**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Promoting/Maintaining Resident Dignity, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of four residents (R) R51 who had an indwelling urinary catheter. Findings include: A review of the facility's undated policy titled Promoting/Maintaining Resident Dignity under the Compliance Guidelines section revealed, 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 12. Maintain resident privacy. Review of medical records revealed, R51 admitted with diagnoses but not limited to muscle weakness (generalized), megalencephalic leukoencephalopathy with subcortical cysts, hypo-osmolality and hyponatremia, other inflammatory disorders of penis. Review R51's admission Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 3, which indicated moderate cognitive impairment; Section H (Bladder and Bowel) indicated the resident had an indwelling catheter. Review of R51's care plans a plan of care with an initiated date of 1/30/2025 revealed, Focus: R51 had an indwelling catheter in place and is at risk for UTIs and skin breakdown around the catheter site. Dx (diagnosis): inflammatory disorder of penis. Intervention: Check tubing for kinks each shift. Observations on 2/22/2025 at 9:38 am revealed, R51 lying in bed with his catheter bag uncovered and visible from the doorway with 50 ml (milliliters) of amber colored urine noted. Observations on 2/23/2025 at 10:29 am and 2/24/2025 at 10:27 am revealed, R51's catheter bag was uncovered with amber colored urine noted. Interview on 2/24/2025 at 9:46 am with Certified Nursing Assistant (CNA) HH confirmed R51 catheter did not have a dignity bag covering it. CNA HH revealed, CNAs are responsible for providing catheter care at the beginning of the shift at 7:00 am, as needed, and at the end of the shift. Interview on 2/24/2025 at 9:54 am with the Administrator confirmed that R51 should have a dignity bag. Interview on 2/24/2025 at 9:57 am with Licensed Practical Nurse (LPN) II confirmed R51's catheter bag should have a dignity bag covering it. LPN II then went to retrieve a dignity bag and covered R51's catheter with it. A follow-up interview with LPN II and CNA HH on 2/24/2025 at 10:42 am revealed they had received in-service training on catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and review of the facility's policy titled, Resident Trust Fund Account, the facility failed to provide resident trust fund account quarterly statements for two of three residents (R) (R24 and R38) reviewed. There were 34 resident trust fund accounts that were managed by the facility. This deficient practice had the potential to affect all residents who had a personal funds account with the facility. Findings include: Review of the facility's policy titled Resident Trust Fund Account, dated 1/9/2022, revealed the Quarterly Statements section included, These are to be done quarterly. Resident Fund Management Service (RFMS) sends them to your facility to be given to the residents. Quarterly statements are to be distributed by the 15th of the month. 1. Review of R24's Minimum Data Set (MDS) End of Prospective Payment System (PPS) Part A Stay assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of (indicating little to no cognitive impairment). Review of the facility-provided document titled Trial Balance revealed R24 had a trust fund account that the facility manages. In an interview on 2/22/2025 at 8:54 am, R24 stated he had a trust fund account that the facility manages. The resident stated he had been a resident for three years and had never received a statement. The resident stated he would like to see his statement to see how much money was in his account. 2. Review of R38's MDS assessment revealed section C (Cognitive Patterns) documented a BIMS of 11 (indicating moderate cognitive impairment). Review of the facility-provided document titled Trial Balance revealed R38 had a trust fund account that the facility manages. In an interview on 2/23/2025 at 1:34 pm, R38 stated there was no reason the facility would give him a quarterly statement. The resident stated he didn't have any money. The resident stated he was not aware that he had a trust fund account with a large balance that the facility manages until informed by the surveyor. In a post-survey interview on 3/5/2025 at 2:08 pm, R38's financial responsible party stated she had not received any quarterly statements for the trust fund account that the facility manages for R38. In an interview on 2/22/2025 at 9:23 am, the Business Office Manager (BOM) stated she was responsible for the resident trust fund account. The BOM confirmed that R24 had a trust fund account that the facility manages. The surveyor accompanied the BOM to R24's room. The resident gave BOM permission to look through his nightstand and stated he was sure there were no statements in his nightstand drawer. The BOM did not find quarterly statements in R24's room. In an interview on 2/22/2025 at 12:50 pm, the Regional Human Resource Coordinator confirmed that the facility document titled Resident Trust Fund Account was the facility's policy. She stated she previously oversaw the business office managers. She further stated that the residents should receive a quarterly statement of the residents' trust fund account that the facility manages. She confirmed the facility policy and procedure was to make two copies of the quarterly statement, provide a copy to the resident, have the resident sign a copy, and the signed copy should be maintained in the business office. She verified that R24 and R38 had trust fund accounts managed by the facility and stated she was unable to provide proof that the quarterly statements had been provided to the residents or their responsible parties.

Based on staff interview and record review, the facility failed to ensure two of two residents' (R) (R38 and R8) trust fund accounts remained under the $2,000.00 limit to maintain eligibility for Medicaid services. There were 34 residents with trust fund accounts that were managed by the facility. This deficient practice had the potential to affect all residents who had a personal funds account with the facility. Findings include: Review of the facility's policy titled Resident Trust Fund Account, dated 1/9/2022, revealed the Spend Downs section included Accounts over $2,000 are to be spent down within 10 days of reaching that amount. 1. Review of R38's Resident Fund Statement dated 10/1/2024 through 12/31/2024 revealed a beginning balance of $2801.28 and an ending balance of $3743.51. 2. Review of the facility-provided document titled Trial Balance revealed that R8's balance on 2/22/2025 was $2075.58. In an interview on 2/23/2025 at 1:00 pm, the Regional Human Resource Coordinator confirmed that R38 and R8's accounts exceeded the $2,000 limit to maintain eligibility for Medicaid services. She stated the Business Office Manager for the facility was in the process of obtaining a burial policy for the residents that have exceeded the $2000.00 limit. In an interview on 2/23/2025 at 4:45 pm, the Administrator confirmed that the facility has some residents who were exceeding the $2,000 limit to maintain eligibility for Medicaid services. She stated that the Business Office Department was in the process of identifying the residents and establishing a burial fund for those residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled Safe and Homelike Environment, the facility failed to maintain a homelike environment for eight of 54 resident rooms on two of four halls and in the main dining room (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] on Hall 100 and Hall 307). These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings include: Review of the facility's undated policy titled Safe and Homelike Environment revealed the Policy Explanation and Compliance Guidelines section included, 1. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. Observations on 2/22/2025 from 10:10 am to 10:40 am revealed eight ceiling tiles in the dining room had large brown stains on them, one ceiling light in the dining room was without a cover over the bulb, and floor tiles with dark stains in the shared bathrooms of resident rooms [ROOM NUMBERS]. Observations on 2/22/2025 at 1:00 pm revealed that the ceiling fan in resident room [ROOM NUMBER] was detached from the ceiling. Observations on 2/22/2025 at 1:05 pm revealed a detached wall plate covering for the outlet for the television cable in resident room [ROOM NUMBER] and a detached ceiling exhaust fan in resident room [ROOM NUMBER]. Observations on 2/22/2205 at 9:19 am, 2/23/2025 at 10:15 am, and 2/24/2025 at 11:15 am revealed brown stains and discolorations on the floor of the shared restroom in rooms [ROOM NUMBERS]. An observation on 2/22/2025 at 9:28 am revealed a water leak around the toilet in the shared bathroom of rooms [ROOM NUMBERS]. During concurrent observations and an interview on 2/24/2025 at 1:15 pm, the Maintenance Director (MD) confirmed the findings and stated all work orders were being submitted through the electronic maintenance reporting system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure that one of seven residents (R) (R36) receiving respiratory care received respiratory care in accordance with professional standards of practice and regulatory requirements. Specifically, the facility failed to obtain a physician's order for oxygen (O2) therapy and ensure proper storage and handling of O2 equipment. The deficient practice had the potential to place R36 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of R36's face sheet revealed they were admitted with diagnoses not limited to chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, hyperlipidemia, cardiomyopathy due to drug and external agent, essential hypertension, chronic kidney disease, and hemiplegia following cerebral infarction. A review of R36's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status (BIMS) score of 13, indicating she is cognitively intact, Section O (Special Treatments, Procedures and Programs) noted O2 use. A review of R36's physician's orders revealed no active order for O2 therapy. A review of R36 ' s care plan revealed the care plan did not reflect the residents' ongoing use of O2. Observation on 2/22/2025 at 10:38 am revealed R36 wearing O2 at 2 LPM (liters per minute) via nasal cannula (NC). The resident refused to speak with the surveyor. Observation on 2/23/2025 at 9:27 am revealed R36 wearing O2 at 2 LPM via NC. The resident refused to speak with the surveyor. Observation on 2/23/2025 at 4:37 pm revealed R36 not wearing her O2. The NC tubing was on the floor, dirty, and not stored in a plastic bag. During an interview on 2/23/2025 at 4:40 pm, the Director of Nursing (DON) stated that the facility failed to obtain a physician's order for O2 therapy after the resident's discharge from the hospital on 1/17/2025. The DON acknowledged that the standard protocol was to reconcile orders upon readmission, but this was not done for R36. She stated that the resident had been receiving O2 without a formal order.

Based on observations, staff interviews, and a review of the facility's policy titled, Blood Glucose Monitoring, the facility failed to ensure the infection control process was followed during glucometer (a device used to test blood sugar results) use for one of eight residents (R) R104) with a physician order for a glucometer reading. The deficient practices had the potential to place residents with a physician's order for glucometer testing at risk of infection due to cross-contamination and increase the spread of infection. Findings include: Review of the facility's undated policy titled Blood Glucose Monitoring, revealed the Policy Explanation and Compliance Guidelines section included .3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. An observation on 2/23/2025 at 11:05 am of Licensed Practical Nurse (LPN) AA performing a glucometer test on R104 revealed that LPN AA gathered the supplies, entered the resident's room, and laid the supplies on the overbed table without a barrier. LPN AA then picked the supplies up and laid them on the bed without a barrier. LPN AA then exited the resident's room and laid the machine on the top of the medication cart without a barrier. After LPN AA performed hand hygiene, the meter was then placed inside of the medication cart. LPN AA completed hand hygiene, removed the same meter from the medication cart, and gathered supplies for a glucometer test on R37. The LPN was asked not to perform the glucometer test on R37 and to please return to the medication cart. In an interview on 2/23/2025 at 11:33 am, the Assistant Director of Nursing (ADON) stated the glucometer machine should be cleaned with a germicidal disposable wipe after each use. She further stated that a barrier must be used when placing the glucometer and supplies on any surface. The ADON stated she would start educating the staff on the proper way to disinfect the glucometer and use a barrier before placing the meter and supplies on any surface. In an interview on 2/23/2025 at 11:40 am, LPN AA stated she had not received education on cleaning a glucometer from the facility.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Date Marking for Food Safety, the facility failed to discard refrigerator food by expiration dates and ensure proper food labeling, storage, and dating, and to ensure dishwasher and sink testing strips were not expired. The deficient practices had the potential to affect all residents who receive meals from the kitchen. Findings include: Review of the undated facility policy titled Date Marking for Food Safety revealed under Policy Explanation and Compliance Guidelines for Staffing: . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. During the initial tour and observation of the kitchen on 2/22/2024 at 7:49 am with the Dietary Manager (DM) revealed two one-gallon pitchers of brown-like liquid labeled sweet-tea with an expiration date of 2/21/2025 and two five-pound bags of diced onions with an expiration date of 2/10/2025 in the double refrigerator. The DM immediately discarded the expired food items. Interview on 2/22/2025 at 7:40 am with the Dietary Manager confirmed she was responsible for labeling and dating and just checked dates recently on 2/21/2025 with the Registered Dietitian during an inspection. The DM mentioned she updated most everything. During a follow-up observation and interview on 2/23/2025 at 8:47 am with the DM, the dishwasher and sink were tested for the concentration of sanitizer by the DM which revealed the [name of test manufacturer] test paper expired June 2022. The DM confirmed she did not have any more testing papers with valid expiration dates and will have to order some but will use the dishwasher.

