**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of facility policy, the facility failed to provide interventions as planned for the prevention of falls for one of three residents reviewed for falls (Resident (R) #26). Findings include: Review of the facility policy titled, Incident and Reportable Event Management dated September 2025, revealed Policy - The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy further revealed, Procedure - The Five I's to Event Management - To help reduce the risk of an event, all residents receive assistance and supervisions as addressed in their care plan. Review of R#26's clinical record revealed an admission date of 6/29/2020 and the diagnoses included dementia, anxiety, contracture of left thigh muscle, fracture of the right femur, and history of falling. Review of R#26's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive impairment. The MDS revealed R#26 required set-up/supervision with ambulating 10 feet and the activity of ambulating 50 or 150 feet did not occur during the assessment period. The MDS revealed the resident had not fallen since the previous assessment. Review of R#26's at risk for falls care plan dated 3/21/2025 revealed the interventions of bed in lowest position when in bed and reposition signage to a more visible location to ask for assistance. Review of R#26's hospital Discharge Summary revealed the resident was transferred to the hospital on 4/20/2025. The resident admitted to the staff she had a fall from the wheelchair approximately three days prior, which she denied telling the nursing staff. The resident admitted that her hip was persistently hurting and she was transferred to the hospital. R#26 was diagnosed with a right femur fracture and did not want surgical intervention. The resident was discharged back to the facility on 4/23/2025. Observation of R#26 on 4/29/2025 at 12:02 pm revealed the resident lying in bed and the bed was at the regular height. Observations of R#26 on 4/30/2025 at 8:07 am and 12:10 pm, revealed the resident lying in bed and the bed was not in the lowest position. Observations of R#26 on 5/1/2025 at 9:20 am and 2:00 pm revealed the resident lying in bed and the bed was not at the lowest position and there was no sign in the room to instruct the resident to call for assistance. An observation on 5/1/2025 at 2:03 pm of R#26's room and an interview with Registered Nurse (RN) DD revealed after the surveyor asked about if the bed was in the lowest position, RN DD lowered the resident's bed approximately 12 inches to the lowest position. RN DD at that time confirmed there was no sign in the room to instruct the resident to call for assistance. In an interview with MDS Coordinator FF on 5/2/2025 at 9:08 am, she stated the Interdisciplinary Team made sure the interventions on the care plan were put in place. The team used an informal process to ensure the intervention was in place, just by completing observations and talking with the staff, but not documented as completed. In an interview with the Director of Nursing (DON) on 5/2/2025 at 9:42 am, she stated the staff should follow the care plan as much as possible. The DON stated the direct care staff found out about the residents' care interventions by reviewing the [NAME], during Grand Rounds, or verbal reports.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide assistance and provide accurate documentation of meal intake for one of five residents (R) (R26) reviewed for nutrition status. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs) dated 9/10/2024, revealed Policy - The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be reported to the nurse. Review of R26's clinical record revealed diagnoses that included but not limited to dementia, anxiety, disorder of plasma-protein metabolism, emphysema, and chronic ulcer of left lower leg. Review of R26's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive impairment; Section GG (Functional Abilities and Goals) revealed R26 required set-up/supervision with eating, weighed 108 pounds, experienced weight loss, and was on a mechanically altered diet. Review of R26's hospital Discharge Summary revealed the resident was transferred to the hospital on 4/20/2025 and discharged on 4/23/2025 with the diagnoses of a right femur fracture. Review of R26's care plan for unplanned/unexpected weight loss revised 4/4/2025 revealed the intervention to record food intake at each meal. Review of R26's care plan for ADL Assistance and Therapy Services revealed the staff should assist the resident with mobility and ADLs as needed. Review of R26's Physician Orders revealed an order for a regular diet/regular texture with the start date of 4/23/2025. Review of R26's Mini Nutritional Assessment revealed a score of seven with a score of zero to seven identified the resident as malnourished. Observations of R26 on 4/29/2025 revealed: 12:10 pm - the lunch tray was on the overbed table, and the overbed table was on the right side of the bed and R26 was lying on their right-side fidgeting with the napkin and not eating. Staff was not present with the resident. 12:20 pm - no staff with R26 and the resident not eating. 12:28 pm - a staff member entered the room and asked R26 if she had it. Staff left the room without cueing or assisting the resident to eat. 12:43 pm - Observation revealed R26 only ate the meat off one side of the chicken leg. 12:56 pm - R26 was lying in bed with her eyes closed and had not eaten anything else. Review of the Meal Intake report revealed staff documented the resident ate 51 to 75 percent (%) of the meal. Observations of R26 on 4/30/2025 revealed: 8:07 am - the breakfast tray was on the overbed table, positioned to the right side of the bed. A staff member entered the room and asked R26 if she was going to eat and stated, it is right here, you didn't eat anything. Staff did not attempt to assist or encourage the resident to eat. 8:58 am - the breakfast tray was observed on the overbed table, and R26 had not eaten anything. 12:10 pm - staff served R26 her lunch tray and placed it on the overbed table on the right side of the bed. The resident was lying on her right side with the head of the bed elevated approximately 45 degrees. The resident was picking at the food. Staff was not present in the room. 12:22 pm - staff had not entered the resident's room to queue or assist R26 and the resident was not eating her lunch meal. 12:44 pm - staff picking up the trays from the residents' rooms. A staff member from the hall asked, You not going to eat? Staff entered the room and then came back out without the tray and stated the resident had changed her mind. 12:47 pm to 12:49 pm - two staff members entered the resident's room, one staff member left and then returned with a package of incontinence briefs. 12:51 pm - the staff removed the tray from the resident's room and the resident ate 0% of the lunch meal. Review of the Meal Intake report revealed staff documented the resident ate 51 to 75% of both the breakfast and lunch meals. An observation of R26 on 5/1/2025 at 9:20 am revealed the resident's breakfast tray was on the overbed table. The coffee mug and the Styrofoam bowl were empty. The plate still contained a piece of toast, bacon, and grits. In an interview with Registered Nurse (RN) DD on 5/1/2025 at 2:03 pm, revealed R26 required extensive assistance with ADLs, but she could feed herself. Staff should set her tray and herself up and either position the tray in front of her or to her side. RN DD also stated the staff should queue R26 to eat if she did not eat on her own. In an interview with Certified Nursing Assistant (CNA) HH on 5/2/2025 at 9:13 am, she stated the resident required extensive assistance with all ADLs except eating, which required supervision and set-up. CNA HH stated they documented meal intake by the percentage eaten of the entire meal served. In an interview with the Director of Nursing (DON) on 5/2/2025 at 9:42 am, she stated the meal intake was the percentage of the entire meal eaten and the CNAs completed that documentation. The DON stated if a resident was not eating, the staff should queue, encourage, and try to get the resident to eat. Staff should also offer the resident alternatives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to