Based on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage for the facility. This failure has the potential to affect all 35 residents living in the facility.Findings Include:The facility's Resident Daily Census Report document dated 8/27/2025, documents 35 residents residing in the facility. Review of the nursing schedules for June and July document that no RN was on shift on 6/8/2025, 7/4/2025, 7/5/2025, 7/6/2025 and 7/11/2025 for 8 consecutive hours.On 8/27/2025 at 2:22 PM, V2 (Director of Nursing) stated she is not aware if there had been any Registered Nurse (RN) coverage on 6/8/2025, 7/4/2025, 7/5/2025, 7/6/2025 and 7/11/2025. V2 stated, there are no RN hours documented on the schedule for those days.On 8/28/2025 at 11:51 AM, V14 (Regional Reimbursement Specialist) stated the facility did not have registered nurse coverage for 8 hours a day, seven days a week on 6/8/2025, 7/4/2025, 7/5/2025, 7/6/2025 and 7/11/2025.On 8/28/2025 at 11:53 AM, V1 (Administrator) stated the facility did not have registered nurse coverage for 8 hours a day, seven days a week on 6/8/2025, 7/4/2025, 7/5/2025, 7/6/2025 and 7/11/2025. V1 stated the facility follows the federal and state staff regulations and does not have a staffing policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement interventions to prevent falls for 1 of 2 (R7) residents reviewed for accidents in the sample of 26. Findings Include: R7's admission Record with a print date of 3/20/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include dementia, depression, hypertension, and low back pain. R7's MDS (Minimum Data Set) dated 2/19/25 documents R7 has a severe cognitive impairment. This same MDS documents R7 has a history of falls without serious injury. R7's Investigation Report for Falls documents the following falls. 11/24/24 documents R7 was found lying on her back in the lobby. The intervention implemented was a physical therapy and occupation therapy evaluation and treatment. 12/20/24 documents R7 was found across from her room in the hall sitting on the floor. The intervention implemented was to check her frequently when in bed and to use a pad alarm instead of a tab alarm. 1/25 (did not document full date) documents R7 was found sitting on the floor next to her bed. The area of concern identified was that her room needed to be closer to the nurse's station and the intervention implemented was bed low to floor. 1/3/25 documents R7 was found seated by a vacant bed. The intervention implemented was a later wake up time as she seeks to get into vacant beds when she is gotten up too early. 1/14/25 documents R7 was found lying on her left side on the floor with her head by the head of her bed and her feet by the door. The intervention implemented was to change her trazadone to bedtime, discontinue the valium, Ativan at bedtime and to offer snacks/drinks when restless. R7's current Care Plan documents a Focus Area of I have had an actual fall with minor injury r/t (related to) Poor Balance, Unsteady gait. Date Initiated: 11/24/2024. The interventions for this Focus Area include, New intervention: Fall mats on both side of the bed. Date Initiated: 1/25/25. On 03/17/25 at 1:24 PM, R7 was observed laying in a bed that was low to the floor, with a floor mat on the floor next to the left side of the bed. On 03/20/25 at 10:40 AM, R7 was observed in bed that was low to the floor with no mats on floor next to bed. V5 (Licensed Practical Nurse/Care Plan Coordinator) was present during observation and after reviewing R7's current fall interventions, stated R7 should have fall mats on the floor on both sides of her bed. The facility Fall Prevention Program policy dated 11/21/17 documents, Purpose: to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness .

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days per week. This failure has the potential to affect all 26 residents living in the facility. Findings include: The Facility schedule for February and March 2025 documents there was no Registered Nurse (RN) coverage on 2/1/2025, 2/8/2025, 2/15/2025, 2/22/2025, 2/28/2025, 3/1/2025, 3/13/2025, 3/14/2025, 3/15/2025, 3/22/2025, and 3/29/2025. On 03/17/2025 at 9:25 AM, R78 states there isn't enough staff at times. On 03/19/2025 at 4:00 PM, V2 (Director of Nursing) stated, they don't have RN coverage for 8 consecutive hours a day, 7 day a week. V2 stated, they usually lack Saturdays, and some Sundays are covered. V2 said they have a RN that works as needed who does every other Sunday. On 03/19/2025 at 4:11 PM, V2 stated, there was no RN coverage on 2/1/2025, 2/8/2025, 2/15/2025, 2/22/2025, 2/28/2025, 3/1/2025, 3/13/2025, 3/14/2025, 3/15/2025, 3/22/2025, and 3/29/2025. The Long-Term Care Facility Application for Medicare and Medicaid dated 03/17/2025 documents the current census is 26.