Based on observations, staff interviews, and record review, the facility failed to ensure essential kitchen equipment was in working order as evidenced by the kitchen hood extinguishing system not operating. This deficient practice had the potential to affect 50 residents receiving an oral diet from the kitchen. Findings include: A review of the facility-provided document titled Kitchen Auto Extinguishing Systems, dated 1/30/2025, revealed the kitchen hood passed the inspection, and inspection results documented that the exhaust fan(s) were not operable. A review of the facility's work order from an electrical service dated 2/22/2025 revealed an on-site inspection that documented there was no voltage to the kitchen hood motor, and the recommendation was made to order a motor. A review of the facility's work order from an electrical service dated 2/24/2025 revealed an on-site service visit documented the kitchen hood motor was operating, and it had no belt. The belt was replaced, and the hood was working. During the initial kitchen tour and observation on 2/22/2025 at 7:49 am, observation revealed the kitchen hood ventilation fan would not turn on. The Dietary Manager (DM) stated she did not remember the fan being in operable order since November 2024. Additional observations on 2/23/2025 starting at 8:47 am during follow-up visits to the kitchen revealed the hood ventilation fan was still not in operation. In an interview on 2/22/2025 at 10:42 am, Life Safety Code (LSC) DD confirmed the facility's kitchen staff and leadership were informed they could not cook on anything under the hood until it was repaired and operable. In an interview on 2/22/2025 at 11:37, the Administrator stated she was not informed about the hood ventilation fan malfunction. The Administrator confirmed the residents would be served alternative meals. In an interview on 2/22/2025 at 11:43 am, the DM stated the residents would be served alternative meals that did not require cooking under the kitchen ventilation hood. In an interview on 2/22/2025 at 11:47 am, Dietary [NAME] EE revealed she did not know when the hood vent went out but thinks it happened sometime after January when there was bad weather. In an interview on 2/22/2025 at 11:53 am, Dietary [NAME] FF revealed she did not know when the hood system stopped working. In an interview on 2/23/2025 at 8:47 am, the DM stated the hood fan was not working. In an interview on 2/23/2025 at 9:06 am, Maintenance Director GG stated he had not been informed of the malfunction of the kitchen hood ventilation fan until 2/22/2025. In an interview on 2/23/2025 at 9:13 am, the Administrator stated that an electrical repair service provided service on 2/22/2025 and ordered a new motor for the kitchen hood ventilation system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the policy titled Abuse Prevention Program, the facility staff failed to report an injury of unknown origin and potential abuse to the facility Administration and to the State Survey Agency (SSA) for one resident (R) R2 of 28 sampled residents. Specifically, Certified Nursing Assistant (CNA) GG was aware of bruising and open area to R2's left hand/arm and bruising to right hand, and failed to report it to Administration. Review of the policy titled Abuse Prevention Program revised December 2016, indicated the policy is that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administrator will: 1. Protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of the clinical record for R2 revealed she was admitted to the facility on [DATE] with diagnoses including unsteadiness on feet, weakness, and Alzheimer's Disease. Review of resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. Resident required extensive assistance for all activities of daily living (ADLs) except eating, where resident was independent. The assessment indicated the resident had not been exhibiting any behaviors. Review of the facility documents including Reportable Occurrences, Incident Logs, and Grievance Logs revealed no evidence that R2's injury of unknown origin was reported by Certified Nursing Assistant (CNA) GG. Review of the electronic medical record (EMR) Nursing Progress Notes revealed no evidence of residents injury or bruising to her hands and arms had been documented. Review of weekly Skin Observation Tool dated 10/4/2023 and 10/11/2023 revealed no open areas and no skin issues were identified. Observation on 10/17/2023 at 9:34 am revealed R2 lying in bed. She is observed with a purple and yellow discoloration resembling a bruise to her right hand by her index and middle finger. Continued observation revealed red and purple discolorations resembling bruises, and an open area, resembling a skin tear, to the left hand and arm. Resident responded, I don't know how I got this. Interview on 10/18/2023 at 10:18 am with CNA GG stated she was aware of the bruising and open skin area on the resident's arms, and stated she did not report it to the nurse because the bruises had been there, and the areas were not new. CNA GG further stated that she is required to report abnormalities to the skin to the nurse, but reiterated the marks were not new, so she did not report it. Interview on 10/18/2023 at 10:21 am the Wound Care Nurse Licensed Practical (LPN) BB revealed she was not aware that R2 had any open skin areas or bruises on her arms. The Wound Care Nurse stated the CNAs are rendering activities of daily (ADL) care and baths, and they are obligated to report any abnormalities with the skin to a nurse immediately. Interview on 10/18/2023 at 10:24 am with Registered Nurse (RN) CC revealed he had not received any reports related to bruises or open skin areas yesterday or today. Interview on 10/18/2023 at 10:36 am the Director of Nursing (DON) stated the CNAs, CMAs, and nurses are required to report any bruises or open skin areas to her as soon as it is identified. She stated that if the source of an injury was unknown, the facility was required to report the injury to the State and launch an investigation. During further interview, she stated she was not aware of R2 having any skin concerns, but confirmed the bruising should have been reported. Interview on 10/18/2023 at 10:43 am the Administrator revealed if a resident presents with areas on their skin of unknown origin and the resident is not able to report how the injury occurred, the facility must investigate the cause, complete a full body audit, report the injury to the state, and notifications made to the local police, residents family and the physician. The Administrator stated that she had conducted a meeting with the staff on 9/28/2023 and discussed allegations of abuse and reporting. During further interview, the Administrator stated there was not a meeting agenda or any notes documented from the meeting held on 9/28/2023. Observation on 10/18/2023 at 10:58 am the Administrator and DON verified the bruises to R2's both arms and the open skin area on her left hand. Administrator asked resident what happened to her arms, and stated the areas were not there the evening of 10/16/2023, when she provided stand by assistance for R2. The resident responded, I don't know what happened. Interview on 10/18/2023 at 11:05 am Certified Medication Aid (CMA) HH confirmed that areas on the skin such as bruises and open skin areas are required to be reported to the Charge Nurse and/or Wound Care Nurse as soon as it is discovered. During further interview, she stated she did not notice the bruises or the open skin area on R#2's hands when she administered her medications this morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that a Discharge Minimum Data Set (MDS) assessment was transmitted within 31 days of completion to CMS (Center for Medicare and Medicaid Services) of Quality Improvement evaluation system (QIES) Assessment Submission and Processing (ASAP) for ten of 46 residents (R) (R17, R18, R22, R26, R29, R33, R40, R42, R48, and R50) sampled. Review of the Resident Assessment Task in the Long-Term Care Survey Process revealed MDS assessments identified as being more than 120 days old include: R17: Quarterly assessment dated [DATE] was coded as 'exported'; Quarterly assessment dated [DATE] coded as 'export ready'. R18: Quarterly assessment dated [DATE] was coded as 'export ready'. R22: Quarterly assessment dated [DATE] coded as 'exported' and end of PPS (Prospective Payment System) stay dated 8/31/2023 - end of PPS part A was coded as 'export ready'. R26: Annual assessment dated [DATE] was coded as 'exported' and Quarterly assessment dated [DATE] was coded as 'export ready'; Annual assessment dated [DATE] coded as 'incomplete'. R29: Quarterly assessment dated [DATE] was coded as 'export ready'. R33: Annual assessment dated [DATE] was coded as 'exported'; Quarterly assessment dated [DATE] coded as 'export ready'; Annual assessment dated [DATE] coded as 'incomplete'. R40: Quarterly assessment dated [DATE] was coded 'exported.' R42: Quarterly assessment dated [DATE] was coded as 'exported'. R48: Quarterly assessment dated [DATE] was coded as 'export ready'. R50: Annual assessment dated [DATE] was coded as 'exported'. Interview on 10/18/2023 at 8:45 am with the MDS Coordinator revealed she had worked at the facility as the MDS Coordinator for two weeks. She stated as far as she was aware, the facility had not had an MDS Coordinator for a few months. She stated other staff had filled in to complete and submit MDS assessments. She stated as far as she was aware, all MDS assessments and submissions were up to date. The MDS assessments identified as being more than 120 days old were reviewed with the MDS Coordinator who verified the ten listed residents with MDS assessments over 120 days. She stated the coding was accurate as far as she knew. She stated she was unsure what the assessment codes of 'exported' and 'export ready' meant. She stated she was receiving virtual training from a corporate MDS Coordinator and was still learning the job. Interview on 10/18/2023 at 3:23 pm with the Administrator revealed the MDS Coordinator had worked at the facility for two weeks and was receiving virtual education from a corporate MDS Coordinator. She verified the listed ten residents with MDS assessments over 120 days old. She stated the previous Assistant Director of Nursing (ADON) and Director of Nursing (DON) were responsible for completion and submission of the MDS assessments. She stated her expectation was for the MDS Coordinator to complete and submit MDS assessments within the required time frame and to follow-up to ensure the assessments were accepted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled Behavioral Assessment, Intervention, and Monitoring, the facility failed to apply for Level two PASARR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for three of six sampled residents (R) (R16, R19, and R38) that were reviewed for Level two PASARR and found to have a positive Level I PASARR for mental illnesses prior to and on admission to the facility. The deficient practice had the potential for R16, R19, and R38 to be denied specialized services for psychological, psychiatric, and functional needs. Findings Include: Review of the policy titled Behavioral Assessment, Intervention, and Monitoring revised March 2019, revealed under Assessment 1. B. If the level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition he or she will be referred to the state PASARR representative for the Level two (evaluation and determination) screening process. 1. Review of the clinical record for R16 revealed the following diagnoses but not limited to bipolar disorder, anxiety disorder, major depressive disorder, schizophrenia, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R16 revealed section C- Cognitive Patterns-Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment, section E-Behaviors-no behaviors exhibited, section I-Active Diagnoses-anxiety, bipolar, and schizoaffective disorders, schizophrenia, and altered mental status, section N-Medication-on antidepressant, antianxiety medication seven days a week, and antipsychotics seven days a week. section O-Special Treatments, Procedures, and Programs-no therapies noted. Review of the care plan dated 8/16/2023 revealed R16 has delusions, hallucinations, and suicidal ideations. Review of the Physician's Orders for R16 revealed orders for Seroquel 200 milligrams (mg) two times a day (BID), start date 8/22/2023, Geodon 20 mg BID, start date 8/3/2023, Haldol 5 mg injection as needed every six hours, start date 5/14/2023, Donepezil 10 mg every day, start date 1/17/2023. Interview on 10/17/2023 at 9:55 am with the Certified Occupational Therapy Assistant (COTA) revealed R16 had declined over the past month, she had quit walking, feeding herself, or wanting to go to activities. She had been exhibiting more behaviors. 