provide housekeeping and/or maintenance services to maintain a clean and orderly environment on four of six nursing units/floors including resident rooms (Resident Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 27, 31, 32, 34, 35, 37, 38, 39, and 43) and failed to ensure the cleanliness of the carpet. Findings include: During an environmental tour of the facility on 4/29/2025, starting at approximately 10:50 am, the following was observed: In Resident room [ROOM NUMBER], there were paint chips on the wall of the bathroom which exposed the drywall. In Resident room [ROOM NUMBER], scuff marks were on the floor, and paint chips which exposed the dry wall were in the bathroom. A cable coming out of the drywall in the room did not have a face plate. Resident room [ROOM NUMBER] had paint chips on the wall of the bathroom exposing the drywall. A cable with a face plate in the room was hanging out of the wall. Brown, black stains were on the privacy curtain. In Resident room [ROOM NUMBER], a cable came out of the drywall in the room, and scuff marks and paint chips exposed the dry wall in the room and bathroom. A ceiling electrical outlet was hanging out of the ceiling tile. In Resident room [ROOM NUMBER] had paint chips that exposed the dry wall in the room and bathroom. A wire was coming out of the PTAC (packaged terminal air conditioner) unit on the wall. Resident room [ROOM NUMBER] had paint chips on the wall of the bathroom which exposed the drywall. The toilet paper holder was broken off the wall. Resident room [ROOM NUMBER] had scuff marks and paint chips exposing the dry wall in the room and bathroom, the head of bed was broken and hanging off, and a ceiling electrical outlet was hanging out of the ceiling tile. Resident room [ROOM NUMBER] had scuff marks and paint chips exposing the dry wall in the room and bathroom, and the bathroom door handle was loose. Resident room [ROOM NUMBER] had a ceiling electrical outlet that was hanging out of the ceiling tile and there was a tear in the flooring under the toilet which exposed the wooden subflooring. In Resident room [ROOM NUMBER], the bathroom door handle was loose. Resident room [ROOM NUMBER] had scuff marks and paint chips exposing the dry wall in the room, and there were brown, black stains on the privacy curtain. The toilet paper holder was broken off the wall. In Resident room [ROOM NUMBER], the bathroom wall molding was separated off the wall, and there was a tear in the flooring near the toilet. The nightstand composite wood was worn away and crumbling at the base. Resident room [ROOM NUMBER] had scuff marks on the floor. Resident room [ROOM NUMBER], floor tile missing behind the bed and missing paint in the bathroom. Resident room [ROOM NUMBER], missing paint in the bathroom and the bathroom wall had holes, entry and bathroom doors with scrapes, handle of bed B's nightstand with only one screw and handle hung downward. Resident room [ROOM NUMBER], entry door and bathroom doors scraped, walls with missing paint. Resident room [ROOM NUMBER], entry and bathroom doors with scrapes and paint missing in the bathroom. Resident room [ROOM NUMBER], entry and bathroom door with scrapes. Resident room [ROOM NUMBER], floor tile missing under bed A, holes in bathroom wall, paint missing on the bathroom and bedroom walls, facing missing on the lower drawer of bed B's nightstand, stained ceiling tile, and entry room and bedroom doors was scraped. Resident room [ROOM NUMBER], floor tile missing under bed A, paint/scrapes/missing in bathroom and across from bed B, and entry room and bathroom drawers scraped. Resident room [ROOM NUMBER], air conditioner cover missing and noted to be under a chair in the room, paint missing on wall by bathroom sink, across from commode the wall paint was bubbled outward, missing sheetrock, ceiling tile bowing downward in room and bathroom doors scraped. Resident room [ROOM NUMBER], bed pan with feces and urine in the bathroom, paper and urine colored liquid in commode and paint missing behind bed A. Carpet going down the ramp from dining room had black/brown stains. A second environmental tour of the facility, on 5/2/2025, at approximately 9:15 am, accompanied by Maintenance Director (MD) GG, he confirmed the above observations and stated the resident environment was to be maintained in a clean, safe, and homelike manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies titled Administration of Medications and Pain Assessment and Management, the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for pain management for two of three sampled Residents (R) (R51 and R5) reviewed for pain. Findings include: A review of facility's policy titled Administration of Medications last reviewed on 9/16/2024, revealed Policy; the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Procedure; 2. Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration. g. Right Assessment; note the resident's history and any parameters around drug administration. A review of facility's policy titled Pain Assessment and Management last reviewed on 9/5/2024, revealed Policy; based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain Management Procedure; 2. The facility will address/treat the underlying causes of the pain, to the extent possible; a. Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both. Review of clinical records revealed that R51 was most recently admitted to the facility on [DATE], with diagnoses to include acute pain due to trauma, spinal stenosis without neurogenic claudication, and T5, T6 vertebra wedge compression fracture. Review of R51's admission Minimum Data Set assessment (MDS) dated [DATE] for Section J, Pain Management, indicated that the resident had frequent pain within the last 5 days, and the pain intensity, rate pain (0 to 10), 0 being no pain and 10 as the worst pain you can imagine, he responded as a 10, for the most severe pain. Review of R51's Care Plan revealed the resident expresses (pain/discomfort) r/t [related to] neuropathy, date-initiated 4/16/2025. Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, observe and report to nurse any s/sx [signs/symptoms] of non-verbal pain. Observe for pain characteristics: quality (e.g. sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors, and relieving factors. Pain medications as ordered, provide the resident with reassurance that pain is time limited. Encourage (resident) to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, report to nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx [signs or symptoms]or c/o [complaints of] pain or discomfort. And the resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain, with date initiated on 4/16/2025. A review of R51's physician orders dated 4/22/2025 revealed, hydrocodone-acetaminophen (an opioid - narcotic pain medication) Oral Tablet 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for Severe pain 7-10 for 7 Days. The order was completed 4/29/2025. A review of Physician Orders dated 4/29/25, hydrocodone-acetaminophen oral tablet 2.5-325 mg. Give 1 tablet by mouth every 6 hours as needed for Severe pain 7-10. The order was discontinued 5/1/2025. A review of R51's April 2025, Medication Administration Record (MAR), revealed that nursing administered the as needed hydrocodone-acetaminophen oral tablet 5-325 mg, for a total of 15 doses, from 4/22/2025, through 4/29/2025. Continued review of the April 2025 MAR revealed the pain scale (0-10 [0 indicating no pain, and 10 the worst pain]) nursing staff had documented the opioid pain medication, hydrocodone-acetaminophen, 5-325 mg, was provided to the resident for a pain scale of five (5) and six (6), [which is below the physician ordered Severe pain 7-10], for a total of 10 out of 15 doses, from 4/22/2025, through 4/29/25. A further review of R51's April 2025, Medication Administration Record (MAR), revealed that nursing administered the as needed hydrocodone-acetaminophen oral tablet 2.5-325 mg, for a total of 2 doses, on 4/30/2025. Continued review of the April 2025 MAR revealed the pain scale nursing staff had documented the opioid pain medication, hydrocodone-acetaminophen, 2.5-325 mg, was provided to the resident for a pain scale of five (5), [which is below the physician ordered