Based on interview and record review the facility failed to provide doctor ordered wound care for 1 of 3 (R5) residents reviewed for wound care in a sample of 9. Findings included: R5's admission Record documented an admission dated of 11/27/2024 with diagnoses in part of Type 1 Diabetes mellitus with diabetic kidney disease, end stage renal disease, muscle wasting and atrophy and acquired absences of left and right legs below the knee. R5's MDS (minimum data set) dated 12/26/2024 documented R5's BIMS (brief interview for mental status) score of 15 out of 15 total which indicates R5 is cognitively intact. The MDS documented R5 is dependent on staff for all toileting, bathing and dressing tasks and needs partial/moderate assistance with all personal hygiene tasks. On 1/21/2025 at 11:00pm, R5 said he has developed a wound on his penis and his doctor has ordered his wound treatment to be done twice per day since 1/8/25, but usually the nursing staff only performs his wound care one per day. R5 said he has spoken with the nursing staff about getting his treatment done twice per day, but it still doesn't get completed. R5 said his wound is getting better despite his treatment not being done twice per day. R5's POS (Physician's order sheet) dated 1/1/25 through 1/31/25 documents the following order: 1/8/25 Santyl ointment 30 grams, cleansed penis with wound cleanser, pat dry, apply Santyl BID (twice per day). R5's TAR (Treatment administration record) dated 1/8/25 through 1/31/25 documented R5 missed the following treatments: 1/12/25 (6p), 1/13/25 (6p), 1/14/25 (6a), 1/14/25 (6p), 1/18/25 (6p) and 1/19/25 (6p). No further documentation was noted on the TAR as to why R5's has missed these treatments. A review of R5's progress notes for January 2025 did not document R5 refusing care. On 1/21/2025 at 2:00pm, V6 (Licensed Practical Nurse/LPN) said R5 has not been getting his treatments twice per day. V6 said she did not know why he's not getting the treatments as ordered by his doctor. V6 said if R5 refused his treatment, the nurse is supposed to document the refusal on the back of the TAR. V6 said she has not seen R5 refused to get his wound care done. On 1/21/2025 at 10:45am, V5 (Certified Nursing Assistant) said R5 tells her he does not get his wound care provided twice per day because the nursing staff won't do it. On 1/23/2024 at 10:45am, V1 (Administrator/LPN) said R5 should have been receiving his wound care twice per day as ordered by his doctor and did not know why R5 has been missing his treatment. V1 said she suspects R5 has been refusing and the staff are not documenting the refusals correctly. V1 said when residents refuse care staff should document the care refusal in the residents chart. V1 reviewed R5's chart and could not find any refusals of care documented for January 2025.

