interview on 08/29/2022 at 11:08 AM, R#51 stated R#57 was formerly his roommate and had taken his pants with footballs on them and a family reunion shirt that had family names on it. R#51 stated this occurred two to three weeks ago and R#57 now resided in another room. R#51 stated he/she had reported the missing clothing to staff, but the items had not been returned. During an interview on 08/30/2022 at 1:09 PM, R#51's Family Member VVV stated about three weeks ago, R#51's roommate took a black family reunion shirt with family names on it, a brown pair of pants with footballs on them, and a green and white striped pair of pants. Family Member VVV stated the clothing was brought in so that R#51 would have something to wear when he/she went out of the facility to the doctor. Review of the facility's Grievance Log dated June through August 2022 revealed no written grievances related to R#51's report of missing clothing. During an interview on 08/30/2022 at 3:13 PM, Social Services Director (SSD) TT stated several weeks ago, she received a complaint that R#51 reported that R#57 was wearing clothing that belonged to R#51. SSD TT stated she had never seen R#51 in anything but a hospital gown and had not seen any clothing for R#51. SSD TT indicated one day when she was not working, an employee spoke with her out in the community and told her R#51 stated R#57 took clothing that belonged to R#51. SSD TT stated she was not able to recall the name of the employee who provided the information. SSD TT stated when she returned to work, she did not have a grievance form, did not think about the issue, and took no action regarding the clothing. SSD TT stated there were grievance forms outside her office door to allow the staff to fill out grievances for the residents. During an observation and interview on 08/30/2022 at 3:24 PM, SSD TT obtained permission from R#51 to look for the missing clothing in the resident's room. The missing clothing was not located in R#51's room. SSD TT proceeded to R#57's room, where she found a pair of brown fleece pants with footballs on them and a black shirt with names on it, including the last name of R#51. There was no name tag inside the pants or shirt to verify to whom the clothing belonged. SSD TT checked the facility's unclaimed clothing in the laundry but did not find a pair of green and white striped pants. SSD TT stated she would verify that the shirt and pants belonged to R#51 and then make sure the resident's name was written in the clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to ensure staff immediately reported an allegation of staff-to-resident abuse to the Administrator for one (Resident [R] #13) of one sampled resident reviewed for abuse. The facility further failed to ensure the allegation of staff-to-resident abuse was reported to the State Survey Agency (SSA) for R#13. Findings included: Review of a facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated January 2022, revealed, Reporting/Investigation/Response Policy. Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary, or voluntary, is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner as detailed below. Reporting - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly. The policy also indicated, The intent of the regulation is that as soon as the facility is aware of a situation that meets the reporting requirements, they must immediately notify the administrator, and other officials in accordance with State law, including the State Survey Agency. Review of an admission Record revealed R#13 had diagnoses of dementia with behavioral disturbance, psychotic disorder with delusions, violent behavior, major depressive disorder, and Alzheimer's disease. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The MDS indicated R#13 exhibited physical, verbal, and other behavioral symptoms directed toward others on one to three days during the seven-day assessment period. Review of an incident report, dated 07/17/2022 at 11:00 PM, revealed Licensed Practical Nurse (LPN) RRR approached R#13 with medications, and the resident refused to take them. The LPN informed the resident of the importance of taking the medications. Per the report, the resident then stood up over the nurse and stated, I'm not taking no medication from no fat [expletive] nurse. LPN RRR returned to the medication cart, and R#13 came and stood behind the nurse. LPN RRR instructed the resident to go to his/her room. Per the report, the resident proceeded to grab LPN RRR and began striking the nurse with his/her hands. The nurse screamed for help, and another resident and staff began to separate the resident from the nurse. The report indicated 911 was activated, and other appropriate parties were made aware. According to the report, R#13 had dementia, was often combative and resistive to care, and frequently refused to take medications, which made it very difficult to keep the resident stable and the behaviors controlled. Review of the police incident report, dated 07/17/2022, revealed an officer was dispatched to the facility and upon arrival, spoke with LPN RRR, who informed the office that one of the residents hit her. LPN RRR reported that R#13 used a closed fist to hit the nurse in the chest and back, then the other nurses were able to get R#13 off of her and call the police. The report indicated upon speaking with the resident, R#13 alleged that he/she wanted to use the bathroom and the nurse hit him/her. R#13 reported that LPN RRR punched him/her several times. The report indicated LPN RRR was evaluated by emergency medical services (EMS), and R#13 was transported by EMS to the hospital for further evaluation. During an interview on 08/31/2022 at 10:07 AM, R#35 stated he/she witnessed the entire incident between R#13 and LPN RRR. R#35 stated he/she was in bed and the incident occurred outside the door to his/her room. According to R#35, R#13 approached LPN RRR and asked about his/her medicine. R#35 stated the nurse instructed R#13 to go back to his/her room and stated she would bring the resident's medication, but R#13 stated, I want my [expletive] medicine now. The nurse again instructed R#13 to return to his/her room and R#13 began to hit the nurse in her face and chest. R#35 stated the nurse started to scream for help, put her hands up to protect herself, and eventually pushed R#13 away. R#35 stated R#13 had a closed fist and hit the nurse at least three times, but maybe more. R#35 stated, it all happened so fast. Per R#35, two staff members responded and walked R#13 back to his/her room. R#35 indicated he/she spoke with the police officer who came to the facility and informed the officer that