Severe pain 7-10], for a total of 1 out of 2 doses, on 5/30/2025. In review of R51's clinical record revealed, lack of documentation of non-pharmacological interventions (NPI) attempted prior to the administration of the opioid pain medication, Hydrocodone-Acetaminophen. During an interview on 5/1/2025, at 11:38 am with the Director of Nursing she confirmed that nursing staff had administered 11 out of 17 doses, below the physician ordered severe pain range, and was unable to provide the documentation of the NPIs used prior to the administration of the opioid - narcotic pain medication, Hydrocodone-Acetaminophen. Review of clinical records revealed that R5 was admitted to the facility with diagnoses that included bilateral primary osteoarthritis of knee, pain in right hip, right knee, and contracture of the right knee. Review of R5's Quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed for Section J (Pain Management), indicated that the resident had occasional pain within the last 5 days, and that the resident's pain intensity was moderate as noted by the resident's response of 5 on a pain scale of zero (0) to 10, with zero (0) being no pain and 10 as the worst pain you can imagine. Review of R5's pain care plan revised 10/19/2023 revealed the resident expressed (pain/discomfort) r/t [related to] OA [osteoarthritis] and CVA [cerebral vascular accident - stroke]. Interventions included: Evaluate the effectiveness of pain interventions, pain medications as ordered, date-initiated 9/21/2023. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe and report to nurse any s/sx [signs/symptoms] of non-verbal pain, observe for pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Provide the resident with reassurance that pain is time limited, and to encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application. And the resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain, date Initiated, 2/25/2025. A review of R5's current Physician Orders (PO) dated 2/16/2025, revealed hydrocodone-acetaminophen (an opioid - narcotic pain medication) oral tablet five (5)-325 milligrams (mg). Give one (1) tablet by mouth every six (6) hours PRN for moderate pain 4 -6, and severe pain 7-10. A review of R5's March 2025, Medication Administration Record (MAR) revealed that nursing staff administered the PRN hydrocodone-acetaminophen oral tablet 5-325 mg, for a total of 34 doses, from 3/1/2025, through 3/31/2025. Continued review of the March 2025 MAR revealed the pain scale (zero [0]-10 [0 indicating no pain, and 10 the worst pain]) nursing staff documented the opioid pain medication, hydrocodone-acetaminophen 5-325 mg, was administered to the resident for a pain scale of 2 and 3 , [which was below the physician ordered moderate pain 4 - 6, and severe pain 7-10], for a total of four (4) out of 34 doses, from 3/1/2025, through 3/31/2025. A review of R5's April 2025, MAR, revealed that nursing staff administered the PRN hydrocodone-acetaminophen oral tablet 5-325 mg, for a total of 43 doses, from 4/1/2025, through 4/30/2025. Continued review of the April 2025 MAR revealed the pain scale (zero [0]-10) nursing staff documented the opioid pain medication, hydrocodone-acetaminophen, 5-325 mg, was administered to the resident for a pain scale of 3, [which was below the physician ordered moderate pain four (4) - six (6), and severe pain seven (7) -10], for a total of seven (7) out of 43 doses, from 4/1/25, through 4/30/2025. In review of R5's clinical record revealed the record lacked documentation of non-pharmacological interventions (NPI) attempted prior to the administration of the opioid pain medication, hydrocodone-acetaminophen. Documented evidence of NPIs were not provided to the survey team prior to the survey's exit on 5/2/2025. Interview with the Director of Nursing (DON) on 5/1/2025, at approximately 11:40 am, confirmed that the current physician order for the hydrocodone - acetaminophen (as prescribed, included pain levels of moderate, and severe, and in addition, that nursing staff administered the narcotic pain medication below the physician ordered parameter, which did not include administering the pain medication for mild levels of pain. This practice was not consistent with facility policy or standards of practice for pain management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility's policies titled Administration of Medications, Nasal spray instillation, Metered-dose inhaler use, and Eyedrop administration, the facility failed to provide medications accurately and as ordered for two of four Residents (R) (R28 and R29) observed during medication pass. The medication pass included 45 opportunities with five errors which resulted in an error rate of 11.11 percent (%). Findings include: Review of the facility's policy titled, Administration of Medications dated 9/16/2024 revealed, Procedure . 2. Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration a. Right Drug . b. Right Resident . c. Right Dose . d. Right Route . e. Right Time and Frequency . f. Right Documentation . g. Right Assessment . h. Right to Refuse . i. Right Evaluation/Response . j. Right Education and Information. Review of the facility's policy titled, Nasal spray instillation dated 5/20/2024 revealed Implementation .Occlude one of the patient's nostrils with your finger to prevent air from entering the nasal cavity, allowing the medication to flow properly. Review of the facility's policy titled, Metered-dose inhaler use dated 5/20/2024 revealed, Implementation .When administering inhaled corticosteroids, such as beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, or triamcinolone, instruct the patient to rinse and gargle with water and then to expectorate using an emesis basin after each dose (if necessary) to help prevent an infection in the mouth. Review of the policy facility's titled, Eyedrop administration dated 5/20/2024 revealed, Instilling Eyedrops .After instilling the eyedrops, instruct the patient to close the eyes gently and to keep them closed. Closing the eyes tightly or squeezing them shut may force some medication out of the eye, resulting in the absorption of an inaccurate dose. Repetitive blinking may push out the medication. If necessary, gently press your thumb or a gauze pad on the inner canthus for 2 [two] to 3 [three] minutes while the patient keeps the eye closed to prevent systemic absorption of medication. 1. Review of R28's Physician Orders included the following orders: Fluticasone Nasal Suspension (Flonase) 50 micrograms (mcg)/activation (act), one spray in both nostrils two times a day for allergies with the ordered date of 3/13/2025; Toprol XL oral tablet, extended release 25 milligrams (mg) one time a day for hypertension and atrial fibrillation, scheduled for 9:00 a.m., with the start date of 3/14/2025; and Olopatadine ophthalmic solution 0.2 percent (%), instill one drop in both eyes one time a day for cataract surgery, scheduled for 9:00 a.m. with the ordered date of 3/14/2025. An observation on 4/30/2025 at 8:11 a.m., revealed Registered Nurse (RN) AA administered medications to R28. Observation revealed the resident's blood pressure (BP) was 100/59. RN AA removed the Toprol from the medication cup and did not administer it to the resident. No parameters were noted on the Medication Administration Record (MAR). Observation revealed RN AA handed the resident the fluticasone nasal suspension and did not instruct the resident on how many sprays to instill. R28 administered two sprays into each nare. RN AA did not observe the resident administer the fluticasone nasal spray. Further observation revealed RN AA did not administer the olopatadine ophthalmic eye drops as ordered. In an interview with RN AA on 4/30/2025 at 12:17 p.m., regarding the parameters for holding the Toprol, RN AA revealed she could not find the parameters, but she held it because R28's BP was 100. Asked the nurse if the facility had standing orders for holding medications regarding BP results and she stated yes. RN AA and two other nurses looked for the standing orders but could not find them. RN AA also stated they did not observe the resident administer two sprays of the Flonase and stated she did not see the eye drops in the cart and was going to look for them. RN AA had R28's BP taken at this time and stated it was 109/70 so she just gave the Toprol, three hours after it was scheduled to be given. The clinical record lacked evidence that the physician was notified the physician. 