Based on record review and interview, the facility failed to notify a medical provider of an out of therapeutic range PT/INR (Prothrombin Time/International Normalized Ratio) lab result for one (R7) of five residents reviewed for unnecessary medications in the sample of 18. Findings include: R7's Face Sheet documented an admission date of 12/4/23 and listed diagnoses including a history of Cerebral Infarction and Unspecified Atrial Fibrillation. R7's Physicians Order Sheet for March 2024 documented an order dated 3/18/24 for Coumadin 4mg (milligrams) by mouth at bedtime Monday, Wednesday, and Friday, alternating with Coumadin 3mg. by mouth at bedtime on Sunday, Tuesday, Thursday, Saturday, and a 12/26/23 order for, PT/INR (to be drawn) weekly. A Lab Report dated 3/26/24 documented, Coagulation: PT-37.6 (reference range 9.8-12.2 seconds). INR-3.8 (reference range 0.9-1.2). Handwritten on this document was, 3/26/24, 18:00. Called (V10/Physician's) office. Awaiting call back, and 3/27/24 14:25: Spoke with (V10's) Nurse, states (she) will call back (when) (V10) is in the office. On 3/26/24 at 9:45am, R7 was in her room lying in bed. R7 was alert but oriented only to herself. On 03/28/24 at 09:10 AM, V9 (Registered Nurse/RN) stated R7 gets her PT/INR drawn weekly to monitor the Coumadin. V9 stated R7 is at baseline functioning and is not showing any side effects of coumadin therapy. V9 stated V10 was in the building on 3/26/24 to sign order sheets and did not give any new orders on R7. V9 stated they had not yet received the lab result when V10 was there. V9 stated staff unsuccessfully attempted to contact V10 on 3/26/24 and 3/27/24. V9 stated he has not tried to call V10 today, but he will now do so. On 3/28/24 at 9:26 AM, V2 (Director of Nurses/DON) stated V10 is also the facility's Medical Director. V2 stated staff should have tried calling V10's cell number or contacting the on call physician. On 3/28/24 9:34 AM, this surveyor was present when V9 called V10's office. V9 told V10's staff he needed to speak to V10 emergently and gave staff the lab results. V9 stated V10's staff consulted with V10 who gave orders to hold one dose of the coumadin and resume it at 3mg. daily thereafter. V9 then documented the interaction on a Telephone Order Sheet. A Notification for Change in Resident Condition or Status Policy dated 12/7/17 stated, The facility and/or facility staff shall promptly notify appropriate individuals (Administrator, Director of Nurses, Physician, Guardian, Health Care Power of Attorney) of changes in the residents medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: M. Abnormal lab findings.

Based on record review and interview, the facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This has the potential to affect all 19 residents residing in the facility. The Findings Include: On 3/26/24 at 1:00 PM, V1 (Administrator) stated she is not able to provide any documentation of minutes or attendance sheets for the facility's quarterly QAPI meetings. V1 further stated she started her employment at this facility in September 2023 and no QA information was available because she has not held a QAPI meeting since being employed. During the survey, a review of facility records revealed no documentation quarterly QAPI meetings were held. No meeting minutes or attendance sheets were found. The facility was unable to provide reproducible evidence QAPI meetings had been scheduled or occurred. The facility's QAPI Plan revised on 12/1/2022, documents Aspects of services and care are measured against established performance goals. Key monitors are measured and trended on a quarterly basis. The QAPI Committee analyzes performance to identify and follow-up on areas of opportunity. The Long Term Care Facility application for Medicare and Medicaid dated 3/26/2024, documents 19 residents reside in the facility.

Based on observation and interview, the facility failed to maintain sinks in working order for 2 of 6 residents, (R1 and R6) reviewed for environment in the sample of 6. Findings: 1. On 2/13/2024, at 9:15 AM, in R1's room there was a sign covering R1's sink that stated out of order. On 2/13/2024, at 10:30 AM, R1 who was alert to name walked this surveyor to his room. When asked what happened to his sink R1 said it was broke. When asked where he washed his hands he pointed and said, I use a bathroom sink down the hall. 2. On 2/13/2024, at 9:18 AM, R6's bathroom sink was noted to be clogged with dirty water. On 2/13/2024, at 9:40 AM, R6 who was alert to person, place and time stated he has problems with his bathroom sink clogging up daily. R6 stated the maintenance person must come daily and unclog his bathroom sink. On 2/13/2024, at 10:00 AM, V1 (Administrator) stated V9 (Regional Maintenance) is coming to the facility on Thursday afternoon, 2/15/2024, to check on R1's bathroom sink. V1 stated the issue is a plumbing issue. V1 stated V9 is bringing more equipment with him to help resolve the plumbing issue. V1 stated the broken sink in R1's room has been like that since she came in September 2023. V1 stated the regional office has known about the broken sink since September 2023. On 2/13/2024, at 10:45 AM, V2 (Maintenance) stated he has been working here 3 months and he has called 2 plumbing companies in the area to come and check out the plumbing/pipes in the facility. V2 stated one of the companies was supposed to come out 2 weeks ago but never showed up and he has not heard back from the other company. V2 stated he has called multiple times to the companies and has no documentation available that these companies have been called. V2 stated V9 (Regional Maintenance) is scheduled to come here on 2/15/2024, in the afternoon to look at the plumbing issues in the facility and help resolve them. V2 stated he must run a snake down R6's bathroom sink daily because it clogs up.