2. Review of the clinical record for R19 revealed the following diagnosis but not limited to psychosis and disorder of the brain. Review of the annual MDS dated [DATE] revealed section I- resident with a psychotic disorder, section N- resident administered antipsychotics seven days a week, and section O- resident is not receiving any psychological therapy. Review of the care plan dated 6/8/2023 revealed R19 had little interest and pleasure in doing things. Review of the Physician Orders for R19 revealed orders for Risperdal 0.25 mg two times a day, start date 8/4/2023. Behavior monitoring for agitation, anger, restlessness, and crying. 3. Review of the clinical record for R38 revealed the following diagnosis but not limited to psychosis, cognitive communication deficit. Review of the annual MDS dated [DATE] revealed section I- psychotic disorder, section N- resident is administered antipsychotics, and antidepressants seven days per week, section O-Special Treatments- resident has received no psychological therapy. Review of the care plan dated 6/8/2023 resident is noted to have delusions and hallucination episodes. Review of the Physician Orders for R38 revealed orders for Seroquel 25 mg ½ tab every day, start date 3/17/2022 and Remeron 15 mg ½ tab every day, start date 10/12/2022. Interview on 10/19/2023 at 1:42 pm with the Social Services Director revealed she had been here for two-weeks and was new to the position overall. She was responsible for PASSAR level two submissions, she revealed she has not been trained for that part of her job yet. Interview on 10/19/2023 at 2:45 pm with the Director of Nursing (DON) and the Administrator revealed the responsibility for PASARR level II was Admissions before admission and Social Services after admission. The Activities Director is completing PASSAR level II's right now while the new Social Services Director is being trained. Interview on 10/19/2023 at 3:30 pm with the Activities Director revealed she did not know she was responsible for entering the PASARR level two submissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the care plan revised on 9/4/2023 for R5 revealed focus as requires assistance with ADLs related to dementia, limited mobility, right above the knee amputation, self-care deficit. She prefers a bed bath. The goals revealed staff will provide needed assistance with ADLs. Interventions included but were not limited to incontinent care on rounds and as needed. The position listed for this intervention was Certified Nursing Assistant (CNA), bathing/showering: assist with bed bath as scheduled (refer to bath sheets at nurse desk) and as needed. Avoid scrubbing and pat dry sensitive skin (date initiated 3/1/2022, revised on 3/24/2022) position listed for this intervention was CNA, LPN. Record review of Minimum Data Set (MDS) assessment dated [DATE] for R5 revealed in section G - Functional status required total assistance with 2+ person assistance for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene, and bathing. Observation of CNA LL on 10/18/2023 at 10:42 am provided perineal care for R5. CNA LL cleaned the bedside table prior to assembling the supplies needed for the task. She prepared a basin of warm water, clean linens, towels, and handcloths. She performed care, cleaning the perineal area from front to back. She attempted to roll the resident over to her right side (the resident was not able to assist with turning). As she was holding the resident on her right-side LPN BB entered the room who performed hand hygiene and donned gloves, moved to the resident's right side to hold the resident in position while CNA LL completed perineal care. Interview on 10/18/2023 with CNA LL revealed she admitted that she should have had a second person to assist her when turning R5 in the bed and throughout the perineal care given. CNA LL stated the area where she charts care given in the EMR reveals that R5 requires two-person assistance when performing care for R5. She stated she did ask another CNA for assistance, but the CNA did not come to help. Interview with LPN BB on 10/18/2023 at 11:16 am revealed that CNA LL should have had a second CNA to assist her with the perineal care for R5. She stated when she discovered CNA LL was doing perineal care for R5 she wanted to complete her skin assessment and that is why she initially came into the room during care but realized she needed assistance, so she assisted with the care and assessed the resident's skin while assisting. She verified and confirmed that the care plan did not indicate the need for two-person assistance for any care except the use of a mechanical lift. She verified and confirmed the minimum data set (MDS) assessment section G revealed that R5 was totally dependent and required two-person physical assistance with ADL care including perineal care and turning in the bed. Interview with the Director of Nursing (DON) on 10/18/2023 at 11:25 am, verified and confirmed the MDS assessment section G revealed R5 was assessed as totally dependent and required two or more-person physical assistance for ADL care. She confirmed the care plan did not reflect this information and it should be developed based on the MDS assessment and the resident's needs. She stated she expected staff to follow the care plan and she expected the MDS/Care Plan Coordinator to create a care plan based upon the MDS assessment. Interview with the MDS/Care Plan Coordinator on 10/18/2023 at 12:42 pm, she verified and confirmed the MDS assessment section G for R5 revealed she was assessed as totally dependent and required 2+ person assistance for ADL care. She stated that the section heading Position of the care plan revealed who was to provide care and that all listed were to be in the room providing care. Based on observations, record review, resident and staff interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to follow the care plan for Activities of Daily Living (ADL) related to nail care for two of four residents (R) (R15 and R44), one resident (R) (R5) related to providing two person assistance during ADL care. In addition, the facility failed to follow the care plan related to establishing a means of communication between the facility and the dialysis center for three of three residents (R) (R15, R22, and R33), and failed to follow the care plan implemented for one resident (R) (R2) reviewed for alterations in skin integrity. This deficient practice had the potential to affect the continuity of care provided for residents. Findings include: Review of the policy titled Care Plans, Comprehensive Person-Centered revised December 2016, revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident. 1. Record review revealed R15 had a diagnosis that included generalized muscle weakness, cognitive communication deficit, lack of coordination, and muscle wasting and atrophy, not elsewhere classified, left upper arm. Record review of the most recent quarterly Minimum Data Sheet (MDS) dated [DATE] for R15 revealed: Section G (Functional Status) personal hygiene and bathing-total dependent. Section O: Received dialysis while a resident. Record review of the care plan for R15 revealed the resident requires assistance with ADL's due to limitations and weakness in bilateral extremities. The resident prefers a bed bath. Intervention: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Further review of R15's care plan revealed that the resident has a diagnosis of End Stage renal Disease (ESRD) and requires dialysis. There was an intervention to establish a means of communication between dialysis and the facility. Review of R15's record revealed there was not any documentation to indicate refusals of care or education related to compliance with ADL care. Review of R15's Dialysis Communication Sheets located in the Electronic Medical Record (EMR) under the Miscellaneous tab revealed there were only 13 communication sheets from the dialysis center that were completed from 9/1/2023 through 10/18/2023. During this time, there were twenty-one visits to the dialysis center. Further review of the dialysis communication sheets revealed there were seven sheets with a note that reads No Sheet Sent, further observation of the sheet revealed the top portion (facility) was blank, indicating the facility did not send a sheet with resident to dialysis. Observations on 10/17/2023 at 9:56 am and 3:48 pm and 10/18/2023 at 9:18 am revealed R15 lying in bed with long dirty fingernails on both hands. 2. Review of the most recent Minimum Data Set (MDS) dated [DATE] for R44 revealed a Brief Interview for Mental Status (BIMS) was coded as 8, which indicated moderate cognitive impairment. Section G revealed resident required extensive assistance with personal hygiene. Record review of the care plan for R44 revealed resident had episodes of refusing nails to be trimmed. Interventions included to approach resident in a calm pleasant manner, educate resident on importance of accepting care and risk of refusing care, encourage resident to participate in nursing home activities of choice, explain to resident what you are about to do prior to beginning care, notify MD as needed, observe resident for changes in behaviors, redirect resident as needed. Observation on 10/17/2023 at 9:26 am, R44 was lying in bed with long nails on all fingers of both hands with food matter underneath. Further observation at 12:51 pm revealed the wound nurse entering the resident's room and delivering a meal tray. The resident was able to self-feed after set-up using fingers to eat some foods. Fingernails continued to have a brown substance underneath all nails on both hands. During an observation and interview on 10/18/2023 at 8:59 am, it was revealed that a resident was lying in bed with their head covered. Resident uncovered head to verbal stimuli and spoke. R44's fingernails continue to be long and have a caked brown substance underneath the nails. The resident also had a dried substance on the fingers of the right hand at the time of this observation. At 9:01 am a caregiver entered the resident's room and closed the door. At 9:04 am a second caregiver entered the resident's room and closed the door. At 9:35 am the caregiver exited the room. The nails on both hands appeared to be cleaner but continued to have brown substances underneath the nails. The resident shook her head no when asked if she wanted her fingernails cut. The resident shook her head yes when asked if she allows caregivers to clean her fingernails. 3. Record review revealed R33 was admitted with the diagnoses end stage renal disease (ESRD), dependence on renal dialysis, and type 2 diabetes mellitus without complications. Record review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] for R33 revealed she received dialysis and had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Record review of the care plan for R33 related to dialysis revealed resident is at risk for weight fluctuations related to ESRD and is dependent on renal dialysis. Interventions included establishing means of communication between the dialysis facility and the facility. Review of R33's Dialysis Communication Sheets, located in the EMR under the Miscellaneous tab, revealed two sheets dated 7/18/2023 and 9/28/2023 were documented pre/post dialysis for R33. Further review revealed Dialysis Communication Sheets dated 2/9/2023, 2/18/2023, 3/4/2023, 3/11/2023, 4/20/2023, and 7/20/2023 in a Dialysis notebook at Station one Nurses Station. 4. Record review revealed R2 was admitted with diagnoses including unsteadiness on feet, weakness, and Alzheimer's Disease. Record review of the most recent annual Minimum Data Set (MDS), dated 7/14/2023, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment. R2 required extensive assistance for all activities of daily living (ADLs) except eating, where the resident was independent. The assessment indicated the resident had not been exhibiting any behaviors. Record review of the care plan revised 7/31/2023 revealed R2 was at risk for impaired skin integrity related to limited mobility, nutritional concerns, incontinence, and dx of diabetes mellitus. Intervention initiated on 9/5/2022 included observing skin during ADL care for early signs of skin breakdown. Notify the charge nurse. Observation on 10/17/23 at 9:34 am revealed R2 lying in bed. R2 was observed with a purple and yellow bruise on the right hand by index and middle finger. The resident was also observed with red and purple bruises and an open area on the left hand and arm. A review of R2's skin observations dated 10/4/2023 and 10/11/2023 revealed no open areas and no skin issues were identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the policy titled Supporting Activities of Daily Living (ADL), the facility failed to provide assistance with grooming for two of four dependent residents (R) (R44 and R15) related to nail care for Activities of Daily Living (ADLs). The findings include: Review of policy titled Supporting Activities of Daily Living revised March 2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching resident in a different way or a different time or having another staff member speak with the resident may be appropriate. 