2. Review of R29's Physician Orders revealed orders for: Breo Ellipta Inhalation Aerosol 100-25 mcg/act, one puff inhaled orally one time a day for shortness of breath, scheduled for 9:00 a.m., with the ordered date of 3/20/2025;Flonase Allergy Relief Nasal Suspension 50 mcg/act, two sprays in both nostrils one time a day for allergies, scheduled for 9:00 a.m. with the ordered date of 3/15/2025; and Latanoprost solution 0.005%, instill one drop in both eyes one time a day related to open-angle glaucoma bilaterally with the start date of 12/10/2024. An observation on 4/30/2025 at 9:11 a.m., revealed Licensed Practical Nurse (LPN) BB administered medications to R29. An observation revealed LPN BB administered one drop of latanoprost into each eye but did not instruct the resident to close their eyes and did not hold the inner canthus to increase absorption and decrease systemic absorption. Continued observation revealed LPN BB handed the resident the Flonase Nasal Spray, did not instruct the resident to hold the opposite nare when instilling the nasal spray and the resident administered two sprays into each nostril without holding the opposite nare, to increase absorption of the Flonase. Further observation revealed the resident administered the fluticasone inhaler, but LPN BB did not offer or provide assistance for the resident to rinse out their mouth. In an interview with LPN BB on 4/30/2025 at 2:46 p.m., she stated she did not have the resident to rinse their mouth after the Breo Ellipta inhalation and said, the resident's daughter said she didn't have to. LPN BB also stated R29 said she received more of the Flonase by not holding the opposite nare when administering it. Review of the Federal Drug Administration (FDA) label dated 1/7/2019 revealed, Breo Ellipta, After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. An interview with the Director of Nursing (DON) on 5/1/2025 at 9:00 a.m., revealed she did not know if the facility had standing orders for the holding parameters for BP medications. She stated the staff usually just follow the physician's orders. An interview with the DON on 5/1/2025 at 10:42 a.m., revealed staff should assist the resident with rinsing their mouth after they received an inhaler. The DON stated the nurse should put those instructions on the orders. The DON also stated the staff did monthly reviews to make sure instructions like that were on the orders. The DON stated the staff should instruct the resident on how many inhalations they should take and to hold the opposite nare when administering nasal spray. The DON further stated staff should follow the facility's policy which followed the [Name] nursing book and professional standards when administering medications. If a steroid eye drop was administered, the staff should hold the inner canthus of the eye. Regarding BP parameters, the DON stated typically the physician will order the parameters as to when to hold the medication. If the staff held the medication, they should notify the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policies titled, Self-Administration of Medication, the facility failed to assess two residents (R) R#11 and R#65 of 31 sampled for the ability to self-administer medications prior to leaving medications at the bedside. Findings include: Review of the policy titled, Resident Self-Administration Medications revised date 10/13/2021 revealed: Policy: The facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications that are requested from a central location (e.g., medication cart or medication room) or the resident is able to safely store the medication in a secure area in their room, and safely administer the medication as prescribed. 1. If the resident desires to self-administer medications, the IDT will contact the resident's primary physician to make them aware of the resident request. 2. The IDT in consultation with the primary physician for the resident will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility. 4. The interdisciplinary assessment will be completed in the electronic medication record, and results review with the resident and/or responsible party. Bedside Storage Determinization: 2. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the room of, or room with, residents who self-administer. The following conditions will be met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is ineffective. b. The medications to the resident for bedside storage are kept in the containers d Dispensed by the provider pharmacy. 1.Observation on 3/14/2023 at 9:26 a.m. of R#11's room revealed one white souffle medication cup sitting on the bedside table containing one pink oblong shaped tablet and one half of a white oblong tablet. An interview with R#11 revealed the nurse normally leaves the medication for her to take when she desires. Further observation of the bedside table revealed a box labeled with resident's name containing a bottle of loteprednol etabonate 0.5 % eye solution, one container of Vicks Vapor Rub, and one bottle of hydrogen peroxide. R#11 revealed that she self-administers the eye drops and also uses both the vapor rub and the hydrogen peroxide. She revealed the nurse was aware she kept the medications in her room. Observation and interview on 3/14/2023 at 9:39 a.m. with Licensed Practical Nurse (LPN) BB revealed she was aware of the medication cup containing two medications and the other medications on R#11's bedside table. LPN BB stated that she always leaves the scheduled medications for resident to take and come back later to make sure she had taken them. LPN BB further stated she does not stay to watch resident ingest the medications because resident thinks the staff is poisoning her. LPN BB further stated that resident's daughter probably brought the eye drops, vapor rub and peroxide into the facility, and it's not supposed to be there. LPN BB stated R#11 did not have a current order for these medications. Observation on 3/14/23 at 11:42 a.m. revealed resident lying in bed. Eye drops, hydrogen peroxide, and Vicks vapor rub continues to be on resident's bedside table at this time. Observation on 3/14/23 at 2:23 9.m. of R#11's room with DON verified the container of loteprednol etabonate 0.5 % eye solution, Vicks Vapor Rub and hydrogen peroxide on the bedside table. DON removed the medication and explained to R#11 the medication would be given to her daughter because she did not have a current physicians order for them. DON verified all medications should be kept in the medication cart and given only if prescribed by the physician. Record review of the electronic medical record (EMR) for R#11 revealed diagnosis including but not limited to generalized anxiety disorder, major depressive disorder, vascular dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, Alzheimer's Disease. Review of the minimum data set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating R#11 was cognitively intact, and required supervision with activities of daily living (ADLS). Resident received and received an antidepressant seven of seven days. Review of the physician's orders revealed medication orders to include: Depakote Delayed Release tablet 125 milligrams (mg) give one tablet by mouth one time a day for delusions, start date 2/02/2023, sertraline HCL 50 mg tablet give 1.5 tablets by mouth one time a day, start date 2/25/2023, Tetrahydrozoline-Zn Sulfate Solution 0.05-0.25% instill one drop in both eyes two times for dry eyes, start date 10/20/2021, artificial tears solution 1% (carboxymethylcellulose sodium) instill one drop into right eye two times a day for dry eyes, start dated 6/14/2022. There was not a physician's order for the medications which were observed at bedside. Review of the clinical record revealed there was no assessment for medication self-administration. During an interview on 3/15/23 at 9:30 a.m. R#11 revealed she was not asked or has not been assessed to be able to self-administer medications. She further stated that there are a couple of nurses who leave her medications with her