Based on interview, observation, and record review the facility failed to provide Registered Nurse services at least 8 hours a day, 7 days a week and failed to provide a full time Director of Nursing (DON). This failure has the potential to affect all 20 residents residing in the facility. Findings include: On 1/25/24 at 10:40am, V1 (Administrator) said she thinks they are doing better with RN/Registered Nurse Coverage. V1 said they now have an RN that comes in when needed. V1 said they do not currently have a DON/Director of Nurses and have not had one in about a month or so. On 1/25/24 at 12:30pm, V5 (LPN/Licensed Practical Nurse) said they do not have a DON/Director of Nurses. The facilities January 2024 licensed nursing schedule documented no Registered Nurse (RN) coverage on 1/5/24, 1/6/24, 1/12/24, 1/13/24, 1/19/24, 1/20/24, 1/25/24, and 1/26/24. On 1/25/24 at 11:00am, V1 verified there was no RN coverage in the facility on the above listed dates. On 1/25/24 and 1/26/24, there were no RN's observed working in the facility during the survey. Facility Document labeled Nurses Midnight Census dated 1/25/24 note there are 21 residents, with 1 resident in the hospital for a total of 20 residents residing in the facility. The facility's undated Facility Assessment Tool documented the facility required 1 full time RN to serve as DON.

Based on observation, interview and record review, the facility failed to provide Registered Nurse services at least 8 hours a day, 7 days a week and failed to provide a full time Director of Nursing (DON). This affects all 23 residents residing in the facility. Findings include: On 12/27/23 at 10:52 AM, V8 (Licensed Practical Nurse/ LPN) said she was the only licensed nurse working on the floor. V8 said the facility did not currently have a Director of Nursing (DON). The facility's December 2023 licensed nursing schedule documented no Registered Nurse (RN) coverage on: 12/2/23, 12/8/23 12/9/23, 12/14/23, 12/15/23, 12/16/23, 12/21/23, 12/22/23, and 12/28/23. On 12/29/23 at 11:23 AM, V1 (Administrator) verified there was no RN coverage in the facility on the above listed dates. On 12/29/23 at 8:32 AM, V1 stated the facility had not had a full time Director of Nursing (DON) since 12/6/23. V1 said no staff were interested in taking the position because they don't want to take call. V1 said the facility had been advertising for the position online but no one had shown interest. V1 said there was a possibility there was a nurse from a sister facility who had shown interest and it was a possibility she would take the position in the future. The facility's undated Facility Assessment Tool documented the facility required 1 full time RN to serve as DON. The facility Roster Matrix with print date of 12/19/23 documents there are 23 residents residing in the facility.