1. Review of the clinical record revealed R44 was admitted to the facility with diagnoses to include unspecified schizophrenia, personal history of traumatic brain injury, and major depressive disorder single episode severe without psychotic features. Review of R44's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) revealed resident required extensive assistance with personal hygiene. Review of R44's care plan revealed resident had episodes of refusing nails to be trimmed. Interventions included to approach resident in a calm pleasant manner, educate resident on importance of accepting care and risk of refusing care, encourage resident to participate in nursing home activities of choice, explain to resident what you are about to do prior to beginning care, notify MD as needed, observe resident for changes in behaviors, redirect resident as needed. Review of R44's record revealed there was not any documentation to indicated refusals of care or education related to compliance of ADL care. Observation on 10/17/2023 at 9:26 am, R44 was lying in bed with long nails on all fingers of both hands with food matter underneath. Further observation at 12:51 pm revealed wound nurse entering residents room and delivering meal tray, resident able to self-feed after set-up using fingers to eat some foods. Fingernails continued to have brown substance underneath all nails on both hands. Observation and interview on 10/18/2023 at 8:59 am revealed resident lying in bed with head covered. Resident uncovered head to verbal stimuli and spoke to surveyor. Resident's fingernails continue to be long and have caked brown substance underneath the nails. Resident also had dried substance on the fingers of the right hand at the time of this observation. At 9:01 am caregiver entered residents room and closed the door. At 9:04 am a second caregiver entered residents room and closed the door. At 9:35 am caregiver exited room. The nails on both hands appeared to be cleaner but continued to have brown substance underneath nails. The resident shook her head no when asked if she wanted her fingernails cut. Resident shook her head yes when asked if she allows staff to clean her fingernails. Interview on 10/18/2023 at 9:01 am with certified Nurse Aide (CNA) HH revealed that she gave resident a bed bath and she cleaned her hands and cleaned some of the brown substance from under her fingernails. She further stated resident refused to allow her fingernails to be cut and sometimes refuses to allow her to do anything with her hands. Interview on 10/18/2023 at 9:41 am with the Activity Director (AD) revealed that she provides 1:1 activity with R44 to include nail care, polishing and cleaning nails weekly. AD further stated resident refuses to allow the staff to cut or trim nails, but she polished and cleaned residents fingernails last Friday (10/13/2023). AD stated that CNAs are responsible for cleaning her nails in between. AD stated R44 feeds herself and sometimes uses her fingers rather than utensils to eat. Interview on 10/18/2023 at 10:04 am with CNA GG revealed R44 eats with her fingers. CNA GG further stated that during ADL care today, she attempted to clean residents fingernails, but resident complained of pain, so she stopped. CNA GG also stated she did not report residents complaint to the nurse. Interview on 10/18/2023 at 10:10 am with Certified Medication Aide (CMA) HH revealed R44 will not allow the staff to trim her fingernails. She further stated that she was not aware that resident refused to have her fingernails cleaned or reported complaints of pain during nail care. Interview on 10/18/2023 at 10:13 am with Registered Nurse (RN) CC revealed that he is relatively new to the facility, so he is not familiar with the process for reporting refusals of care. RN CC further stated he did not think the CNAs are required to report refusal of care to the nurses. RN CC stated that the CNAs are not reporting refusals to the nurses, and he was not aware of resident refusing care. 2. Review of the clinical record revealed R15 was admitted with the diagnoses generalized muscle weakness, cognitive communication deficit, lack of coordination, and muscle wasting and atrophy, not elsewhere classified, left upper arm. Review of R15's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Section G revealed resident was totally dependent with personal hygiene. Review of R15's care plan revealed resident required assistance with ADLs due to limitation and weakness to bilateral lower extremities. Interventions on the care plan included checking nail length, trim and clean on bath day and as necessary. Review of R15's record revealed there was not any documentation to indicate refusal of care or education related to compliance of ADL care. Observations on 10/17/2023 at 9:56 am, 3:48 pm, and on 10/18/2023 at 9:18 am revealed resident lying in bed with long dirty fingernails on both hands. Observation and interview on 10/19/2023 at 9:12 am revealed resident lying in bed. R15 stated that she allows the staff to file her nails, does not want them cut, but she would not mind the staff cleaning her nails because she does not like them dirty. During walking rounds on 10/18/2023 at 10:15 am with CMA HH and RN CC verified R44's nails to have a buildup of brown substance caked underneath nails and R#15's fingernails were dirty and need cleaning. Interview on 10/18/2023 at 10:22 am with DON revealed it is her expectation that CNAs would provide nail care to residents daily as needed and report resident refusal of care and any discomfort to the nurses. DON further stated nurses should follow up to see why the resident is refusing and document the refusals in the progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide treatment and services for one of 28 sampled residents (R) (R16) displaying symptoms of a known diagnosis of anxiety disorder, depression, bipolar disorder, schizophrenia, schizoaffective disorder, and altered mental status. Findings include: Record review of the admission Record for R16 revealed that she was initially admitted on [DATE]. A diagnosis included but was not limited to bipolar disorder, anxiety disorder, major depressive disorder, Schizophrenia, and schizoaffective disorder. Record review of the quarterly Minimum Data Set (MDS) for R16 dated [DATE] revealed under section O-Special Treatments, Procedures, and Programs-no therapies noted. Record review of a Behavior Note dated [DATE] R16 stated I am confused, where am I? throughout the beginning of pm shift. The resident required frequent redirection and positioning in bed to prevent issues or/and fall activities. Record review of a Behavior Note, dated [DATE] for R16 revealed the resident is up sitting at nurses station for the pm shift due to confusion and combative behavior. R16 was re-directed multiple times, PRN medication administered without effective results. Snacks offered/ drinks given. Stated someone died and my mom is picking me up for the funeral. continued to re-orient to place, time, and situation. Calling staff profanities and threatening to hit if not let outside. Monitored closely for safety of resident and other/ staff. Interview on [DATE] at 1:42 pm with the Social Services Director (SSD) revealed she has only been at this facility for two weeks and is new to the position overall. She does not know why services stopped but is sure she will be learning that aspect of her position. Interview on [DATE] at 2:45 pm with the Director of Nursing and Administrator revealed it will be the responsibility of SSD to maintain appointments, and at this time the SSD is new to the facility and her position. The SSD is receiving training for all aspects of her position. Record review of R16 Electronic Medical Record revealed her last visit with Psychiatry visit was [DATE].

Based on record review, staff interviews, and review of the policy titled Antipsychotic Medication Use, the facility failed to ensure that psychotropic medications/antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) R16 reviewed for unnecessary medications. Findings include: Review of the policy titled Antipsychotic Medication Use, the policy statement revealed Antipsychotic medications will be prescribed at the lowest dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Review of the admission Record for R16 revealed the following diagnoses but not limited to bipolar disorder, anxiety disorder, major depressive disorder, schizophrenia, and schizoaffective disorder. Record review of the most recent quarterly Minimum Data Set (MDS) for R16 dated 8/4/2023 revealed section C- Cognitive Patterns-Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment, section E-Behaviors-no behaviors exhibited, I-Active Diagnoses-anxiety, bipolar, and schizoaffective disorders, schizophrenia, and altered mental status, section N-Medication- antidepressant, antianxiety medication 7 days a week, and antipsychotics 7 days a week. Record review of the care plan dated 8/16/2023 for R16 revealed she has delusions, hallucinations, and suicidal ideations. Record review of the physician's orders for R16 revealed orders for Seroquel 200 milligrams (mg) two times a day (BID), start date 8/22/2023, Geodon 20mg BID, start date 8/3/2023, Haldol 5mg injection as needed every 6 hours, start date 5/14/2023, Donepezil 10mg every day, start date 1/17/2023. Review of the Medication Administration Record (MAR) dated August 1, 2023-August 31, 2023, revealed R16 received an injection of Haldol on August 2, 2023. Review of the MAR dated September 1, 2023-September 30, 2023, revealed R16 received an injection of Haldol on September 16, 2023, September 20, 2023, and September 21, 2023. Review of the MAR dated October 1, 2023-October 31, 2023, revealed that R16 received an injection of Haldol on October 14, 2023. Interview on 10/17/2023 at 9:55 am with the Certified Occupational Therapy Assistant (COTA) revealed R16 has declined over the past month, she has quit walking, feeding herself, or wanting to go to activities. She has been exhibiting more behaviors. Interview on 10/18/2023 at 4:40 pm with the Pharmacy Consultant revealed she recommends for appropriate use that a PRN psychotropic be discontinued after 14 days. The doctor may reassess the resident and order the medication for an additional 14 days. On 5/30/2023 it was recommended to the physician to discontinue medication, but the physician declined. On 10/15/2023 Pharmacy consultant informed the doctor that an end date listed as indefinite is not appropriate for a PRN psychotropic medication and recommended the medication be discontinued, but the doctor refused.

Based on observations, interviews, and review of the policy titled Administering Medications, the facility failed to ensure medications and biologicals were discarded by the expiration date and failed to ensure that all medications were secured and stored properly, for one of four medication carts. Findings include: Review of the policy titled Administering Medications, dated April 2019, revealed Policy Interpretation and Implementation Number 12: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Number 19: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on 10/18/2023 at 8:30 am revealed that Licensed Practical Nurse (LPN) BB placed a 31-day medication card with one tablet remaining in the card, on top of the medication cart while entering a resident's room to administer medications. The medication cart was in the hallway and easily accessible to residents and others passing by. Observation on 10/19/2023 at 8:45 am revealed in station two medication cart there was one opened bottle of Thiamin 100 milligrams (mg) with 12 tablets remaining in the bottle, which had an expiration date of 8/2023. Interview on 10/18/2023 at 8:40 am with LPN BB revealed she needed to reorder the medication, so she didn't want to put it back in the drawer until she had done so. She stated she should have asked the Certified Medication Aide (CMA) HH to stay with the cart until she returned from the resident's room. Interview on 10/19/2023 at 8:50 am with LPN E revealed that she usually checks for expired medications but with the State here she was so nervous. She stated she knows what she should do but she forgot. Interview on 10/19/2023 at 2:45 pm with the Director of Nursing (DON) revealed the nurses know the policies for expired medications and leaving medications unattended. She stated she did not know what happened and will re-educate all nurses and CMAs.