R#13 started the altercation when R#13 hit LPN RRR. R#35 stated LPN RRR was nice to R#13 throughout the entire incident. Review of a quarterly MDS dated [DATE] revealed R#35 had a BIMS score of 10, indicating moderate cognitive impairment. During an interview on 08/31/2022 at 10:17 AM in R#13's room, R#13 denied remembering an incident with a nurse. During a telephone interview on 08/31/2022 at 11:11 AM, Certified Nursing Assistant (CNA) VV stated she was eating in the dining room, so did not see the altercation, but heard hollering at the time of the incident. CNA VV stated after the incident, she saw LPN RRR cheeks were red. CNA VV stated abuse and suspected abuse should be reported to the Administrator, but she did not report anything related to this incident because she thought LPN RRR would. On 08/31/2022 at 11:09 AM and 4:55 PM, a telephone interview was attempted with LPN RRR. On both occasions, there was no answer. The surveyor left a voice mail message requesting a return call, but no return call was received. During an interview on 09/01/2022 at 2:20 PM, the Director of Nursing stated the Administrator was the abuse coordinator and that abuse should be investigated and reported to the State Agency within two hours. During an interview on 08/30/2022 at 12:19 PM, the Administrator stated allegations of abuse should be reported to the State Agency within two hours after the allegation was received. During a follow-up interview on 08/30/2022 at 12:53 PM, the Administrator stated she should have reported the allegation of abuse voiced by R#13. The Administrator offered no reason as to why the allegation was not reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility policy review, and review of an incident report and police report, it was determined the facility failed to investigate an allegation of staff-to-resident physical abuse for one (Resident [R] #13) of one sampled resident reviewed for abuse. Findings included: Review of a facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated January 2022, revealed, Investigation. All alleged violations involving mistreatment, sexual inappropriate behaviors, and abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. The policy listed the steps of the investigation included the following: - 2. Interview the resident or other resident witnesses. - 4. Interview the staff member implicated. Interviewer is to document the staff member's knowledge and/or version of the incident in a written narrative that is dated and signed. - 5. Interview all staff on that unit, as well as other staff or other available witnesses. Review of an admission Record revealed R#13 had diagnoses of dementia with behavioral disturbance, psychotic disorder with delusions, violent behavior, major depressive disorder, and Alzheimer's disease. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The MDS indicated R#13 exhibited physical, verbal, and other behavioral symptoms directed toward others on one to three days during the seven-day assessment period. Review of an incident report, dated 07/17/2022 at 11:00 PM, revealed Licensed Practical Nurse (LPN) RRR approached R#13 with medications, and the resident refused to take them. The LPN informed the resident of the importance of taking the medications. Per the report, the resident then stood up over the nurse and stated, I'm not taking no medication from no fat [expletive] nurse. LPN RRR returned to the medication cart, and R#13 came and stood behind the nurse. LPN RRR instructed the resident to go to his/her room. Per the report, the resident proceeded to grab LPN RRR and began striking the nurse with his/her hands. The nurse screamed for help, and another resident and staff began to separate the resident from the nurse. The report indicated 911 was activated, and other appropriate parties were made aware. According to the report, R#13 had dementia, was often combative and resistive to care, and frequently refused to take medications, which made it very difficult to keep the resident stable and the behaviors controlled. Review of the police incident report, dated 07/17/2022, revealed an officer was dispatched to the facility and upon arrival, spoke with LPN RRR, who informed the office that one of the residents hit her. LPN RRR reported that R#13 used a closed fist to hit the nurse in the chest and back, then the other nurses were able to get R#13 off of her and call the police. The report indicated upon speaking with the resident, R#13 alleged that he/she wanted to use the bathroom and the nurse hit him/her. R#13 reported that LPN RRR punched him/her several times. The report indicated LPN RRR was evaluated by emergency medical services (EMS), and R#13 was transported by EMS to the hospital for further evaluation. During an interview on 08/31/2022 at 10:07 AM, R#35 stated he/she witnessed the entire incident between R#13 and LPN RRR. R#35 stated he/she was in bed and the incident occurred outside the door to his/her room. According to R#35, R#13 approached LPN RRR and asked about his/her medicine. R#35 stated the nurse instructed R#13 to go back to his/her room and stated she would bring the resident's medication, but R#13 stated, I want my [expletive] medicine now. The nurse again instructed R#13 to return to his/her room and R#13 began to hit the nurse in her face and chest. R#35 stated the nurse started to scream for help, put her hands up to protect herself, and eventually pushed R#13 away. R#35 stated R#13 had a closed fist and hit the nurse at least three times, but maybe more. R#35 stated, it all happened so fast. Per R#35, two staff members responded and walked R#13 back to his/her room. R#35 indicated he/she spoke with the police officer who came to the facility and informed the officer that R#13 started the altercation when R#13 hit LPN RRR. R#35 stated LPN RRR was nice to R#13 throughout the entire incident. Review of a quarterly MDS dated [DATE] revealed R#35 had a BIMS score of 10, indicating moderate cognitive impairment. During an interview on 09/01/2022 at 2:20 PM, the Director of Nursing stated the Administrator was the abuse coordinator and that abuse should be investigated and reported to the State Agency within two hours. During an interview on 08/30/2022 at 12:53 PM, the Administrator stated she talked with staff about the incident between R#13 and LPN RRR; however, she did not get statements from the staff or document anything she had done to investigate the allegation. During a follow-up interview on 08/31/2022 at 10:20 AM, the Administrator confirmed there was no investigation into R#13's allegations related to the incident that occurred on 07/17/2022 between R#13 