Based on observation, interview and record review, the facility failed to provide medical grade gloves for resident care. This affects all 23 residents residing in the facility. Findings include: On 12/27/23 at 11:29 AM, V4 (Certified Nursing Assistant/ CNA) and V5 (CNA) said the facility had one Personal Protective Equipment (PPE) storage room. V4 and V5 said the only gloves available from the PPE storage room were vinyl food handler gloves. Boxes of food handler gloves were observed being used for resident care around the facility. On 12/27/23 at 11:57 AM, V1 (Administrator) said facility nursing staff had been using the vinyl food handlers gloves for about a month due to the medical supply company having gloves on back order. V1 said due to the facility not being able to acquire medical grade gloves, the food handler gloves were better than no gloves. V1 said she had not tried to contact the local health department for assistance with acquiring PPE. On 12/27/23 at 1:03 PM, V7 (Health Department Director of Nursing) said the local health department no longer was assisting facilities to acquire PPE. V7 said a facility was to contact the State of Illinois if they needed assistance. On 12/29/23 at 9:29 AM, V9 (Medical Supply Company Operator) said the facility had received a shipment of gloves on 8/1/23 including 1 case of small gloves and 2 cases of extra-large gloves, again on 9/1/23 including 1 case of medium gloves, and again on 10/1/23 including 1 case of large gloves. V9 said the facility had not ordered any gloves on back order and further stated he was not aware of any back orders on any gloves provided by the medical supply company. V9 said he had checked the product numbers of gloves previously ordered by the facility and all showed they were in stock. On 12/29/23 at 8:59 AM, 5 resident rooms noted to be on contact and droplet precautions due to being positive for Covid-19 had PPE bins outside their doors with boxes of food handlers gloves on them. The PPE storage room contained a case of medium food handler gloves, a case of large food handler gloves, and 9 boxes of small food handler gloves. The facility provided an undated informational sheet from the food handler glove manufacturer that documented in part . This product complies with FDA 21 CFR 175 as safe for food contact. This product is general purpose and is not intended for medical use . The facility Roster Matrix with print date of 12/19/23 documents there are 23 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to maintain effective pest control of rodents. This has the potential to affect all 23 residents residing in the facility. Findings include: On 12/12/23 at 10:10 AM V2 (Registered Nurse/ RN) said the facility had a chronic mouse problem. V2 said R6's room had mice. V2 said she had reported the mice to V1 (Administrator). On 12/12/23 at 2:50 PM V5 (Certified Nursing Assistant/ CNA) said she had seen mice all around the facility. V5 said she had reported it to the nurses, V1, and V6 (Maintenance Director). V5 said she had heard there was a staff member who found a mouse in a resident's bed but could not recall which staff member or the specific resident. 1. R6's face sheet documented an admission date of 1/20/18. R6's Physician Order Sheet (POS) documented diagnoses including: hypertension, anxiety disorder, muscle weakness (generalized), cellulitis of right lower limb, difficulty in walking, venous insufficiency. R6's 11/3/23 Cognitive Assessment documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. On 12/12/23 at 10:24 AM R6's room was observed to have a large amount of mouse droppings around the perimeter of the room and under R6's bed. On 12/12/23 at 10:28 AM R6's room was set up like a sitting area and had a large amount of mouse droppings around the perimeter of the room. On 12/12/23 at 10:41 AM the hand washing sink in the kitchen was observed to have two mouse droppings on it. The dry good storage room was observed to have a large amount of mouse droppings and whitish-brown small, shredded material that looked like shredded cardboard. Mouse droppings were observed sparsely on the shelves of the dry good storage area. 2. R4's face sheet documented an admission date of 9/11/23. R4's POS documented diagnoses including: type 2 diabetes, atrial fibrillation, bipolar disorder, major depressive disorder, hypertension. R4's 11/2/23 MDS (Minimum Data Set) documented a BIMS score of 14, indicating R4 was cognitively intact. On 12/12/23 at 11:52 AM R4 said he saw a mouse in his room two days prior to this investigation. R4 said he had a mouse living in the closet in his room. R4 said he usually ate in his room and the mouse would come out at night to eat the crumbs he dropped during the day. R4 said he had told several staff members. R4 said he had mice in his room so long he had started to name them. 3. R5's face sheet documented an admission date of 10/11/22. R5's POS documented diagnoses including: type 2 diabetes mellitus with hyperglycemia, homelessness, asthenia, diabetic polyneuropathy associated with type 2 diabetes. R5's 10/19/23 Cognitive Assessment documented a BIMS score of 13, indicating R5 was cognitively intact. On 12/12/23 at 11:55 AM R5 said he had two mice in his room regularly. R5 said he had seen the mice in his room two days prior to this investigation. On 12/12/23 at 3:09 PM V6 (Maintenance Director) said he had been employed at the facility for three weeks prior to this investigation. V6 said he did not have a log of work orders. V6 said when he received a work order he would fix the problem and throw the work order away. V6 said he had called the pest control company to come to the facility for an extra visit approximately two weeks prior to this investigation. The facility's 11/20/23 pest control company report documented 3 mechanical rodent traps and 8 rodent bait stations without activity. The facility's Nurses Midnight Census dated 12/12/23 documented a census of 23 residents. The facility's undated Insect and Pest Control Policy documented in part . It is the policy to contract with a duly licensed exterminating service to protect and/ or control against infestations of insects and rodents. A preventative treatment, both interior and exterior, shall be applied at least once every month. Treatments will be applied more often if required . The following procedures shall apply regarding pest control: 1. Any employee observing insects or rodents of any kind shall inform their supervisor giving the exact location and type of infestation. 2. The employee shall fill out a work order form and give it to the maintenance person. 3. The maintenance person shall contact the pest control company for eradication .