Based on staff interviews, review of training records, and review of the Alliant Health Solutions Staff Development, the facility failed to maintain an in-service training program to ensure the continuing competency of Certified Nurse Aides (CNAs) for the required 12 hours of annual in-service training. The census was 48. Findings include: Review of the Alliant Health Solutions staff development review dated 7/13/2023 indicated please ensure in the future that your yearly in-services include Quality of Care, transfers, turning and positioning, incontinent care/skin care, weight loss, and dining techniques (feeding, assistive devices . etc.) Also, the facility may want to include more in-service hours for Alzheimer's, cognitively impaired, and dementia. Interview on 10/19/2023 at 2:00 pm with Certified Medication Aide (CMA) HH revealed she did not remember the last time they received in-services on dining, Alzheimer's, dementia, transfers, turning and positioning, or quality of care. Interview on 10/19/2023 at 2:30 pm with Certified Nursing Assistant (CNA) FF stated she was unable to recall the last time she received in-services on dining, Alzheimer's, dementia, transfers, turning and positioning, and quality of care. Interview on 10/19/2023 at 2:45 pm with CNA GG revealed she did not remember receiving in-services on dining, Alzheimer's, dementia, transfers, turning and positioning, and quality of care. Interview on 10/19/2023 at 3:00 pm with the Administrator and Director of Nursing (DON) revealed after asking for the CNA education documentation with the education material that was presented and the sign-in sheets to verify CNA attendance, the documentation could not be produced for the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of policy titled Quality of Life-Homelike Environment, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment in 11 of 49 resident rooms (101, 103, 104, 107, 108, 110, 112, 115, 118, 119, 318) and one of three shower rooms, as evidence by stained privacy curtains, stains on the bathroom floor tiles, broken drawer, baseboards, and curtain track, holes in ceiling tiles, scuffed walls and hole in wall, and lingering malodorous smell throughout the facility. Findings include: Review of the policy titled Quality of Life-Homelike Environment revised May 2017, revealed the policy is that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation Number 2 a. Clean, sanitary, and orderly environment; f. Pleasant, neutral scents. Observations on 10/17/2023 from 9:27 am to 3:27 pm during the initial tour of residents rooms revealed the following identified concerns: A-Hall *room [ROOM NUMBER]: Two ceiling tiles stained with black substance, one with a vent and one with a sprinkler head. The bathroom had a strong foul odor. Exhaust vent in the bathroom was covered with dust. *room [ROOM NUMBER]: Bathroom has strong urine odor. *room [ROOM NUMBER]: Window curtain was stained with a brown stain on the side facing the window and was missing a hanger from the track. There was one urinal hanging from the handrail near the entrance to room [ROOM NUMBER] with 102 written on it, but not stored inside a bag and one urinal hanging from rail in the corner of the bathroom near entrance to room [ROOM NUMBER] not labeled or stored inside a bag. *room [ROOM NUMBER]: Bathroom tile flooring surrounding the toilet is stained and with black debris noted behind the toilet. *room [ROOM NUMBER]: Scuffed and uneven drywall alongside bed B. Bathroom floor with black substance surrounding the base of toilet. *room [ROOM NUMBER]: Resident room had one ceiling tile stained and one ceiling tile with a hole in it; bathroom flooring stained with rusty areas on the floor tiles surrounding the commode; baseboards under the sink, the left side and behind the toilet were broken with black debris on them. *Hall ceiling tiles between rooms 109-111 noted with holes and one tile is stained. *room [ROOM NUMBER]: Two ceiling tiles with black stains and bathroom malodorous. B Hall *room [ROOM NUMBER]: The drywall along the right side of bed A is scuffed and uneven. *room [ROOM NUMBER]: Floor tiles in the bathroom around the toilet are stained dark brown color, baseboards in bathroom are dirty with black debris and are broken, and there was a strong lingering urine odor from bathroom out into the hallway. *room [ROOM NUMBER]: Severe foul odors in the room, walls were dirty and scuffed, dresser drawers stained and paint chipping and uneven and appear to be broken. * Shower room labeled Bathroom [ROOM NUMBER] wood covering the lower part of the door is not fastened securely to the door. D Hall *Three ceiling tiles between rooms 310-315 noted with brownish color stains and holes in the tiles. * room [ROOM NUMBER]: Room was very plain and lacked a homelike environment. There was a hole in the wall that was attempted to be patched. However, the attempt did not successfully complete the needed repair. During a walk-through on 10/19/2023 at 1:28 pm with the Maintenance Director and the Director of Nursing (DON), verified and confirmed the concerns identified during the survey and stated they needed repairs. Interview on 10/19/2023 at 2:00 pm the Maintenance Director confirmed the issues identified in rooms 101, 103, 104, 107, 108, 110, 112, 115, 118, 119, 318, the ceiling tiles, and the bathroom door needed maintenance or repair. He stated he routinely completes a walk-through of the building daily to identify items that need repairs. He stated he is the only one that the repairs fall on and expressed he lacks the time to fulfill the need for the repairs. He stated his expectation was that these issues would be corrected as soon as he could get around to them. Interview on 10/19/2023 at 2:07 pm with the Director of Nursing (DON) confirmed maintenance issues identified and revealed they had been working on maintenance and repairs daily. She stated expected maintenance and repairs to be completed as timely as possible. Interview on 10/19/2023 at 3:38 pm with Licensed Practical Nurse (LPN) EE revealed that room [ROOM NUMBER] typically has a foul urine odor even though the housekeeper does clean the room. She stated the odor in that room is worse than others due to the resident urinating on the floor. Interview on 10/19/2023 at 3:51 pm with Housekeeping/Laundry Manager revealed she is aware that room [ROOM NUMBER] has a lingering foul odor. She stated the resident goes to the bathroom and urinates on the floor, and she believes that the urine is now under the tiles. During further interview, she stated her plan was to replace the floor tiles in that bathroom.

Based on record review, staff interviews, and review of policy titled Abuse Prevention Program, the facility failed to obtain and complete reference checks for five of 10 employee records reviewed. Findings include: Review of the undated policy titled Abuse Prevention Program revealed Policy Interpretation and Implementation: Number 2: as a part of the resident abuse prevention, the administration will conduct background checks on employees and will not knowingly employe any individual found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, or mistreatment of residents or misappropriation of funds, or have a disciplinary action in effect against professional license by a state licensure body as a result of finding abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property. Review of employee files revealed reference checks were not completed for the Administrator, Director of Nursing (DON), Dietary Manager, Social Service Director, and RN NN. Interview on 9/19/2023 at 12:36 pm, the Administrator revealed she had been the Administrator for approximately three weeks. She stated she was unable to provide documentation of reference checks for herself, the DON, Dietary Manager, Social Service Director, or Registered Nurse (RN) NN. She indicated the background checks are completed to ensure residents were protected from potential abuse. During further interview, she stated the Corporate Human Resource office was responsible for ensuring background checks were completed for each employee upon hire. She further stated she had contacted the Corporate Human Resource Office to request the missing documentation, but none had been presented at time of exit. Facility failed to obtain background check for 5 out of 10 employee records reviewed. QA'd

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, review of the Outpatient Dialysis Service Agreement, and review of policy titled Care of a Resident with End-Stage Renal Disease, the facility failed to ensure ongoing communication between the facility and the dialysis center for three of three residents (R) R22, R15, and R33 reviewed for dialysis. In addition, the facility failed to provide Physician Orders for dialysis services and ongoing monitoring for R22 dialysis access site. Substandard Quality of Care was identified related to Dialysis Findings include: Review of the policy titled Care for a Resident with End Stage Renal Disease revised September 2010, revealed the policy is residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation: 2. Education and training of staff includes, specifically: b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. c. Signs and symptoms of worsening condition and/or complications of ESRD. g. The care of grafts and fistulas 4. Agreements between this facility and the contracted ESRD facility include all aspects of how resident's care will be managed . b. How information will be exchanged between the facility. Review of the Dialysis Contract with an effective date of November 1, 2022, and signed by the facility Administrator on December 8, 2022 and the Dialysis Administrator on December 15, 2022, revealed . Interchange of Information - The Long-Term Care Facility shall provide for the Interchange of information useful or necessary for the care of the ESRD Residents, including a contact person at the Long-Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents. 1. Review of the clinical record revealed R22 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, congestive heart failure (CHF), end stage renal disease (ESRD) with dependence on renal dialysis, and anemia in chronic kidney disease. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating resident was cognitively intact. Section O revealed resident was receiving Dialysis. Review of the updated care plan revised 9/4/2023 documented resident has ESRD and requires hemo-dialysis twice per week. Interventions for care include ensure and encourage resident to attend dialysis as scheduled, monitor lab reports of electrolytes and report to physician, notify if potassium (K+) is over 5.5, monitor/document/report any signs and symptoms of acute renal failure. Review of the October 2023 Order Summary Report for R22 revealed no evidence of Physician Orders for dialysis services, including monitoring or location of dialysis access site, or for dialysis-related complications such as bleeding and infection. Review of hospital note dated 9/30/2023 indicated resident will continue to dialyze on Monday and Friday and will be using her Permcath as her AV fistula is not yet matured. Review of R22's medical record revealed Dialysis Communication Sheet, for 5/29/2023, 7/3/2023, 7/17/2023, 7/21/2023, 8/14/2023, and 9/18/2023 were documented pre/post dialysis information for R#22. Dialysis Communication Sheets dated 1/16/2023, 2/6/2023, and 3/30/2023 were located in a Dialysis notebook at Station one Nurses Station. Observation on 10/17/2023 at 9:00 am revealed R22 was not in her room, staff reported resident is out of the facility at dialysis but should be returning soon. Interview on 10/19/2023 at 8:54 am, R22 reported that her dialysis days were recently changed to Tuesdays and Thursdays, and she goes early in the morning. Resident stated that her dialysis site is on her right chest wall. Resident points to chest and pulled top of shirt downward to reveal a double lumen subclavian port to right chest wall. 2. Review of the clinical record revealed R15 was admitted to the facility on [DATE] with diagnoses including ESRD, chronic congestive heart failure (CHF), hypertension, and type 2 diabetes mellitus. The resident's most recent quarterly MDS dated [DATE], revealed a BIMS score of eight, indicating moderate cognitive impairment. Section O revealed resident was receiving Dialysis. Review of the updated care plan revised 8/15/2023 documented resident has ESRD and requires dialysis. Interventions for care include establishing means of communication between dialysis and facility, observe dialysis site for signs and symptoms of infection, bleeding, etc., arrange transportation to and from Dialysis facility. Review of the October 2023 Order Summary Report for R15 revealed orders dated 10/21/2023 for Dialysis on Monday, Wednesday, and Friday, remove dressing from left arm on Tuesday, Thursday, and Saturday, and check dialysis access for the following: bruit and thrill, signs and symptoms of infection and bleeding every shift related to End Stage Renal Disease. Review of