and LPN RRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to change an indwelling urinary catheter at the frequency specified by the physician for one (Resident [R] #62) of three sampled residents reviewed for urinary catheters. Findings included: Review of an admission Record revealed the facility admitted R#62 on 06/24/2022 with diagnoses including stage 3 pressure ulcer to the sacrum and dementia without behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#62 was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status. The MDS indicated the resident had an indwelling urinary catheter. Review of the July 2022 Medication Administration Record (MAR) revealed R#62 was to have a #17 French indwelling Foley urinary catheter with a 30-milliliter (mL) balloon, to be changed every 30 days and as needed, based on an order dated 07/22/2022. The MAR indicated the catheter was to be changed initially on 07/22/2022; however, the MAR did not indicate this was completed. Further review revealed no catheter change was documented as completed during the month of July 2022. Review of the August 2022 MAR revealed the catheter was changed on 08/08/2022. During an interview on 08/31/2022 at 11:10 AM, LPN CCC stated there was no #17 French catheter available on 07/22/2022, so she did not change R #62's catheter. The LPN stated there was a smaller size and a larger size, but not a size 17. The LPN asserted she told some of the staff working that night and the supervisor the next morning before she left that the catheter was not available but could not recall the names of the staff she told. LPN CCC stated she documented the information in the computer, in the area where the nurses documented information for shift report. During an interview on 08/31/2022 at 1:48 AM, Unit Manager CC stated the nurses used a communication board in the computer system to document their shift reports. The Unit Manager checked the communication board in the computer and stated there were no notes from LPN CCC on 07/22/2022 or 07/23/2022 to indicate there was not a #17 French catheter available to change the resident's catheter. During an interview on 08/31/2022 at 12:57 PM, LPN DDD, who worked 7:00 AM to 7:00 PM on 07/23/2022, stated she did not recall anyone reporting a problem to her regarding not having the correct size catheter to change the catheter for R#62. During an observation on 08/31/2022 at 12:45 PM with Certified Nursing Assistant EEE, the resident's urinary catheter was noted to be a #18 French. During an interview on 09/01/2022 at 9:07 AM, Weekend Supervisor FFF stated LPN CCC did not say anything about not having the correct size catheter to change R#62's catheter on the morning of 7/23/2022. During an interview on 09/01/2022 at 9:25 AM, Physician GGG stated he could not recall why he ordered for R#62's catheter to be changed every 30 days. He stated he did not write this order for all of his patients with an indwelling urinary catheter but if he ordered the catheter to be changed every 30 days, it should have been changed. During an interview on 09/01/2022 at 2:23 PM, the Administrator stated there was no such thing as a #17 French Foley catheter and that the nurse should have called the physician to clarify the size of the catheter and changed the catheter. During an interview on 09/01/2022 at 4:35 PM, the Director of Nursing stated the nurse should have called the doctor and clarified the order for R#62's catheter and changed the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy titled, RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to develop person-centered, comprehensive care plans for four (Resident [R] #13, R#35, R#57 and R#60) of 24 residents whose care plans were reviewed. Specifically, the facility: - Failed to develop a care plan that addressed behavioral management for R#13. - Failed to develop a care plan that addressed R#35's pressure ulcer care. - Failed to develop a care plan with resident-specific interventions addressing R#57's nutritional needs and tracheostomy care. - Failed to develop a care plan for R#60 that accurately addressed behavioral symptoms that were pertinent to the resident. Findings included: Review of a facility policy titled, RAI [Resident Assessment Instrument]/Care Planning Management, dated July 2022, revealed, Problems will be identified and written in an interdisciplinary CAA [Care Area Assessment] integrated format. A discharge plan will be included in the care plan at admission. Goals will be resident specific, measurable and realistic. Interventions will be action verb directed and specific to each resident. 1. Review of an admission Record revealed R#13 had diagnoses including dementia with behavioral disturbance, psychotic disorder with delusions, violent behavior, major depressive disorder, and Alzheimer's disease. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS indicated R#13 had physical and verbal behavioral symptoms directed toward others on one to three days during the seven-day assessment period. Review of an Order Summary Report revealed R#13 had physician's orders for the following: - Behaviors: Monitor for restlessness, hitting, biting, kicking, spitting, cussing, delusions, hallucinations, psychosis, aggression, refusing care, ordered 08/03/2022. - Haloperidol decanoate solution (an antipsychotic medication) 100 milligrams per milliliter (mg/mL). The directions were to inject 0.5 ml intramuscularly every 30 days for violent behavior and dementia with behavioral disturbance, ordered 07/20/2022. - Lorazepam (an anti-anxiety drug) 0.5 mg twice a day for agitation, ordered 06/22/2022. - Olanzapine (an antipsychotic medication) 15 mg at bedtime for dementia with behavioral disturbance, ordered 08/03/2022. - Sertraline (an antidepressant medication) 100 mg daily, ordered 06/17/2022. Review of a Care Plan, dated 06/22/2022, revealed R#13 had behavior problems. Interventions included: - Resident will use plastic silverware. - Administer medications as ordered, monitor/document side effects. - Anticipate and meet resident needs. - Provide opportunity for positive interaction, attention; stop and talk when passing by, explain all procedures to the resident before starting. - Intervene as necessary to protect the rights and safety of others. - Resident placed on 1 on 1. Observation on 08/29/2022 at 9:43 AM revealed R#13 sitting on the edge of the bed in his/her room. The resident did not have a roommate. The resident was alert and stated he/she had lived at the facility for six years. The resident mumbled when speaking and did not make eye contact. Observation on 08/30/2022 at 8:52 AM revealed R#13 sleeping in a chair in his/her room. Observation on 08/31/2022 at 10:17 AM revealed R#13 sitting on the edge of his/her bed. The resident was leaning back against the wall and was sleeping. There was a fall mat by the bed. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed a care plan regarding behaviors was developed for R#13 but the interventions in place were not resident-specific. The MDS Nurse stated the care plan should include the use of the specific medications and the signs and symptoms of Haldol use, like extrapyramidal symptoms (EPS), oversedation, sleepiness, increased falling, disorientation, and mental changes. The MDS Nurse confirmed the resident was no longer on 1-on-1 supervision and that this intervention would be removed from the care plan. The MDS Nurse stated the safe way to approach R#13 varied, depending on the time of day and the staff member, and just talking to the resident did not always work. 2. Review of an admission Record revealed R#35 had diagnoses including pressure ulcer of sacral region - stage 3, local infection of skin, and paraplegia (paralysis of the legs and lower body). Review of a quarterly Minimum Data Set (MDS) dated the 07/13/2022 revealed R#35 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated R#35 had a stage 3 pressure ulcer and was at risk for developing pressure ulcers. Review of an Order Summary Report revealed R#35 had physician's orders for the following: - Clean sacral wound with wound cleanser and Dakin's solution ½ strength. The directions were to apply Dakin's solution half strength-moistened gauze to the wound bed and cover with a sacral foam dressing, ordered 05/03/2022. - Skin prep to the left heel one time a day every three days, ordered 04/25/2022. Review of a Care Plan, dated 08/09/2022, revealed R#35 had a sacral wound. Interventions included to provide the diet as ordered, notify the physician as needed, refer to the RD, supplement as ordered, observe wound for signs and symptoms of delayed healing during care, refer to a wound consultant as indicated, suprapubic catheter care as indicated, and treatments as ordered. Observation on 08/29/2022 at 9:21 AM revealed R#35 in bed on a low air-loss mattress. The resident was noted to have a colostomy and suprapubic catheter. Observation and interview on 08/30/2022 at 8:38 AM revealed R#35 in bed. R#35 stated he/she received wound care once or twice a week but not daily. R#35 stated he/she went to the wound clinic once a month and thought the wound on the sacrum was healing. Observation on 08/31/2022 at 10:25 AM revealed LPN RR providing wound care to R#35. LPN RR used proper clean technique to provide wound care to the sacral wound. LPN RR did not provide wound care to the left heel at this time. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed the interventions on the care plan for sacral wound care were not resident-specific for R#35. The MDS Nurse acknowledged that R#35 was to receive wound care daily for a sacral wound and had monthly appointments at the wound care clinic. The MDS Nurse stated R#35's care plan interventions should have included notification of the physician if the wound started draining or started to have an odor. The MDS Nurse stated the care plan should also have included the type of wound care to be provided, the frequency of the care, and when to measure the wound. The MDS Nurse confirmed R#35 did not receive any nutritional supplements. 3. Review of an admission Record revealed R#57 had diagnoses including aphasia (difficulty speaking) following cerebrovascular disease, encounter for attention to tracheostomy (tube placed in neck to provide an artificial airway for breathing), need for assistance with personal care, and developmental disorder of scholastic skills. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#57 had modified independence in cognitive skills for daily decision-making and required only supervision and set-up assistance with eating. According to the MDS, the resident received tracheostomy care. Review of an Order Summary Report revealed R#57 had physician's orders dated 06/23/2022 for the following: - Regular diet, mechanical soft food with chopped meat texture. - Suction as needed. - Tracheostomy (trach) care every shift and as needed (PRN) with a #6 Shiley flex (a flexible tracheostomy tube without a cuff to maintain position and an inner canula to be reused after cleaning). Review of Care Plan, dated 06/30/2022, revealed R#57 had a tracheostomy. Interventions included to ensure the trach ties were secured; monitor/document for restlessness, agitation, confusion, increased heart rate, level of consciousness, mental status, and lethargy; provide good oral care daily and as need; provide paper and pencil if needed; and suction as necessary. Review of a Care Plan, dated 08/09/2022, revealed R#57 was at risk for alteration in nutritional status. Interventions included providing the diet as ordered, completing laboratory services (labs) as ordered, notifying the physician as needed, referring to the Registered Dietitian (RD), supplements as ordered, and weighing the resident monthly and as needed. Observation on 08/29/2022 at 9:52 AM revealed R#57 was in his/her room, sitting in a wheelchair, eating breakfast. The tray consisted of scrambled eggs, chopped sausage, cream of wheat, and a biscuit. The resident had a tracheostomy in place with a cap, which allowed the resident to answer questions easily. Observation on 08/31/2022 at 2:03 PM revealed Licensed Practical Nurse (LPN) PP in R#57's room providing tracheostomy care to the resident. LPN PP followed proper sterile technique throughout the procedure, during which the LPN cleaned and dried the trach cap placed it back over the resident's trach. During an interview with LPN PP at this time, LPN PP stated the resident could speak easily with the cap in place on the tracheostomy tube. LPN PP stated the resident did not use a paper and pencil or communication board to communicate because the resident was able to speak. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed the care plans regarding R#57's nutritional status and tracheostomy care were not resident-specific. The MDS Nurse acknowledged being aware that R#57 had an order for mechanically altered food and that this should have been included in the care plan. The MDS Nurse stated the care plan interventions should have included notification of the physician with concerns such as coughing while eating, refusing meals, weight loss, and other concerns specific to the resident. The MDS Nurse confirmed Resident #57 did not receive any special supplements and that the interventions regarding tracheostomy care should include the type of trach used, how to clean it, and the size of the tracheostomy tube. 4. Review of an admission Record revealed the facility admitted R#60 on 08/02/2022 with diagnoses including unspecified dementia with behavioral disturbance, major depressive disorder, and generalized muscle weakness. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#60 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS indicated R#60 did not exhibit any behavioral symptoms. Review of an Order Summary Report revealed R#60 had physician's orders dated 08/02/2022 for the following medications: - Olanzapine (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and psychosis) 10 milligrams (mg) daily for behaviors. - Mirtazapine 7.5 mg at bedtime for depression. Review of a Care Plan, dated 08/03/2022, revealed R#60 used psychotropic medications related to behaviors. Interventions included: - Administer medications as ordered. Monitor for side effects and effectiveness every shift. - Behaviors: Monitor for itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Observation and interview on 08/29/2022 at 9:48 AM, revealed R#60 in bed. The resident responded to questions appropriately and stated he/she had pain in the groin area and was not sleeping well. Observation on 08/31/2022 at 9:00 AM, revealed R#60 ambulating in the hallway with staff assistance. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed a care plan regarding behavior monitoring was developed for R#60 but the interventions and behavior monitoring in place were not resident-specific. The MDS Nurse acknowledged being unaware of what behavioral symptoms R#60 exhibited but confirmed the resident did not have any aggressive behaviors; did not exit-seek; did not hit, kick, or spit; and did not exhibit any verbal behaviors. The MDS Nurse stated the interventions were selected from a computer-generated library of possible interventions, and that the MDS Nurse should have talked to staff to identify R#60's behaviors. The MDS Nurse confirmed the interventions on R#60's care plan were not appropriate. During an interview on 09/01/2022 at 12:22 PM, Licensed Practical Nurse (LPN) PP revealed R#60 did not have physically or verbally aggressive behaviors. LPN PP stated the resident liked to ambulate in the halls to look around but did not exit-seek. LPN PP stated the resident was pleasant but sometimes resistive to care. During an interview on 09/01/2022 at 2:20 PM, the Director of Nursing (DON) stated R#60 liked to walk around and was sometimes resistive to care. The DON indicated the purpose of care planning was to tell staff what they needed to know be able to care for the resident, to evaluate the plan, and to adjust the care plan as needed. During an interview on 08/30/2022 at 12:19 PM, the Administrator stated care plans directed the residents' care and explained to staff what the residents' needs were. The Administrator stated the care plans should paint a picture of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of R#65's admission Record revealed R#65 was admitted with a diagnosis of dementia with behavioral disturbance. A review of R#65's significant change (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. A review of R#65's physician orders, dated 07/25/2022, revealed a treatment order directing staff to apply Betadine (povidone-iodine; used to help prevent infection in minor cuts, scrapes, and burns) to the left heel every two days during the dayshift to treat a deep tissue pressure injury (DTPI). A review of R#65's medication administration record (MAR), dated 08/01/2022 through 8/31/2022, revealed nine of 16 ordered Betadine treatments were not documented as completed. During an interview on 08/31/2022 at 11:51 AM, Licensed Practical Nurse (LPN) RR (wound care nurse) stated the treatment orders for R#65 were to apply Betadine to the left heel every two days. She stated that, after treatments were completed, she documented them on the MAR. She stated a check mark and initials on the MAR meant a treatment was completed. She stated the empty space on R#65's MAR meant the treatment was not checked off as completed. LPN RR stated the only day of the month in August of 2022 when she did not work (Monday through Friday) occurred on 08/19/2022. She noted she sometimes worked the medication cart, during which times she only conducted treatments scheduled on her hall. She stated she worked the medication cart for several days through the month. During an interview on 09/01/2022 at 12:50 PM, Director of Nursing (DON) KK stated she expected wound care to be completed per physician orders. She stated if a treatment was completed, staff initials would be placed in a corresponding space on the MAR. She stated if the treatment record was blank, the care was not provided. DON KK stated R#65's treatments were not administered in accordance with physician orders per the MAR. During an interview on 09/01/2022 at 12:59 PM, Administrator stated she expected wound care to be done as prescribed by the physician. She stated the empty spaces on the MAR indicated staff had not done the treatment or had not checked the treatment as completed. She stated if the treatment was completed, she would expect it to be documented. During an interview on 09/01/2022 at 5:40 PM, LPN SS stated if there were residents with wounds on the hall, the wound care nurse conducted wound treatments. She stated if there was not a treatment nurse, the nurse on the floor would be responsible to do the wound care. Per LPN SS, she could not recall if she conducted R#65's wound care on 08/19/2022. She stated if she had done the wound care, it would be documented on the MAR. 3. A review of an admission Record for R#35 revealed the facility admitted the resident with diagnoses including stage III pressure ulcer of the sacral region, local infection of skin, and paraplegia. A review of R#35's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS indicated R#35 had a stage 3 pressure ulcer and was at risk for developing additional pressure ulcers. A review of the care plan for R#35 indicated a comprehensive care plan had been developed on 08/09/2022 with a sacral wound focus area. Interventions directed staff to provide colostomy care as indicated, provide a diet as ordered, notify the physician as needed, refer to the Registered Dietician as needed, provide supplement as ordered, observe wound for signs and symptoms of delayed healing during care, refer to wound consultant as indicated, provide suprapubic catheter care as indicated, and provide treatments as ordered. A review of R#35's physician Order Summary Report revealed the following orders: -Clean sacral wound