Based on interview and record review the facility failed to provide the services of a Registered Nurse for eight hours a day, seven days a week: and failed to have a Registered Nurse to serve as a Director of Nursing on a full-time basis. This has the potential to affect all 21 residents that reside in the facility. Findings include: V1 (Administrator) stated, the facility currently does not have Registered Nurse (RN) coverage. However, they have hired a Director of Nursing (DON) that is starting next week. V4 (Minimum Data Set Coordinator/MDS) stated, the facility does not have a Registered Nurse seven days a week for at least eight hours a day. V4 stated they did hire a DON that is starting next week. The facility schedule titled, October 2023 documents the facility did not have a RN working on: 10/07/23, 10/12/23 - 10/14/23, 10/19/23 - 10/21/23. The facility document titled, September 2023 documents the facility did not have a RN working on: 09/04/23 - 09/06/23, 09/11/23, 09/12/23, 09/21/23, and 09/28/23. There is no DON listed on the schedule or DON hours for October 2023. The facility's document titled, Nurses Midnight census dated 10/25/23 documents 21 residents reside at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide sufficient dietary staff. This has the potential to affect all 21 residents that reside in the facility. Findings include: On 10/26/23 at 11:45 AM V1 (Administrator) stated, V12 (Previous Dietary Manager) quit on 09/11/23 and they hired V3 (Dietary Manager) on 10/12/23. V1 said that on 09/08/23, 10/02/23, 10/03/23, 10/04/23, V13 (Registered Dietician) helped in the kitchen. V1 said that on 09/25/23 through 09/27/23, and 09/29/23, V14 (Dietary Manager from another facility) helped in the kitchen. On 10/11/23 through 10/13/23, V15 (Dietary Manager from another facility) helped in the kitchen, and on 09/10/23 through 09/13/23, 09/21/23, 09/28/23, and 09/30/23 through 10/08/23 there was no one scheduled for dietary. V1 said that on 09/15/23, 09/16/23, 09/18/23, 09/19/23, 09/20/23, 09/22/23, 09/24/23 through 09/27/23, 09/29/23 and 10/08/23 there was one person scheduled for dietary services. V1 stated, V1 and V2 (Business office manager/Social Service Director), V4 (Minimum Data Set Coordinator), V16 (cook), V17 (dietary aide), V18 (previous Activities Director) helped in the kitchen. On 10/25/23 at 1:42 PM V6 (Certified Nurse Aide) stated, she did help in the kitchen during the timeframe the kitchen did not have any staff. She did not cook but she helped with drinks and the dietary cards. On 10/25/23 at 1:47 PM V2 (Business Office Manager/Social Services Director) stated, she was hired on October 2, 2023. V2 stated her first week of work she worked in the kitchen. V2 said she did not have any true kitchen experience but she sure learned a lot about mechanical soft diets and how to make puree foods. On 10/25/23 at 12:55 PM V5 (Registered Nurse) stated, V9 (dietary) started as needed to help in the kitchen but she did not have any dietary experience. V5 said they did not have any staff in the kitchen. V5 stated she knows V1 (Administrator), V2 (BOM/SSD), V6 (CNA) and other worked in the kitchen. On 10/25/23 at 2:55 PM V10 (Speech Therapy) stated, there was a period that they did not have dietary staff, staff from other positions did step into rolls that were not their jobs. On 10/25/23 at 1:30 PM V4 (Minimum Data Set Coordinator/MDS) stated, he did assist in the kitchen when they had no dietary staff. V4 said he followed the menu to the best of his/their ability. V4 said some of the dietary staff quit, and some were terminated due to no call/no shows. The facility document titled, work schedule for the week of [DATE] - 16 Dept (Department) Dietary documents: no staff scheduled for 09/10/23 - 09/13/23 and only V18 (dietary) scheduled from 5 - 1 (5:00 AM - 1:00 PM) on 09/15/23 and only V17 (dietary aide) scheduled 6 - 6 (6:00 AM - 6:00 PM) on 09/16/23. The facility document titled, work schedule for the week of [DATE] - 23 Dept (Department) Dietary documents, only V16 (Cook) working 5 - 6 (5:00 AM - 6:00 PM) on 09/18/23 - 09/20/23 and no