R15's medical record revealed from 9/1/2023 through 10/18/2023, there were only 13 Dialysis Communication Sheets from the dialysis center that were completed, out of 21 visits. Further review of the dialysis communication sheets revealed seven sheets with a note that indicated No Sheet Sent and revealed the top portion (facility) was blank, indicating the facility did not send a sheet with resident to dialysis. Interview on 10/19/2023 at 9:16 am with Certified Nursing Assistant (CNA) FF stated she provides care for dialysis residents. She stated that the facility had not provided her with education regarding caring for dialysis residents, but stated she knows not to use resident arm that much and not to get it wet. 3. Review of clinical record revealed R33 was admitted to the facility on [DATE] with diagnoses including ESRD with dependence on renal dialysis, hypertension, obesity, and type 2 diabetes mellitus without complications. The resident's most recent quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Section O revealed resident was receiving Dialysis. Review of the updated care plan revised 10/6/2023 documented resident has ESRD and is dependent on renal dialysis. Interventions for care include establish means of communication between dialysis and facility, do not draw blood or obtain blood pressure in arm with dialysis port, observe dialysis port for signs and symptoms of infection, please arrange transportation to and from Dialysis center. Review of the October 2023 Order Summary Report for R33 revealed orders dated 2/1/2023 for Dialysis on Tuesday, Thursday, and Saturday, and check dialysis access for the following: bruit and thrill, signs and symptoms of infection and bleeding every shift for renal failure. Review of R33's medical record revealed two Dialysis Communication Sheets, dated 7/18/2023 and 9/28/2023 documented pre/post dialysis information for R#33. Dialysis Communication Sheets dated 2/9/2023, 2/18/2023, 3/4/2023, 3/11/2023, 4/20/2023, and 7/20/2023 were located in a Dialysis notebook at Station one Nurses Station. Observations on 10/17/2023 at 10:11 am, 10/18/2023 at 8:19 am, and 4:12 pm revealed resident lying in bed with a white gauze dressing to left upper arm dialysis graft site. Interview on 10/19/2023 at 8:49 am R33 revealed the dialysis center uses the port on her right chest wall for dialysis and the new site on her left arm is not being utilized at this time. During further interview, R33 stated she does not always have the communication form being sent to the dialysis center with her. Interview on 10/19/2023 at 9:21 am with Licensed Practical Nurse (LPN) EE revealed she provided care for R33. She verified the Physician Orders indicated the dialysis days but not the time or specified the dialysis access site. During further interview, LPN EE stated resident had a dialysis access site on her right arm but now it is on her left arm and was not aware of a port to her right chest. LPN EE stated if the dialysis communication forms are not returned with the resident, then the nurse should call the dialysis center and ask for the form to be faxed to the facility. Interview on 10/18/2023 at 3:16 pm, Medical Record Clerk indicated that all the Dialysis Communication Sheets that have been given to her, had already been scanned into the residents electronic medical record (EMR). During further interview, she stated the nurse sends the forms with the residents to dialysis, and if the form is not returned to the facility, the nurse is responsible for contacting the dialysis center and having the form faxed to the facility. Interview on 10/18/2023 at 3:39 pm, the Wound Care Nurse revealed there are times when the nurses have to call the dialysis center for updates on residents care, but the Dialysis Communication Sheets are the primary means of communication between the two facilities to collaborate residents care. She further stated if the Dialysis Communication sheet is not returned with the resident, it is the responsibility of the Director of Nursing (DON) or assistant Director of Nursing (ADON) to call the dialysis center and have the communication form faxed to the facility. Interview on 10/18/2023 at 3:46 pm, ADON revealed she had only worked at the facility for six days and believed the Dialysis Communication Sheets are initiated by the charge nurse. She stated if the Dialysis Communication Sheets are not returned with the resident, then either she or the DON would contact the Dialysis center to get the forms sent back. The ADON stated that she had not been doing that. Interview on 10/18/2023 at 4:04 pm with Registered Nurse (RN) CC revealed he is not familiar with the process regarding the communication between the dialysis center and the facility. Telephone interview on 10/19/2023 at 8:34 am with RN DD, from the Dialysis Center confirmed R2, R15, and R33 received dialysis services at their clinic. She stated R15 has a left arm AV graft and R2 and R33 have subclavian chest wall catheters used for dialysis. Registered Nurse DD stated the Dialysis Communication Sheets are utilized as a means of communication between the two facilities. During further interview, she revealed the nursing facility often times does not provide the dialysis center with the communication sheets for them to complete. Interview on 10/19/2023 at 9:33 am the DON confirmed each resident should have specific orders related for dialysis, including scheduled days to be dialyzed, location and monitoring of dialysis access site (bruit/thrill for grafts), monitoring sites for dialysis bleeding, and signs/symptoms of infection. She verified R22 did not have current orders related to dialysis. She stated the facility nurse should be sending the Dialysis Communication Sheet with each resident for all dialysis visits, and then ensures the sheets are returned when resident returns to the facility. During further interview, she stated that there is pertinent information on the Dialysis Communication Sheet to help the nurse care for resident upon return to facility. Cross Refer F656

Based on observations, staff interviews, and review of the policy titled All foods stored will be properly labeled according to the following guidelines, the facility failed to ensure opened food items in the refrigerator were properly labeled, dated, and stored. This deficient practice had the potential to affect 47 of 48 residents who receive an oral diet from the kitchen. Findings included: Review of the policy titled Food Labeling and Dating revealed, under subsection titled, Discussion .B. Proper food labeling- All leftover foods or foods removed from their original containers require proper labeling when stored. Proper food labeling requires the following: NAME, IDENTIFICATION, DATE OF PREPARATION AND DATE FOODS ARE TO BE USED OR DISCARDED .2.(a) At the time food is being removed from its original container and placed in another container, DATE IT. During an initial kitchen tour with the Dietary Manager (DM) on 10/17/2023 at 8:47 am, an observation of the refrigerator revealed the following: *One medium size clear container of various chopped and shredded vegetables was undated. *A plastic bag with chicken inside that had been opened was undated. *A plastic bag with one package of hotdogs inside that had been opened was undated. *A plastic bag with lima beans inside that had been opened was undated. The DM acknowledged that the food items had been opened and were undated at the time the observation of the refrigerator was made. Interview on 10/19/2023 at 2:12 pm with the DM revealed food items should be labeled with an open date once opened. She revealed all dietary staff are responsible for ensuring food items were labeled with an open date once opened and stored appropriately. Interview on 10/19/2023 at 2:30 pm with the Administrator, revealed her expectations of the dietary staff were to date and label all opened food items and to throw away opened food items that were not labeled and dated.

Based on record review, staff interviews, and review of policies titled Quality Assurance and Performance Improvement (QAPI) Committee and Quality Assurance Committee Report and Warrenton Health and Rehab QAPI Plan 2023, the facility failed to maintain and effective Quality Assurance and Performance Improvement (QAPI) program which systemically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility failed to show good faith in implementing the action plan, measure the success of the actions, and track performance related to Dialysis Communication Sheets for three of three residents receiving dialysis resources outside the facility. The census was 48. Findings include: Review of the policy titled Quality Assurance and Performance Improvement (QAPI) Committee dated July 2016, revealed Policy Interpretation and Implementation Number 1. The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain, and oversee the QAPI program. Goals of the Committee: The primary goals of the committee are to: 1. establish, maintain, and oversee the facility systems and processes to support the delivery of quality of care and services. 3. Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately. 5. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care. Committee Audit Process: 2. The QAPI Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches shall include specific time frames for implementation and follow-up. 4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor and ensure that changes are implemented. Review of the facility Quality Assurance Committee Report dated June 2023 revealed the problem identified as late/missing dialysis communication forms. Actions taken to correct the problem were documented as 1. educate staff nurse and new hire nurses on how to complete communication forms for dialysis; 2. arrange a meeting with the Dialysis Center Administrator to formulate best practices to decrease delay/missing communication between the centers; 3. check Dialysis communication forms daily after treatment days upon return to facility and review daily in stand-up meeting. Follow up was documented to occur monthly and quarterly. Review of the Warrenton Health and Rehab QAPI Plan 2023 dated 6/21/2021 revealed Identifying Change as an Improvement: Changes will be implemented using an organized and systematic process, depending on the nature of the change to be implemented, and will include clear communication of the structure, purpose, and goals of the change to all involved parties. Measures will be established that will monitor progress for Performance Improvement Project (PIP) and widespread improvement activities. Staff QAPI Adoption: The QA&A Committee will develop a culture that involves leadership-seeking input from nursing center staff, residents, their families, and other stakeholders; encourages and requires staff participation in QAPI initiatives when necessary; and holds staff accountable for taking ownership and responsibility of assigned OAPI activities and duties. Overall PIP Plan: Performance Improvement Projects (PIP) will be a concentrated effort on a particular problem in one area of the nursing center or on a facility-wide basis. They will involve gathering information systematically to clarify issues or problems and intervening for improvements. The nursing center will conduct PIPs to examine and improve care or services in areas that the nursing center identifies as needing attention. Interview on 10/19/2023 at 5:26 pm Administrator revealed she has been at the facility for three weeks and has not had time to focus on QAPI. She stated she was not aware of the facility's identified problem with the Dialysis Communication Forms and that a plan had been put in place to address the issue. She stated she is unsure if the previous administration met with the Dialysis Center to discuss and develop a plan to decrease missing/delayed communication between the two facilities. During further interview, she stated the facility has not had any follow-up discussions regarding the Dialysis Communication Forms during the daily morning stand up meetings since he has been at the facility. She stated the QAPI plans are reviewed with the Regional [NAME] President (RVP) when they visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of policies titled Surveillance for Infections, Legionella Water Management Program, Soiled Laundry and Bedding, and Handwashing/Hand Hygiene, the facility failed to maintain an effective Infection Prevention and Control Program (IPCP) that demonstrated ongoing surveillance, recognition, investigation, and control of infections to prevent the onset and spread of infections. Specifically, the facility failed to implement a procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system and failed to ensure infection control policies were followed during medication administration and handling and processing of linens, cleaning of lint traps, and personal items in the clean laundry storage. The facility census was 48. Findings include: 1. Review of the policy titled Surveillance for Infections revised September 2017 indicated the policy is the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventive interventions. Policy Interpretation and Implementation indicated: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 3. Infections that will be included in routine surveillance include a. evidence of transmissibility in a healthcare environment; c. clinically significant morbidity or mortality associated with infection (e.g. pneumonia, UTIs, C. difficile; d. pathogens associated with serious outbreaks (e.g. invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza). 