with wound cleanser and Dakin's solution ½ strength (25%). Apply Dakin's Solution Half Strength (25%) to moistened gauze to wound bed, cover with sacral foam dressing daily, dated 05/03/2022. -Skin prep left heel one time a day every three days. Order written 04/25/2022. A review of a July 2022 medication administration record (MAR) for R#35 indicated sacral wound care was ordered daily but was not initialed in the MAR as completed for 15 of 31 days in the month. Though wound care to the left heel was ordered once every three days, it was not initialed as completed on four of 11 ordered days for the month. A review of the August 2022 MAR for R#35 indicated sacral wound care was ordered daily until 08/31/2022 but was not initialed on the MAR as completed on 17 of 31 days for the month. Wound care to the left heel was ordered once every three days but was not initialed as completed for 5 out of 10 ordered days for the month. Observation on 08/29/2022 at 9:21 AM revealed R#35 was in bed, had a low air loss mattress in place, and had a colostomy and suprapubic catheter in place. Observation on 08/30/2022 at 8:38 AM revealed R#35 was in bed with a low air loss mattress in place. R#35 stated he/she received wound care once or twice a week but not daily. R#35 stated he/she was seen at the wound clinic once a month and noted he/she thought the wound on the sacrum was healing. During an interview on 08/30/2022 at 2:19 PM, Licensed Practical Nurse (LPN) RR (wound care nurse) stated R#35 was seen by the wound care clinic once a month. LPN RR stated all wound measurements were completed by staff from an outside wound care company who came to the facility weekly except for R#35, who went to the clinic monthly. LPN RR stated the wound measurements were completed for R#35 at the outside wound care clinic visits. LPN RR stated that all wound care was provided by her except on the days she was not working or was pulled to work the floor as a charge nurse. LPN RR confirmed there were 15 undocumented wound care treatments for R#35's sacral wound and four undocumented wound care treatments to the left heel for the month of July 2022 and 17 days of undocumented wound care treatments to the sacral wound and 5 undocumented left heel wound treatments documented for the month of August 2022. LPN RR stated any nurse who completed a treatment was to initial the electronic MAR to indicate the treatment was completed. LPN RR stated, If it wasn't documented, it was not done. LPN RR stated she took full responsibility for not signing the MAR when she completed R#35's treatment and noted that a blank (uninitialed) area on the MAR meant the treatment was not done. LPN RR stated that in the month of August 2022, she did not always work as the treatment nurse because she was pulled from the treatments to work as a charge nurse on the floor six days in August 2022. LPN RR stated that when she worked as a treatment nurse, either she or the Director of Nursing (DON) notified staff that each nurse had to provide wound care for their assigned residents. During an interview on 08/30/2022 at 8:58 AM, LPN OO stated the treatment nurse was responsible to provide wound care but if the treatment nurse was not working, each nurse was responsible for wound care for their residents. During an interview on 08/30/2022 at 9:10 AM, LPN PP stated each nurse was responsible to provide wound care and treatments to their residents if the treatment nurse was not working. LPN PP stated the DON usually notified staff if they needed to do their own treatments. LPN PP stated that a blank spot on the MAR indicated that a treatment was not done, or a medication was not given. LPN PP stated, If you didn't document it, it was not done. During an interview on 09/01/2022 at 2:20 PM, the DON stated wound care was provided by the treatment nurse and, if the treatment nurse was pulled to work the floor as a charge nurse, the floor nurses were responsible for the wound care for their residents. The DON confirmed she was not aware that there were many missed wound care treatments for R#35 until the survey. During an interview on 08/30/2022 at 12:19 PM, the Administrator stated nurses were expected to follow physician orders as written. Administrator stated that if the wound care nurse was unavailable, each floor nurse was expected to perform wound care for their residents. During an interview on 09/01/2022 at 10:02 AM, the facility Medical Director stated he expected staff to follow physician's orders and to be notified if care was not delivered or if there were medications or treatments not available. The Medical Director stated he was not made aware of missed treatments for R#35. Based on observations, record review, interviews, and policy review, the facility failed to ensure staff followed physician orders regarding medication dosing and wound care frequency for three (Resident [R] #35, #51, and #65) of four sampled residents reviewed for physician orders. Findings included: A review of the facility's policy, titled, Physician Services indicated It is the standard of this facility that all medications and treatment protocols are ordered by the resident's attending physician or designee. Physician's orders include medications including strength, dosage, frequency, route of administration, supporting diagnosis and a stop date when appropriate. 1. A review of an admission Record revealed the facility admitted R#51 on 05/06/2022 with diagnoses of chronic pain, anxiety, and major depressive disorder. A review of a quarterly Minimum Data Set (MDS) assessment, dated 08/02/2022, revealed R#51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Per the MDS, R#51 had verbal behaviors for 1-3 days and rejected care for 1-3 days during the review period. A review of physician orders revealed an order dated 08/03/2022. The order directed staff to administer amitriptyline (used to treat nerve pain and depression) 25 milligrams (mg) 1 tablet at bedtime. The order was signed by Nurse Practitioner DD. A progress note, dated 08/03/2022 at 11:00 AM, noted the new order for amitriptyline and identified that there were possible drug interactions between the amitriptyline and some other medications prescribed for R#51. A review of a pharmacy invoice revealed the pharmacy sent 30 tablets of amitriptyline 25 mg on 08/04/2022. A review of R#51's Medication Administration Record (MAR) for August 2022 revealed one 25 mg tablet of amitriptyline was documented as administered at bedtime from 08/04/2022 through 08/11/2022. A review of a physician's order dated 08/12/2022 revealed it directed staff to administer one 50 mg tablet of amitriptyline to R#51 at bedtime. The