staff scheduled on 09/22/23 and only V17 (dietary aide) working 6 - 6 (6:00 AM - 6:00 PM) on 09/23/23. There is no documentation of a dietary schedule for 09/30/23 - 10/08/23. V1 (Administrator) stated, V16 (cook) quit on 09/19/23 and V17 (dietary aide) quit on 09/25/23. V1 said the schedule of 09/24/23 - 09/30/23 is not what was worked, only the 09/24/23 was worked by the facilities dietary staff. V1 said there was no schedule for 09/30/23 - 10/08/23 because they did not have any dietary staff to put on it. V1 stated she worked in the kitchen most of those days. The facility assessment dated [DATE] documents: Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Staff type: Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents. Potential data sources include staffing records, organization chart, and Payroll-Based Journal reports. Considering the following type of staff and other professionals/practitioners, list (or refer to or provide a link to) your staffing data, directories, organization chart, or other lists that show the type of staff needed to care for your resident population. Administration (e.g., Administrator, Administrative Assistant, Staff Development, QAPI, Infection Control and Prevention, Environmental Services, Social Services, Discharge Planning, Business Office, Finance, Human Resources, Compliance and Ethics), Nursing Services (e.g., DON, RN, LPN or LVN, CNA or NAR, medication aide or technician, MDS nurse), Food and Nutrition Services (e.g., Director, support staff, registered dietician). Staffing plan: 3.2. Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Food and nutrition services staff: with 3 documented. The facility's document titled, Nurses Midnight census dated 10/25/23 documents 21 residents reside at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure residents reside in an environment free of rodents. This has the potential to affect all 22 residents who live in the facility. The Findings Include: On 06/28/23 at 8:18 AM, R2 was alert and oriented to person, place, time, and location. R2 stated he has seen mice in his room at the door to his closet, has watched them run out of his room and go across the hall into R1's room, or down the hall to R5's room. R2 stated the mice run around especially when it rains - We have some sticky strips out, but I don't know if they've ever caught a mouse on the sticky strip. There were no open food items in R2's room currently. On 06/28/23 at 8:21 AM, R3 was alert and oriented to person, place, time, and location. R3 stated he sees 2-3 mice every now and then. R3 stated he did catch 2 in his waste that could not get out so staff took them outside and disposed of them. R3 confirmed the facility puts out traps. There were no open food items in R3's room currently. On 06/28/23 at 9:37 AM, R1 was alert and oriented to person, place, time, and location. R1 stated there are mice in the building and wished they could get some (brand name poison) and hide it so the residents can't see it in the rooms. R1 stated then when the mice eat it, they would die, but V12 (Maintenance) needs to seal the cracks in the building. R1 said he has asked V12 about doing that or using caulk to seal the holes. R1 said sometimes the sticky strips don't work because the mice run right over them. R1 stated he has told V12 he needs more help because one person alone cannot fix this building the way it needs to be fixed. R1 stated there are gaps around the doors leading to the outside and they need to get new doors. R1 continued, Mice do bite and they carry disease and I don't want to get bit. When asked, R1 confirmed he has seen a mouse on his silver half bedrail but he was playing games on his tablet at his bedside table and was not in the bed at the time. R1 stated he tapped his foot on the floor and the mouse ran. R1 could not provide an exact date when this happened but stated it has been within the last month. R1 did not have any open food items in his room. On 06/28/23 at 11:00 AM, R4 was alert and oriented to person, place, time, and location. R4 confirmed he has seen mice in his room as recent as last night. R4 