5 Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Charge Nurse as soon as possible. 6 If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse and IP immediately. 7 When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 8 The Charge Nurse will notify the Attending Physician and the IP of suspected infections. Gathering Surveillance Data: The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. Interpreting Surveillance Data: Analyze the data to identify trends. a. Compare the rates to previous months in the current year b. Consider how increases or decreases might relate to recent process changes, events, or activities in the facility (i.e. change in handwashing preparations, increased turnover in personnel or residents, etc.) Review of the facility's Infection Surveillance documents revealed the monthly infection monitoring logs were incomplete and not being utilized to capture information that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); and ABT Tx (antibiotic treatment). Further review revealed there was no monthly line listings that contained information such as the resident's signs and symptoms; if a culture or x-ray was done, if the organism was sensitive to the ordered antibiotic, if infection was facility acquired, and when infection was resolved. There was no line listing of the antibiotics/infections or mapping of infections for months January 2023 through September 2023. The facility's infection rate was not calculated for the months of January 2023 through May 2023 and September 2023. Interview on 10/18/2023 at 11:16 am the Director of Nursing (DON) confirmed the documentation for the infection control surveillance was not in the binder provided to the surveyor. She stated she did not know where it could be. 2. Review of policy titled Legionella Water Management Program revised July 2017 revealed the facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: a. The Infection Preventionist, b. The administrator, c. the medical director, d. the director of maintenance, and f. the director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program includes the following elements: a. An interdisciplinary water management team b. A detailed description and diagram of the water system in the facility, including the following: 1) Receiving, 2) Cold water distribution, 3) Heating, 4) Hot water distribution and, 5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) storage tanks, 2) water heaters, 3) Filters, 4) aerators, 5) Showerheads and hoses, 6) Misters, atomizers, air washers, and humidifiers, 7) Hot tubs, 8) Fountains, 9) Medical devices such as CPAP machines, hydrotherapy equipment, etc. The facility was unable to provide evidence of a Water Management program with descriptions of the building water systems identifying measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency, or EPA). Interview on 10/18/2023 at 2:48 pm the Administrator and Maintenance Director verified the facility did not have a water management plan and had not tested the potable water for Legionella. A review of the facility books/logs did not include testing of the water. 3. Review of the policy titled Soiled Laundry and Bedding revised October 2018 revealed soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Policy Interpretation and Implementation: Handling: Number 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. Transport Number 5. Clean linens are protected from dust and soiling during transport and storage to ensure cleanliness. 6. Clean linens are stored separately, away from soiled linens at all times. Observation on 10/18/2023 at 11:25 am of the laundry room with Laundry Aide II revealed two commercial washers in the dirty area of the laundry room. A large accumulation of spilled chemicals was observed on the floor on the left side of the washers. The washer had rust on exterior of the machine. Interview on 10/18/2023 at 11:25 am, Laundry Aide II stated she was not sure who was responsible for cleaning the outside of the machines, and stated she thought that it was maintenance responsibility. During further interview with Laundry Aide II stated there once was a blue apron for use when handling soiled laundry, but stated it is no longer available, so she doesn't use an apron when handling soiled laundry. Laundry Aide II stated she only utilizes PPE if handling laundry in red bags (biohazard). Observations on 10/18/2023 at 11:30 am of the laundry with Laundry Aide JJ revealed two industrial dryers in use. There was a table used for folding laundry with staff personal items including a cell phone and a Styrofoam drinking cup with straw, on the folding table with clean linen. Laundry Aide JJ confirmed the personal items on the table and revealed she was aware the items were not supposed to be there. During further observation of the laundry area revealed two uncovered carts with resident personal clothing and one uncovered cart with unfolded bed linens. Observation of the lint trap of the two industrial dryers revealed a blanket of lint on the filter in both dryers. Interview on 10/18/2023 at 11:30 am, Laundry Aide JJ stated she was hanging clothes earlier that morning and stated she didn't realize she needed to close the carts while in the laundry. She stated she was aware that the carts should be closed when she was on the floor delivering the clothes and linen. Laundry Aide JJ stated she had not cleaned the lint trap since 8 am that morning and revealed it should have been cleaned. She stated she was aware it is important to keep the lint trap/filter clean because it could result in a fire. Interview on 10/18/2023 at 11:42 am with the Housekeeping/Laundry Supervisor indicated that personal items should never be stored on the clean linen folding table and stated the linen carts should be closed when not in use. She verified the lint traps needed cleaning and stated they should be cleaned every two hours. Interview on 10/18/2023 at 12:32 pm the Maintenance Director stated he is only required to check the dryer lint traps once a week for compliance to ensure they are clean and blow them out if needed. Observation on 10/18/2023 at 2:16 pm, 5:19 pm, and 5/19/2023 at 11:02 am on B Hall revealed one clean linen cart and the dirty linen hampers positioned side by side along the wall between rooms [ROOM NUMBERS]. Interview on 10/19/2023 at 11:02 am with Assistant Director of Nursing acknowledged that clean linen and dirty linen should not be close together and stated they should be separated. 4. Review of policy titled Handwashing/Hand Hygiene revised August 2019 revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2: All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7: alcohol-based hand rub or alternatively soap and water for situations including: a. before and after coming on duty b. before and after direct contact with residents c. before preparing or handling medications f. before donning gloves p. before and after assisting a resident with meals 8. Hand Hygiene is the final step after removing and disposing of personal protective equipment. Observation on 10/17/2023 at 12:06 pm kitchen staff member exited from the kitchen pushing a cart with a metal pan on top of the cart. She removed the pan and walked over to the ice machine. Without performing hand hygiene or donning gloves, she removed the ice scoop from the container and proceeded to scoop ice from the ice machine into the pan. After the pan was filled with ice, she replaced the scoop in the storage container and pushed the cart into the kitchen and placed the ice filled pan on a table in the kitchen. Observation on 10/17/2023 at 12:14 pm Certified Occupational Therapy Assistant (COTA) KK entered the dining room and without washing her hands or performing hand hygiene, she began to assist a resident with her meal. The COTA KK placed her hands in her pockets and continued to assist the resident with her meal. She eventually donned a pair of gloves but did not perform hand hygiene prior to donning gloves. Interview on 10/17/2023 at 12:30 pm with COTA KK confirmed she did not perform hand hygiene when she entered the dining room, nor did she put on gloves before assisting the resident with her meal. She reported she performed hand hygiene as she left the therapy department on her way to the dining room. She verified that she put her hands in her pocket and did not perform hand hygiene before donning gloves to assist a resident with her meal. She stated she should have performed hand hygiene prior to donning gloves. Observation on 10/18/2023 at 8:35 am Certified Medication Aide (CMA) HH during medication administration failed to sanitize her hands prior to preparing medications and after administering the medications. Interview on 10/18/2023 at 8:55 CMA HH stated she was nervus with two surveyors observing her that she forgot to wash her hands. Interview 10/19/2023 at 1:46 pm with Dietary Manager stated staff should perform hand hygiene and wear gloves while preparing food for the residents. She stated staff should perform hand hygiene prior to donning gloves and after doffing gloves. During further interview, she stated the staff know the procedures in the kitchen. She stated her expectation is the kitchen staff should wash their hands before and after entering and exiting the kitchen. Interview on 10/19/2023 at 5:26 pm the Administrator revealed staff just completed a handwashing audit which revealed the need for improvements. She stated she planned to place handwashing in QAPI, reiterate hand washing education, and monitor the staff for hand washing. 5. Review of policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised October 2018, revealed the resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: Number 3. durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Observation on 10/17/2023 at 9:27 am room [ROOM NUMBER]/104 shared restroom revealed two male urinals hanging from the handrail: one was un-labeled and un-bagged while the other one was inside a clear bag but was not labeled with a resident's name. Observation on 10/18/2023 at 9:30 am of Certified Nursing Assistant (CNA) LL entered room [ROOM NUMBER] with a mechanical lift. She was not observed to clean the mechanical lift prior to use on R5. Interview on 10/18/2023 at 11:10 am CNA LL stated she retrieved the mechanical lift from a room down the hall and revealed she could not verify if the mechanical lift was clean before she used it on R5. She confirmed she did not clean the mechanical lift prior to use for R5 and she did not clean the mechanical lift after using it on R5. She stated she just placed it along the wall in the hallway. Interview on 10/18/2023 at 11:45 am the Director of Nursing (DON) stated it is her expectation that resident personal care items be kept in a bag for storage and the bag be labeled with residents' name and room number and placed in the restroom or in a drawer in the resident's room. During further interview, she stated she expected all equipment to be sanitized prior to use and after each resident use. Observation on 10/19/2023 at 8:30 am with Licensed Practical Nurse (LPN) EE during medication administration, revealed she dropped a medication blister pack on the floor, pick the blister pack up off the floor, and placed it back in the medication cart. She did not sanitize her hands after picking the blister pack off the floor. Observation on 10/19/2023 at 11:20 am, LPN EE while checking Finger Stick Blood Sugar (FSBS) for three residents, revealed she failed to place a protective barrier on the overbed table before placing the FSBS supplies in each resident room. Interview on 10/19/2023 at 8:35 am with LPN EE revealed she didn't know what to do with the blister pack of medication that fell on the floor. She stated she didn't think it was a problem because the pills themselves were still clean. During further interview, she stated, I did not know I should have used a barrier going from room to room, I guess I forgot. Interview on 10/19/2023 at 2:45 pm the DON revealed she expects every member of her staff to follow the infection control policies related to washing hands, and cross contamination. She stated the medication blister pack that fell on the floor should have been placed in a zip lock bag and sent to the pharmacy for repackaging. Interview on 10/19/2023 at 3:30 pm with Administrator and DON, revealed the expectation is for staff to perform hand hygiene before and after resident care, use PPE when needed, store resident personal care items appropriately, and keep personal items separate in the laundry.