and come back to see if she has taken it. During an interview on 3/15/23 at 9:49 a.m. with the Director of Nursing (DON) she revealed her expectations are for medications to be kept secured in the medication carts and not be left in a resident's room unless the resident had been assessed for self-administration of the medication, approved by the interdisciplinary team, and had a physician's order for self-administration of medication. She revealed her expectation is for medications to only be administered with a physician's order. She verified that R#11 did not have a medication self-administration assessment for any medications and did not have a physician's orders for the medications which were at her bedside. DON further stated that families sometimes bring residents medications into the facility and as the staff sees it, they are supposed to remove the medications and call the family to pick it up. DON stated nurses should not leave medications at the bed side or during the medication pass and are required to observe residents swallow the medications prior to leaving the room. During an interview on 3/16/23 at 12:18 p.m. with LPN Restorative/ Risk Management Nurse FF revealed that the IDT (Interdisciplinary Team) which consists of the DON, Assistant Director of Nursing (ADON), Social Worker and the resident's charge nurse makes the decision to allow a resident to self-administer medications. She further stated that there is also an assessment that is completed to help with the determination as to whether resident should be allowed to self-administer medication. 2. An observation conducted on 3/14/2023 at 9:50 a.m. revealed two bottles (one empty and one with solution) of azelastine 0.1% nasal spray left at bedside. An interview with R#65 conducted during this time reported nurses give her medicines but leave the nasal spray in her room. She reported she did not bring them from home and that it came from the pharmacy that the facility uses. An observation on 3/14/23 at 2:29 p.m. revealed two bottles (one empty and one with solution) of azelastine 0.1% nasal spray left at bedside. Review of Records revealed R#65 admitted on [DATE] with diagnoses but not limited to chronic diastolic congestive heart failure, anxiety, major depressive disorder, and atherosclerotic heart disease. Review of the admission MDS assessment dated [DATE] revealed that the resident had a BIMS score of 15, indicating that the resident is cognitively intact. Review of Physician Orders dated 11/4/2022 revealed an active order for azelastine HCl solution 0.1 % two sprays in both nostrils two times a day for allergies. No records of order indicating may use home medication were noted. Further observation on 3/14/2023 at 2:30 p.m. revealed the same bottles of nasal spray as previously mentioned at bedside. An interview with the DON was conducted during this time. She confirmed the two bottles of nasal spray, one which was empty and one with solution left at bedside. She reported this should not have been left in her room and her expectations of staff are to safely and properly store all medications on the medication cart. Review of R#65's record revealed an assessment for self-administration of medication was completed on 3/14/23 at 3:50 p.m. after observations of nasal spray left at bedside. Further review of Progress Note dated 3/14/23 at 8:04 p.m. revealed the DON, an LPN, and social services spoke with R#65 about self-administering nasal spray and they recommended that she could administer her own nasal spray. Resident was alert and oriented, prefers to keep spray at bedside and aware of the procedure. She stated, I am not stupid. Medical Director (MD) was called and new order obtained; will continue to educate. Review of the resident's current care plan revealed there was no evidence that resident had a care plan to self-administer medications or keep medications at bedside. Interview on 3/15/2023 at 8:35 a.m. with LPN II who confirmed medications should not be left in a resident's rooms unless they have been assessed and there is a doctor's order to self-administer medication. She reported medications should be secured on the medication cart. An Interview on 3/15/2023 at 8:47 a.m. with LPN Restorative Nurse/Risk Management FF reported on 3/14/2023 MD approved R#65 to self-administer nasal spray. She reported R# 65 was educated on self-administration of nasal spray. She reported once they get a locked box with key, R#65 would be able to keep nasal spray at bedside but until then it would remain stored on the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Self-Administration of Medication, the facility failed to provide an environment that was free from potential accidents and hazards for two residents (R) (R#11 and R#65) of 31 sampled residents related to properly storing medications which were located on the bedside tables in resident's rooms. Findings include: A review of the policy titled, Self-Administration of Medication revised date 10/13/2021 revealed: Policy statement: The facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications that are requested from a central location (e.g., medication cart or medication room) or the resident is able to safely store the medication in a secure area in their room, and safely administer the medication as prescribed. Bedside Storage Determination 2. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the room of, or room with, residents who self-administer. The following conditions will be met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is ineffective. 1.Record review of the electronic medical record (EMR) for R#11 revealed diagnosis including but not limited to generalized anxiety disorder, major depressive disorder, vascular dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, Alzheimer's Disease. Review of the minimum data set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating R#11 was cognitively intact and received an antidepressant seven of seven days of the review period. Review of the Orders Summary Report Active Orders as of 3/14/2023 for R#11 revealed there was not an order for Loteprednol Etabonate 0.5 % eye solution, Vicks Vapor Rub or Hydrogen Peroxide. Record Review revealed R#11 had not been assessed to determine if she was a candidate to self-administer medications. Observation on 3/14/2023 at 9:26 a.m. of R#11's room revealed one white souffle medication cup sitting on the bedside table containing one pink oblong shaped tablet and one half of a white oblong tablet. An interview with R#11 revealed the nurse normally leaves the medication for her to take when she desires. Further observation of the bedside table revealed a box labeled with resident's name containing a bottle of Loteprednol Etabonate 0.5 % eye solution, one container of Vicks Vapor Rub and one bottle of Hydrogen Peroxide. R#11 revealed that she self-administers the eye drops and also uses both the vapor rub and the hydrogen peroxide. She revealed the nurse was aware she kept the medications in her room. Observation and interview on 3/14/2023 at 9:39 a.m. with Licensed Practical Nurse (LPN) BB revealed she was aware of the medication cup containing two medications and the other medications on R#11's bedside table. LPN BB further stated she does not stay to watch resident ingest the medications because resident thinks the staff is poisoning her. LPN BB further stated that resident's daughter probably brought the eye drops, vapor rub and peroxide into the facility, and it's not supposed to be there. Observation on 3/14/2023 at 11:42 a.m. revealed resident lying in bed. Eye drops, hydrogen peroxide, and Vicks vapor rub continues to be on resident's bedside. Observation on 3/14/2023 at 2:23 9.m. of R#11's room with Director of Nursing (DON) verified the container of loteprednol etabonate 0.5 % eye solution, Vicks Vapor Rub, and hydrogen peroxide on the bedside table. DON removed the medication and explained to R#11 the medication would be given to her daughter because she did not have a current physicians order for them. DON verified all medications should be kept in the medication cart. During an interview on 3/15/2023 at 9:49 a.m. with the DON it was revealed that medications should be kept secured in the medication carts and not be left in a resident's room. DON further stated that families sometimes bring residents medications into the facility and as the staff sees it, they are supposed to remove the medications and call the family to pick it up. DON stated nurses should not leave medications at the bed side during the medication pass and are required to observe residents swallow the medications prior to leaving the room. DON reported that the facility had identified five residents that wander in the facility and these five residents had the potential to wander into R# 11 and R#65's room and gain access to the medications at bedside that were not properly stored or secured. During an interview on 3/16/2023 at 12:07 p.m. with CNA EE revealed that she has visualized the Vicks Vapor rub in residents' room and her applying it to her chest in the past. She further stated that resident refused to allow her to remove it. CNA EE stated that each time this happened she reported it to the nurse. During an interview on 3/16/2023 at 12:18 p.m. with LPN Restorative/ Risk Management Nurse FF revealed that medications should never be left at the resident bedside. 