order was signed by Nurse Practitioner DD. A review of the August 2022 MAR revealed the medication was signed as given from 08/12/2022 to 08/26/2022. A review of the August 2022 MAR revealed R#51 refused amitriptyline on 08/27/2022. An 08/28/2022 entry on the August 2022 MAR revealed the amitriptyline was not administered to R#51. The 08/28/2022 entry referred the reader to a nurse's note and was signed by Licensed Practical Nurse (LPN) BB. A review of an associated nursing progress note dated 08/28/2022 at 7:45 PM and signed by LPN BB indicated the increased dosing of amitriptyline to one 50 mg tablet daily at bedtime was ordered on 08/12/2022, but staff were still waiting on the pharmacy to send 50 mg tablets, leaving staff with no 50 mg tablets and a limited and/or non-existent supply of 25 mg amitriptyline tablets remaining from the 08/03/2022 order. An 08/29/2022 entry on the August 2022 MAR referred the reader to a nurse's note and was signed by LPN EE. However, a review of nursing progress notes for 08/29/2022 failed to reveal a note related to amitriptyline documented by LPN EE. On 08/31/2022 at 8:25 AM, an observation of the medication cart on the 100 Hall was made with LPN FF. LPN FF looked through R#51's medications, including back-up medications, and stated there was no amitriptyline on the cart for R#51. On 08/31/2022 at 2:30 PM, Consulting Pharmacist GG stated the 50 mg dosing of amitriptyline was never sent to the facility by the pharmacy due to a warning that the amitriptyline could cause an undesired interaction with other medications prescribed for R#51. Consulting Pharmacist GG stated a fax was sent to the facility on [DATE] asking staff to clarify the order for 50 mg of amitriptyline with the prescriber. An interview was conducted with Unit Manager CC on 08/31/2022 at 2:34 PM. Unit Manager CC stated Nurse Practitioner DD entered the orders for amitriptyline herself in the computer on 08/03/2022 and 08/12/2022. Unit Manager CC stated a drug interaction warning showed up at that time and Nurse Practitioner DD had to indicate via electronic signature that she wanted the medication to be given. The unit manager stated when the nurse practitioner ordered the medication on 08/03/2022 and noted the warning, Nurse Practitioner DD ordered an electrocardiogram (EKG; measured electrical activity of the heart to detect cardiac problems) for R#51 (due to the potential for heart rhythm-related issues associated with the warning), which was conducted on 08/03/2022. On 08/31/2022, an interview was conducted with LPN FF, who initialed an 08/21/2022 MAR entry indicating she administered 50 mg of amitriptyline to R#51, even though the pharmacy had not sent 50 mg tablets of amitriptyline. LPN FF stated she could not recall the amitriptyline order or how many tablets she administered. During an interview on 08/31/2022 at 4:30 PM, Unit Manager CC stated a copy of the document faxed by the pharmacy on 08/12/2022 could not be located, noting she planned to call the pharmacy to request they re-fax the document. Unit Manager CC stated Nurse Practitioner DD was aware of the drug interaction warning and noted that R#51 did not want to take the medication due to drowsiness (a potential side effect of the medication). Per Unit Manager CC, Nurse Practitioner DD stated R#51 needed the medication due to behaviors. A review of a fax resent to the facility by the pharmacy on 08/31/2022 noted the fax was originally sent on 08/12/2022 and identified that the amitriptyline 50 mg ordered for R#51 had the potential for significant drug interactions. Via the faxed message, the pharmacy asked the facility to verify with the prescriber that medication therapy should proceed, noting the pharmacy could not send the 50 mg amitriptyline tablets until this was addressed. There was no documentation that the amitriptyline dosing was clarified with Nurse Practitioner DD or a physician. On 09/01/2022, an interview was conducted with Nurse Practitioner DD, who stated she entered orders on 08/03/2022 for R#51 to be administered amitriptyline 25 mg every night and then entered orders on 08/12/2022 for staff to administer amitriptyline 50 mg nightly to R#51. The nurse practitioner stated she was aware of the medication interaction warning and, on 08/03/2022, she ordered an EKG and the EKG was normal. Nurse Practitioner DD further stated R#51 wanted ordered pain medications increased and that R#51 had behaviors, so she was trying to find a medication to help with both issues. Nurse Practitioner DD stated Unit Manager CC notified her the day prior, on 08/31/2022, that the pharmacy did not fill the 50 mg amitriptyline order due to possible drug interactions. Nurse Practitioner DD stated she told Unit Manager CC to send the 08/03/2022 EKG report to the pharmacy and tell them she was following the resident very closely. A review of R#51's August 2022 MAR revealed LPN BB signed off that amitriptyline 50 mg was given on 08/23/2022 and 08/24/2022. LPN BB was called for an interview on 09/01/2022 at 12:10 PM. However, a message was received that the mailbox was full and the caller was unable to leave a message for LPN BB to return the call. A review of R#51's August 2022 MAR revealed LPN EE signed to indicate she administered amitriptyline 50 mg on 08/25/2022. On 09/01/2022 at 12:44 PM, Nurse EE stated in an interview she could not recall the specifics of R#51's amitriptyline order or how many amitriptyline tablets she gave to the resident. On 09/01/2022 at 2:33 PM, an interview was conducted with the Administrator and the Regional [NAME] President. The Administrator stated there was no way to know what dose of amitriptyline R#51 received (after the 50 mg tablets were not delivered by the pharmacy), stating the scenario represented a medication error. The Administrator stated the missed fax from the pharmacy was also a problem. The Regional [NAME] President stated staff needed to check the fax machine for received documents, including on the weekends. The Regional [NAME] President also stated the nurse administering medications should have called the pharmacy regarding R#51's amitriptyline when the order changed from 25 mg daily to 50 mg daily and the 50 mg dose was not on the medication cart. During an interview on 09/01/2022 at 4:40 PM, the Director of Nursing (DON) stated nursing staff should have matched the medication in the cart against the order on the bubble pack of medication and against the order on the MAR for R#51, noting if the order and the dose of the medication on the bubble pack did not match, the nurse should have clarified the order. The DON further stated nursing staff had apparently failed to read R#51's new amitriptyline order.