Based on record review, staff interviews, and review of the policies titled, Surveillance for Infections and Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and document follow-up measures in response to the data for nine of nine months of infection control data reviewed (January 2023 through September 2023). The deficient practice had the potential to affect residents who were prescribed with an antibiotic. The facility census was 48 residents. Findings include: Review of the policy titled Surveillance for Infections with a revision date of September 2017, revealed the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventive interventions. 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Charge Nurse as soon as possible. 6. If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse and IP immediately. 7. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 8. The Charge Nurse will notify the Attending Physician and the IP of suspected infections. Review of the policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised December 2016 revealed antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. As part of the facility Antibiotic Stewardship Program, all clinical infection treated with antibiotics will undergo review by the Infection Preventionist (IP) or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify situations that are not consistent with the appropriate use of antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. a. Residents name and medical record number b. Unit and room number c. Date symptoms appeared d. Name of antibiotic e. Start date of antibiotic f. Pathogen identified g. Site of infection h. Date of culture i. Stop date j. Total days of therapy k. Outcome l. Adverse events Review of the Antibiotic Stewardship Book revealed monthly infection monitoring logs were not being utilized to capture information that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); and ABT Tx (antibiotic treatment). Further review revealed there were not any monthly line listings that contained information such as the resident's signs and symptoms; if a culture or x-ray were done; if the organism was sensitive to the ordered antibiotic; if infection was facility acquired, and when infection was resolved. There was not a line listing of the antibiotics/infections, no mapping of infections for months January 2023 through September 2023. In addition, the facility's infection rate was not calculated for the months January 2023 through May 2023 and September 2023. During an interview on 10/18/2023 at 12:25 pm with Director of Nursing (DON) it was revealed that she is new to the position at the facility. She further stated that she had not had the opportunity to review the facility's Infection Control Policies or the Antibiotic Stewardship Program. DON further stated she was aware that prior to her coming to the facility, there was not a specific person in place monitoring the program. DON stated that the nurses should have been tracking and trending infections, but she has been unable to locate any documentation that this had been completed. DON stated that it is her expectation that residents should be monitored for signs and symptoms of infections, complete documentation, followed up with any labs or diagnostic test completed and followed up with the physician.

Based on staff interviews the facility failed to ensure evidence that a qualified Infection Preventionist (IP) was serving in the position at the facility. This deficient practice had the potential for creating an ineffective infection prevention program that may contribute to the spread of infections for all residents in the facility. The census was 48 residents. Findings include: Interview on 10/18/2023 at 12:21 pm with Registered Nurse (RN) CC revealed he worked at the facility part-time and is currently working on the training modules to become certified as the IP for the facility. RN CC stated the Administrator asked him two weeks ago to step into the IP role. RN CC further stated the facility did not have a certified IP and he had not conducted any infection surveillance. Interview on 10/18/2023 at 12:25 pm with Administrator and Director of Nursing (DON) confirmed there was not a certified IP employed at the facility. Administrator stated she was not sure when the last IP left, as there was no one in the role when she started working at the facility a month ago. The Administrator stated that she and DON were responsible for infection control in the facility until someone from their nursing staff received an IP certification. The facility failed to provide surveyor with the policy related to their Infection Prevention and Control Program as requested.

Based on staff interviews and review of the Facility Assessment, the facility failed to provide evidence of implementation and maintenance of an effective training program for all staff. This deficient practice had potential to adversely affect the care given to all residents in the facility. The facility census was 48. Review of the Facility Assessment 2023 revealed a listed acuity - diseases, conditions and treatments, cognitive, mental, and behavioral status, cultural, ethnic, and religious factors which the facility is equipped to care for. Under sections related to clinical staff cares on pages 27, 28, 30, 38, 41 revealed clinical staff are educated upon hire and checked off for skill competencies annually. Review of the undated form titled Annual Competency -LPN/RN revealed the competency covered introduction to the unit, policy and procedure books, resident chart, ordering supplies, emergency kits, phone and paging system, communication (24 hour report/EMR), universal precautions (hand hygiene/glove use), staff information/numbers, documentation guidelines, abuse, infection control records, reports/investigations; drug administration including rules for medication administration, charting, routes, antipsychotic monitoring, release of medication while on leave of absence, and medication errors and reports; medication supply - new admission, renew medication supply, receiving medication from pharmacy, stock medication, automatic stop orders, medication labeling, storage of medication, abandon medication procedure, controlled drug count, read pharmacy policy and procedure book; Equipment orientation included intravenous poles/stands, feeding pump/formula, glucose monitoring machine/cleaning, medication carts, oxygen equipment, suction machines; general nursing duties; charge nurse duties; abuse/reporting; resident rights; infection control; skin/wound care; care of dementia/behavioral resident; communication; cultural competency; pain management. Requested policy for clinical staff training and education, the facility provided a copy of the federal regulation for F730. Requested completed clinical staff skill competency check offs for all clinical staff but none were provided. Interview on 10/19/2023 at 3:40 pm with the Director of Nursing (DON) revealed the Infection Control Prevtionist (ICP) and Staffing Coordinator will be same person, who will start next week. She revealed education was provided at least monthly and as a concern was identified, ad hoc education was provided. She revealed nursing staff were required to complete annual competency check offs. She revealed all new hires complete the orientation training and it included skills check offs for Certified Nursing Assistants (CNAs) and licensed nurses. Interview on 10/31/2023 at 2:30 pm with the DON and the Administrator revealed they were unable to supply competency check offs for any clinical staff currently employed. The DON and Administrator revealed the new ICP/Staffing Coordinator will be starting on 11/1/2023 and they plan to have a skills fair the following week to complete competency check offs for all clinical staff. Both stated the ICP will be responsible for maintaining documentation and providing staff education. Interview on 10/31/2023 at 3:00 pm with the Administrator revealed they did not have any documentation of competency skill check offs for the nurses or the Certified Nursing Assistants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and resident and staff interviews, the facility failed to ensure an Activity of Daily Living (ADL) Care Plan was implemented for one resident (Resident (R) 10) of 29 sampled residents. This failure had the potential to result in R10 not receiving necessary assistance with ADLs. Findings include: Review of the undated Face Sheet, found in the electronic medical record (EMR) under the Profile tab, revealed R10 was originally admitted to the facility on [DATE] with diagnoses including adjustment disorder with mixed anxiety and depressed moods, major depressive disorder, and morbid obesity. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/21, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. This indicated the resident was cognitively intact and could be reliably interviewed about her care. The MDS assessment further indicated R10 was totally dependent on one staff member for bathing and hygiene care and required two staff assistance for transfers with a mechanical lift. Review of R10's ADL Care Plan, dated 11/10/21 and found in the paper chart, revealed R10 required assistance to complete all her ADLs, including bathing and hygiene. Approaches included: Shower per schedule and prn [as needed] and Bed bath per resident's preference. The resident was dependent on at least one staff to provide a bed bath and/or shower and was scheduled for baths on Mondays, Wednesdays, and Fridays, on day shift. Review of R10's December 2021 CNA - ADL Tracking Forms, found in the paper chart, revealed her showers were not provided per the Care Plan. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 02/17/22 at 8:30 AM, the DON confirmed that R10 was scheduled for bed baths on Mondays, Wednesdays, and Fridays and that refusals should be documented in the EMR. The ADON and DON reviewed the CNA - ADL Tracking Forms for R10 and confirmed that there were multiple dates in December that indicated R10 had not been bathed per her plan of care. The DON stated her expectation was that every resident's bathing and grooming needs be provided as scheduled and if not provided, then there should be a documented reason why the Care Plan was not followed. There was no facility policy that specifically addressed implementation of the ADL care plans, but in an interview on 02/16/22 at 9:30 AM, the ADON confirmed it was her expectation that the resident's Care Plans would be followed. Cross-reference F677

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and procedure, record review, observations, and resident and staff interviews, the facility failed to ensure one resident (Resident (R) R10) of 29 sampled residents reviewed for Activities of Daily Living (ADLs) consistently received grooming and bathing services. Findings include: Review of the facility's undated Activities of Daily Living (ADLs) Policy revealed, The facility will, based on the resident's comprehensive assessment and consistent with the residents needs and choices, ensure a resident's ADL abilities do not deteriorate unless unavoidable . A resident who is unable to carry out ADLs independently will receive necessary services to maintain good nutrition, grooming, and hygiene. Review of the undated Face Sheet, found in the electronic medical record (EMR) under the Profile tab, revealed R10 was originally admitted to the facility on [DATE] with diagnoses including adjustment disorder with mixed anxiety and depressed moods, major depressive disorder, and morbid obesity. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/21, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. This indicated the resident was cognitively intact and could be reliably interviewed about her care. The MDS assessment further indicated R10 was totally dependent on one staff member for bathing and hygiene care and required two staff assistance for transfers with a mechanical lift. Review of R10's ADL Care Plan, dated 11/10/21 and found in the paper chart revealed R10 required assistance to complete all her ADLs, including bathing and hygiene. Approaches included: Shower per schedule and prn [as needed], and bed bath per resident's preference. The resident is dependent on at least one staff to provide a bed bath and/or shower and is scheduled for baths on Mondays, Wednesdays, and Fridays, on day shift. Review of CNA - ADL Tracking Forms, found in the paper chart and dated 12/01/21 through 02/14/22, revealed no documentation that R10 received a bed bath or shower on 12/10/21 through 12/14/21, and again 12/22/21 through 12/27/21. No further documentation of baths/showers could be found in the resident's record. Review of ADL Records, dated 11/02/21 through 02/14/22 and found in the EMR under the Tasks tab, did not provide additional evidence that baths or showers had been provided to R10 on those dates. Observations of and interviews with R10 on 02/14/22 at 10:35 AM, 02/14/22 at 4:00 PM, 02/15/22 at 8:40 AM, 02/16/22 at 3:45 PM, and 02/17/22 at 9:10 AM revealed R10 was awake in her bed and either watching TV or knitting. R10 had a bariatric bed with an air mattress and a bariatric wheelchair in her room. There were no offensive odors in the room. R10 stated the facility had new management and things were slowly improving since she filed a complaint in October 2021. She stated she preferred bed baths to showers due to a fear of falling from either the lift or the shower cot. When asked how frequently she wanted her baths, she stated at least twice a week. R10 stated she was lucky to get one full bath on some weeks, and if she did refuse, then it could be up to a week before she was offered a bed bath again. R10 had no notable body odor, but her hair appeared greasy and in need washing. She stated she sometimes used a dry shampoo herself but, it was time for a wash. During an interview on 02/16/22 at 1:10 PM, Certified Nurse Aid (CNA) 1 stated that she frequently cared for R10 and thought she did get her bed baths at least twice a week. CNA1 stated R10 received a partial bath a couple of times a day with incontinence care, but the CNA agreed that did not constitute a full bath with hair care and grooming. The CNA stated that R10 occasionally refused cares, but she always tried to reapproach when R10 refused. CNA1 stated sometimes her second attempt would be successful, and sometimes not. During an interview with the Assistant Director of Nursing (ADON) on 02/17/22 at 8:30 AM, the ADON confirmed that R10 was scheduled for bed baths on Mondays, Wednesdays, and Fridays and that refusals should be documented in the EMR. The ADON stated her expectation was that every resident's bathing and grooming needs be provided as scheduled and if not, then there should be a documented reason why the care was not provided. The ADON and DON reviewed the CNA - ADL Tracking Forms for R10 and confirmed that there were multiple dates in December that indicated R10 had not been bathed per her plan of care and/or her preferences.