2. An observation conducted on 3/14/2023 at 9:50 a.m. revealed two bottles (one empty and one with solution) of azelastine 0.1% nasal spray left at bedside. An interview with R#65 conducted during this time reported nurses give her medicines but leave the nasal spray in her room. She reported she did not bring them from home and that it came from Omnicare, the pharmacy that the facility uses. An observation on 3/14/2023 at 2:29 p.m. revealed two bottles (one empty and one with solution) of azelastine 0.1% nasal spray left at bedside. Review of Records revealed R#65 admitted on [DATE] with diagnoses but not limited to chronic diastolic congestive heart failure, anxiety, major depressive disorder, and atherosclerotic heart disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact. During an observation and interview on 3/14/2023 at 2:30 p.m. DON acknowledged the nasal spray being at the bedside. DON reported this should not have been left in R#65's room and her expectations of staff are to safely and properly store all medications on the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy titled, Indwelling Urinary Cather (Foley) Management and How to Care for Your Foley Catheter , the facility failed to ensure one resident (R) (R#6) of four residents, with catheters, catheter bag was below the level of bladder, tubing not looped, and off the floor. This had the potential to increase R#6's risk of urinary tract infection (UTI). Findings include: Review of facility-provided policy titled Indwelling Urinary Catheter (Foley) Management dated 4/1/2022 revealed: General Urinary Catheter Maintenance Guidelines 2. Maintain unobstructed urine flow. A. Keep the catheter and collecting tube free from kinking. B. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Additional care practices related to catheterization 5. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. Review of facility-provided undated policy titled How to Care for Your Foley Catheter revealed: Care for the catheter - Keep the tube secure, you may want to use Velcro straps or some other device to keep the bag or catheter on your leg. Do not let the tube kink or loop. Care for the drainage bag- keep your urine bag below the bladder. Observation on 3/14/2023 at 9;33 a.m. revealed catheter drainage bag on the floor. The indwelling catheter is observed coming out the top of resident's pants with the tubing looping upward resulting in the potential for backflow of urine into the bladder. There is not a securing device in place at the time of this observation. Observation 3/15/2023 at 1:01 p.m. and 1/16/2023 at 8:51 a.m. revealed resident lying in bed with catheter connected to leg drainage bag. Review of R#6's admission Record located in his Electronic Medical Record (EMR) revealed R6 was admitted to the facility on [DATE] with multiple diagnoses including paraplegia, complete, personal history of transient ischemic attack (TIA), encounter for attention to other artificial openings of urinary tract, other muscle spasms. Review of R#6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/2022 revealed a Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating he was cognitively intact, and he had an indwelling catheter. Review of R#6's care plan located in the resident's EMR revealed resident has an ADL self-care performance deficit due to weakness and mobility. Toilet Use: The resident requires extensive assistance by 1 staff for toileting. Review of record revealed resident has a supra-pubic catheter and a colostomy. Electronic medical record (EMR) review revealed a Progress Note dated 1/24/2023 that indicated R#6 appeared more confused than normal and the Physician was notified and gave orders to get a urine sample. EMR review of Progress Note dated 1/25/2023 at 3:59 p.m. indicated that R#6 was to start Macrobid 100 mg (milligrams) by mouth twice per day for seven days for urinary tract infection and the urine culture was pending. Observation and interview with resident on 3/15/2023 at 8:47 a.m. revealed resident lying in bed. Resident's indwelling catheter is observed to be attached to leg drainage bag lying in the bed with resident. The drainage bag is not positioned below the level of the bladder. The tubing is looped upward. There is not a securing device in place at the time of this observation. R#6 reported that he often has the leg bag on while in the bed and it is very seldom that the bag is changed to the bedside drainage bag when he is in the bed. R#6 further stated that staff does not come in to change the bag, so he does it himself. During an interview on 3/15/2023 at 9:27 a.m. Certified Nursing Assistant (CNA) CC revealed that when she cares for R#6 he usually has a bedside drainage bag hanging on the side of the bed. CNA CC further stated that resident usually uses the leg drainage bag when he is out of bed to his electric wheelchair. CNA CC stated resident is not supposed to have the leg drainage bag on while in bed and she has not ever seen him with a catheter securing device in place. During an interview on 3/15/2023 at 9:29 a.m. with Licensed Practical Nurse (LPN) BB revealed that R#6 usually has the leg bag on while in the bed. She further stated that R#6 is usually not in the bed but is up in his wheelchair. LPN BB verified resident in bed with leg bag attached to indwelling catheter that is not below the level of the bladder, tubing looped upward, and catheter not secured with a securing device. During an interview on 3/15/2023 at 9:47 a.m. with the Director of Nursing (DON) she stated R#6 changes the drainage bags himself. DON further stated that resident is usually up in the electric wheelchair and not in the bed. She acknowledged that R#6 should have a bedside drainage bag attached to the catheter while in bed to prevent the backflow of urine into his bladder. She further stated resident is independent and cares for himself. DON stated that staff are responsible for assuring that resident has the correct bag attached to the catheter when he is in the bed and that the bedside drainage bag should never be on the floor but should be properly anchored to the bed to reduce tension on the catheter. DON verified the leg bag attached to catheter while resident in bed and catheter securing device is not in place. During an interview on 3/15/2023 at 10:03 a.m. with LPN DD Treatment Nurse/Unit Manager revealed R#6 should have a bedside drainage bag attached to catheter while he is in bed. She stated that resident has been educated about the drainage bag and there is not an order specifically stating which bag he needs to have in place. She further stated that resident is very independent. LPN DD stated resident also had the leg bag on while in bed yesterday afternoon when she did his wound care. LPN DD stated it is the staff responsibility to ensure the bag is changed to a bedside drainage bag when he returns to bed. During an interview with resident on 3/15/23 at 10:05 a.m., R#6 stated that no one has ever informed him of the importance of changing the leg bag to a drainage bag while in bed. During a follow up interview on 3/16/23 at 8:42 a.m. with the