Based on observations, interviews, and review of the facility's infection control policy titled, Pandemic Pathogen Plan (Coronavirus), and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure that all staff were wearing face masks appropriately when the COVID-19 county transmission level for the facility was high. This had the potential to affect all 67 residents in the facility. Findings included: A review of the facility's policy titled, Pandemic Pathogen Plan (Coronavirus), dated 03/2020, revealed in part the following: Person to person appears like other respiratory viruses, mainly due to respiratory droplets produced when an infected person coughs or sneezes. These droplet land in the mouths, nose and/or eyes of people who are nearby or possibly inhaled into their lungs. A review of the CDC COVID Data Tracker, indicated that at the time of the survey entrance, 08/29/2022, the facility was located in a county with high community transmission of COVID-19. A review of the CDC guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 02/02/2022, indicated, Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: - Are not up to date with all recommended COVID-19 vaccine doses; or - Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or - Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection for 10 days after their exposure, including those residing or working in areas of a healthcare facility experiencing SARS-CoV-2 transmission (i.e., outbreak); or - Have moderate to severe immunocompromise; or - Have otherwise had source control and physical distancing recommended by public health authorities. An observation on 08/29/2022 at 12:20 PM revealed Dietary Aide (DA) HHH was sitting in the dining room without a face mask. There were three residents observed sitting in the dining room less than six feet from the staff member at that time. DA HHH stated she had her mask in her pocket and did not have a reason for not wearing it. DA HHH stated the facility policy was to always wear a face mask while in the nursing home. An observation on 08/29/2022 at 12:10 PM revealed Certified Nursing Assistant (CNA) III sitting behind the front nurses' station without a mask on. CNA III stated the facility policy was to wear a mask whenever there was anyone around her, and she did not wear one because there was no one around. CNA III later confirmed a nurse had been sitting next to her at the nurses' station immediately prior to this surveyor approaching her. An observation on 08/29/2022 at 11:46 AM revealed the Administrator sitting at her desk in her office. The DON was standing behind her chair, leaning over the Administrator's desk. The DON's face mask was pulled down under her chin. An observation on 08/29/2022 at 2:13 PM revealed the DON leaning across the front hall nurses' station, talking to a staff member. The DON's face mask was pulled down under her chin. The DON stated the mask had slipped under her chin. She stated the facility's policy was to have the mask always covering the nose and mouth in the facility. An observation on 08/29/2022 at 2:36 PM revealed Licensed Practical Nurse OO sitting behind the back hall nurses' station with a surgical mask under her nose. LPN OO stated she did not pinch the nose piece and the mask slid down. LPN OO stated the facility's policy was to wear a face mask always covering the nose while in the facility. An observation on 08/29/2022 at 1:30 PM revealed DA KKK emptying tray carts and handing trays to the dishwasher through the service window in the dining room. There were staff members within six feet of him. DA KKK did not have a mask on. DA KKK stated he removed his mask because his nose itched. DA KKK stated the facility policy was to wear a mask at all times that covered the nose and mouth. An observation on 08/29/2022 at 1:32 PM revealed [NAME] LLL walking down the main hallway pushing a food cart and not wearing a face mask. [NAME] LLL walked past residents, proceeded to the front lobby area, and picked up a mask. [NAME] LLL stated there were no masks in the kitchen and someone needed to get the kitchen staff a box of masks. An interview was conducted on 08/29/2022 at 2:36 PM with LPN CC, who was the infection preventionist. LPN CC stated the facility's last outbreak for COVID-19 was between 06/25/2022 and 07/26/2022, and the positive COVID-19 cases were employees. LPN CC stated the facility policy was to wear masks covering the nose and mouth at all times while in the facility. LPN CC stated the residents were encouraged to wear masks, and staff was trained on proper mask wearing and usage at least monthly and whenever there was an outbreak. An interview was conducted on 09/01/2022 at 2:20 PM with the DON. The DON stated face masks were to be worn at all times and should cover the nose and mouth completely. The DON stated that if the mask was ill fitted, staff should get a mask that fit properly. The DON stated there was no excuse for not wearing the mask properly. An interview was conducted on 08/30/2022 at 12:19 PM with the Administrator. The Administrator stated face masks were to be worn covering the nose and mouth and should be worn at all times. The Administrator stated that not wearing masks properly could cause a COVID-19 outbreak and may have been the cause of the most recent outbreak. The Administrator stated she would conduct additional training. An interview was conducted on 08/29/2022 at 2:36 PM with LPN CC, who was the infection preventionist. LPN CC stated the facility's last outbreak for COVID-19 was between 06/25/2022 and 07/26/2022, and the positive COVID-19 cases were employees. LPN CC stated the facility policy was to wear masks covering the nose and mouth at all times while in the facility. LPN CC stated the residents were encouraged to wear masks, and staff was trained on proper mask wearing and usage at least monthly and whenever there was an outbreak. An interview was conducted on 09/01/2022 at 2:20 PM with the DON. The DON stated face masks were to be worn at all times and should cover the nose and mouth completely. The DON stated that if the mask was ill fitted, staff should get a mask that fit properly. The DON stated there was no excuse for not wearing the mask properly. An interview was conducted on 08/30/2022 at 12:19 PM with the Administrator. The Administrator stated face masks were to be worn covering the nose and mouth and should be worn at all times. The Administrator stated that not wearing masks properly could cause a COVID-19 outbreak and may have been the cause of the most recent outbreak. The Administrator stated she would conduct additional training.