DON, she stated that resident having a drainage bag connected to the indwelling catheter that is not below the level of the bladder and the tubing looped has a potential to cause a UTI. DON stated resident is alert and does his own thing as he chooses and does have a history of recurrent UTIs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations conducted during the survey period on revealed disrepair of baseboard in bathroom and scuffed walls behind the headboards of beds in rooms as follows: Observations on 3/14/2023 at 10:25 a.m. and 2:24 p.m., on 3/15/2023 at 8:25 a.m. and 8:55 a.m., 3/16/2023 at 8:45 a.m. disrepair of baseboard in bathroom of room [ROOM NUMBER]. Observations on 3/14/2023 at 10:27 a.m. and 2:25 p.m., on 3/15/2023 at 9:13 a.m., and on 3/16/2023 at 8:47 a.m. of scuffed walls behind the headboards of beds in room [ROOM NUMBER]. Observations on 3/14/2023 at 2:30 p.m., on 3/15/2023 at 8:45 a.m., and on 3/16/2023 at 9:02 a.m. of scuffed walls behind the headboards of beds in room [ROOM NUMBER]. Observations on 3/14/2023 at 10:39 a.m., on 3/15/2023 at 8:49 a.m., on 3/16/2023 at 9:03 a.m. of scuffed walls behind the headboards of beds in room [ROOM NUMBER]. Interview conducted on 3/16/2023 at 12:05 p.m. while rounding with the Administrator and Maintenance Director and they both confirmed the base board shoe mold had fallen in room [ROOM NUMBER] bathroom. Maintenance Director stated, he did not know it fell and it would be an easy fix to glue and stick it back up there. An additional interview conducted on 3/16/2023 during rounding between 12:08 p.m.-12:12 p.m. with the Administrator and Maintenance Director both confirmed the scuffed walls behind the headboards of A and B beds in rooms [ROOM NUMBER]. Maintenance Director stated this was an easy fix and they would patch and paint them. The Maintenance Director reported this is an ongoing process because both staff and residents damage the walls when they adjust the beds up and down. During an interview on 3/16/2023 at 12:50 p.m. with the Administrator reported would address the issues as quickly as the corporate office and residents would allow. He reported all supply purchases would need approval by corporate and he does not want to inconvenience the residents by moving them out the room while making repairs. His expectations of making the necessary repairs will be completed as quickly as circumstances would allow. 3. Observation on 3/14/2023 at 8:56 a.m. of room [ROOM NUMBER] in which the wall by window next to the bathroom door had missing and chipped paint, base board with some pieces detaching from wall, and missing tile on floor by detached cold base. Observation on 3/14/2023 at 9:05 a.m. of room [ROOM NUMBER] revealed missing tile under foot of bed. Ceiling tile above bed B had stains. Wall behind A bed scuffed up with missing paint. Wall on left side of bathroom door scuffed up with missing paint. Observation on 3/14/2023 at 9:15 a.m. of room [ROOM NUMBER] revealed chipped paint in the wall behind the bed. Observation on 3/14/2023 at 9:30 a.m. revealed room [ROOM NUMBER] B bed privacy curtain had brown stains on the right side in the middle of the curtain and at the bottom by the hem. Also in room [ROOM NUMBER] ceiling tile was hanging from the ceiling near A bed. Environmental rounds conducted with Administrator, Maintenance Director, and Housekeeping Supervisor on 3/16/2023 at 12:20 p.m. confirmed all environmental issues of detached base board from wall, missing and chipped paint on wall next to the window by bathroom door for room [ROOM NUMBER]; missing tile under foot of the bed and stained ceiling tiles for bed B, chipped and missing paint on walls, and scuffed bathroom door with missing paint in room [ROOM NUMBER]; and stained privacy curtain for bed A and ceiling tile hanging from the ceiling in room [ROOM NUMBER]. Interview on 3/16/2023 at 12:30 p.m. with Maintenance Supervisor revealed the issues were a matter of patching and repairing. He stated that he was just one man and that he had been in the position for nine years. He stated that he had asked for an assistant several times, but he was not given an assistant. Interview with the Housekeeping Supervisor on 3/16/2023 at 12:45 p.m. revealed he has been in the position for 10 years. He stated that he has been behind and short staffed because of COVID. Housekeeping supervisor stated that he has not been keeping up with housekeeping cleaning logs. He stated that it had been a while since he did them. Housekeeping supervisor stated that he could provide surveyor with his latest audit. Interview with the Administrator on 3/16/2023 at 12:50 p.m. revealed that he was aware of the stained privacy curtain in room [ROOM NUMBER]. He stated that the curtain was removed and washed a couple of months ago. Administrator stated that the curtain was not dirty but stained. He stated that it was rust stained and that the stain could not come out. Administrator stated that he did not have another curtain to replace it with. He stated that his plan now is to request new curtains from corporate. He stated his plans for the repairs of the room issues is to fix and repair as long as the residents will allow them too. Review of the audit form submitted by the Housekeeping Supervisor revealed a log titled Housekeeping Weekly Audit Resident Room date of audit 2/9/2017 room [ROOM NUMBER]. Housekeeping Supervisor stated that this was his latest audit log. Based on observations, staff interview, and review of form titled, Maintenance Director Job Description Primary the facility failed to maintain a clean, sanitary, homelike environment that included but not limited to, build-up of dust on the vent covers in bathrooms, scuffed up walls, walls needing painting repairs, plastic wall trim/molding behind toilet had fell off, chipped and missing paint, loose baseboards, a stained privacy curtain, stained ceiling tiles, sagging ceiling tiles, floor tiles in disrepair, and cracked caulking around one bathroom sink. This deficient practice effected four of six halls in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]. Findings included: 1.Review of policy titled, Maintenance Director Job Description Primary, revealed essential functions included but not limited to, must be able to plan, supervise, and direct maintenance programs; must be able to schedule preventive maintenance, repairs, and replacements; and must be able to inspect equipment/systems regular for proper functioning and safety. Observations during initial tour and throughout the survey period revealed the following: On 3/14/2023 at 9:33 a.m. and 3/16/2023 at 8:12 a.m. in room [ROOM NUMBER], dusty vent in bathroom. On 3/14/2023 at 9:40 a.m. and 3/16/2023 at 8:14 a.m. in room [ROOM NUMBER], dusty vent in bathroom, scuffed up paint over sink and on wall in front of toilet. 3/14/2023 at 9:50 a.m. and 3/16/2023 at 8:16 a.m. in room [ROOM NUMBER], dusty vent in bathroom, scuffed up wall in bathroom, plastic molding coming off wall behind toilet. 3/14/2023 at 10:00 a.m. and 3/16/2023 at 8:20 a.m. in room [ROOM NUMBER], dusty vent in bathroom. 3/14/2023 at 10:08 a.m. and 3/16/2023 at 8:30 a.m. in room [ROOM NUMBER], dusty vent in bathroom scuffed up wall in bathroom. 3/14/2023 at 10:15 a.m. and 3/16/2023 at 8:33 a.m. in room [ROOM NUMBER], scuffed up wall in bathroom. 3/14/2023 at 10:25 a.m. and 3/16/2023 at 8:38 a.m. in room [ROOM NUMBER], cracked caulking around bathroom sink. Observation and confirmation during walking rounds on 3/16/2023 starting at 12:06 p.m. and ending at 12:29 p.m. with the Maintenance Director and the Administrator, confirmed the following: In room [ROOM NUMBER], cracked caulking around bathroom sink. In room [ROOM NUMBER], scuffed up wall in bathroom. In room [ROOM NUMBER], dusty vent in bathroom scuffed up wall in bathroom. In room [ROOM NUMBER], dusty vent in bathroom. in room [ROOM NUMBER], dusty vent in bathroom, scuffed up paint over sink and wall in front of toilet. In room [ROOM NUMBER], dusty vent in bathroom, scuffed up wall in bathroom, molding coming off behind toilet. In room [ROOM NUMBER], dusty vent in bathroom. During an interview with the Administrator on 3/16/2023 at 12:40 p.m. he revealed that there is a process that he must go through to order new curtains and supplies, and he would have to get approval from corporate to get financing for any repairs and maintenance. The process had to be followed, residents have to give permission for them to work in their room, or to move them out so they could work in their room, and not cause harm from any dangerous fumes from paint, glue, etc. He revealed the turnaround time would depend on resident's allowing them to make those changes. He further explained that the facility only had one maintenance staff and one person could not get everything done immediately. He revealed as far as the vents, that was just a matter of cleaning dust. His expectation was to put in an order for maintenance and repairs to see if corporate would approve it, and then they would get right on it.

Based on observation, interview and review of facility policy titled Eyedrop Administration, Use of Linen cart, and Laundry Services-General Policy, the facility failed to ensure nursing staff performed hand hygiene while administering medications to one of four sampled residents observed for medication administration (R#58) and failed to maintain infection control during storage of clean laundered Hoyer lift pads. The facility had 10 resident who used a mechanical lift for transfers. Findings include: 1.Review of facility revised policy titled Eyedrop Administration dated May 20, 2022, under Implementation revealed: perform hand hygiene, put on gloves to comply with standard precautions, after instilling the eyedrops instruct the patient to close the eyes gently without squeezing the lids shut, remove and discard your gloves, perform hand hygiene. Observation of medication administration on 3/15/2023 at 8:29 a.m. revealed Licensed Practical Nurse (LPN) BB did not sanitize or wash hands before or after administering eyedrops to R#58. After by mouth medications were administered, LPN BB applied gloves, administered Artificial Tears Solution 1-0.3 % 1 drop both eyes and Cosopt Ophthalmic Solution 22.3-6.8 mg/ml 1 drop into both eyes. LPN BB returned to medication cart without performing hand hygiene by either washing hands or utilizing alcohol-based hand sanitizer. Nurse BB returned to the medication cart, discarded gloves and opened the medication cart. Interview with LPN BB on 3/15/2023 at 8:35 a.m. confirmed that handwashing procedures were not adhered to during the above observations of medication administration. Review of LPN education file revealed LPN BB received training on hand hygiene on 7/21/2022. Interview with the Director of Nursing (DON) on 3/15/2023 at 1:45 p.m. revealed that all staff are expected to follow infection control guidelines and policy and procedures during medication administration and while performing care to residents. 2. Review of facility policy titled Use of Linen cart reviewed 7/28/2022 revealed: personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Review of facility policy titled Laundry Services-General Policy reviewed 7/28/2022 revealed: clean linens must always be kept separate from contaminated linen. Procedure: All clean linen must be kept at least six (6) feet from soiled containers. During an observation of the laundry on 3/15/2023 at 12:32 p.m. revealed the laundry has a separated dirty and clean area. Observation revealed on the dirty area of the laundry a cart containing clean folded Hoyer lift pads and mop heads on the bottom of the cart. On the top of the cart was clean unfolded linen. This cart was positioned beside the washer. During an interview on 3/15/2023 at 12:37 p.m. with Laundry Aide AA it was revealed that the mop heads, Hoyer lift pads, and unfolded linen on the cart was cleaned. She further stated that the mop heads and Hoyer pads were stored on the cart in the dirty area because there is no other place to store those items. Laundry Aide AA also stated that the staff come to the laundry and retrieve them when needed. During this interview, Laundry Aide AA was observed walking from the clean area (folding table) to the dirty area holding clean linen and then carried the linen back into the clean area and placed on the folding table with other clean linen. Laundry Aide AA acknowledged what she had done. During an interview on 3/15/2023 at 12:41 p.m. with the Laundry Supervisor he acknowledged that he is aware that the cart containing the clean items are stored in the dirty area of the laundry. He further stated that it is stored there because there is nowhere on the clean side to store it. The Housekeeping Supervisor verified that the clean laundry is stored on the dirty side and the dirty bins come into the laundry and passes the area of the clean cart to get to the washers. During an interview and observation on 3/15/2023 at 1:01 p.m. with the Executive Director in the Laundry room the clean cart was observed on the dirty side of the laundry. The Executive Director verified that the clean cart should not be in the dirty area and that all residents in the facility uses linen from the laundry room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to follow up timely in getting a Physician's Order for Restoril 15 milligrams (mg) for one resident (R#48) of five residents reviewed for medications. Findings include: Record review revealed R#48 was admitted to the facility on [DATE] with diagnoses including but not limited to fracture of right lower leg, Parkinson's disease, type 2 diabetes mellitus, obstructive sleep apnea, chronic pain syndrome, and anxiety disorder. Review of admission Minimum Data Set, dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of behavioral health progress note dated 2/11/22 revealed the Nurse Practitioner was contacted by the facility's Social Services Director and asked to make a visit with resident because she had to make the decision to remove her daughter from the ventilator and needed something to help her sleep. Further review of progress note revealed an order was given for Restoril 15 (mg) by mouth (PO) every night at bedtime (QHS) as needed (PRN). Review of document titled Fax order request/notification form revealed the order for Restoril 15 mg PO QHS PRN for insomnia was faxed to the Primary Care Physician (PCP) on 2/11/22 for signature. Review of progress noted dated 2/14/22 revealed the social services director faxed the form to the PCP on 2/11/22 and called the PCP on 2/14/22 to follow-up on the medication request. Review of progress noted dated 2/16/22 revealed the charge nurse called the PCP office and requested to get a prescription for the Restoril 15 mg. Review of progress note dated 2/16/22 revealed the Director of Nurses (DON) notified the PCP of need for a prescription for the Restoril15 mg and the PCP agreed to sign the prescription. During interview on 2/16/22 at 9 a.m. with R#48 she revealed her daughter passed away on 2/11/22. R#48 reported that the Nurse Practitioner from a behavioral health provider spoke with her, then ordered a medication to help her sleep. R#48 reported that she had requested the medication but was told it was not yet available from the pharmacy. R#48 further reported that at the time of this interview she had not received the medication. Review of the electronic medical record (eMAR) revealed that R#48 received her first dose of Restoril 15 mg at 9 p.m. on 2/16/22. During interview on 2/17/22 at 9:00 a.m. with Licensed Practical Nurse (LPN) AA who confirmed that R#48 was given Restoril 15 mg last night for the first time since it was ordered. During an interview on 2/17/22 at 10:30 a.m. with the DON who reported that she was not aware that R#48 had not received her medication until yesterday (2/16/22). DON reported that typically when ordering medications if the medication was not in the emergency kit (e kit) it could be gotten from the pharmacy. She further reported that someone could also go to the pharmacy to pick up a medication that was needed stat. DON confirmed that R#48 did not get her medication from 2/11/22 until 2/16/22. During interview on 2/17/22 at 12:30 p.m. with Social Services Director she revealed she faxed the order for the Restoril for R#48 to the Physician on 2/11/22 but when she returned to work on 2/14/22, the order had not been faxed back to the facility from the PCP. She reported that she refaxed the order on 2/15/22.