stated it ran from his room across the hall to R1's room. R4 was not sure if the facility was doing anything about it, but also stated he had not complained about it. R4 confirmed he, R2, and R3 are keeping their food and snacks sealed and thinks maybe that helps. On 06/28/23 at 11:30 AM, R5 was alert and oriented to person, place, time, and location. R5 confirmed she had seen mice in her room. R5 stated they go along the wall where her air conditioner and dresser are, come around the edge of the wall by her short dresser and night stand and get in the drawers. R5 stated she checks the drawers daily and cleans the mouse droppings. R5 stated she does not keep food there so she doesn't know what they're after. R5's short dresser was observed to have mouse droppings in the first and third drawer. R5 also had mouse droppings in the drawer of her night stand. R5 stated the facility knows about the mouse problem. R5 had no open food items in her room or in her furniture drawers. On 06/28/23, the following staff interviews were conducted: At 8:06 AM, V6 (Registered Nurse/RN) stated both the pest control company they use and the facility have placed mouse bait stations and glue strips inside and outside the facility. V6 stated this has been effective and they have caught several mice. At 8:09 AM, V9 (Housekeeping) stated she has observed mice in the kitchen. V10 (Housekeeping) stated she has seen mice in the laundry room. V9 and V10 both stated they check the glue strips in the facility daily and when they catch a mouse, they dispose of it and place a new glue strip. V9 and V10 stated residents will also tell them when they see a mouse and they put the white mouse bait boxes in the room out of sight such as under the chairs or under the radiator. At 8:11 AM, V13 (Certified Nursing Assistant/CNA) confirmed the facility has mice, she has seen them, and is terrified of them. V13 stated the mouse problem is nothing new, but they did change the kind of traps they were using. At 8:23 AM, V3 (Director of Nursing/DON) stated she has worked in the facility for 2 weeks now and has seen a mouse in V1's (Administrator) office. V3 confirmed V1 has glue strips in her office. At 8:31 AM, V2 (Licensed Practical Nurse - LPN/Minimum Data Set Coordinator - MDS) confirmed they do have an active pest control company that comes to the facility on a regular basis. V2 stated he has not personally seen a mouse in his office for 2-3 weeks but is aware there have been reports of mice in other areas of the facility. V2 stated they have attempted to educate residents about not leaving snacks and food out. At 8:35 AM, V14 (CNA) stated the only location she had personally seen mice was running from R2-R4's room across the hall to R1's room. V14 stated the facility has been placing silver box type mouse traps and sticky traps. V14 added that she does know therapy caught a mouse on a sticky strip. V14 stated she believed the facility was doing everything they could to try and correct the problem. At 8:40 AM, V12 (Maintenance) stated he works more than one job, and was at his other job when this facility called and asked him to come in. V12 stated he had not always known the facility to have a mouse problem like this but there are a few residents who will not pick up food and will leave it out. V12 confirmed he has seen mice in R2-R4's room and R1's room and stated it has gotten worse in the last couple of months, in his opinion. V12 stated the pest control company is aware and are putting traps outside and inside, supplying black glue strips, and service the facility monthly and as needed. V12 stated he had personally gone and bought the white cardboard box type mouse traps because they can't put the glue strips in the resident's room due to being a hazard. V12 stated the glue strips are placed in the kitchen, behind the nursing station, laundry, and in offices where residents will not encounter them. At 8:50 AM, V1 stated she saw a mouse in her office in May 2023 but has not personally seen any since one was caught on a sticky strip around that time. V1 stated she did know V10 caught several mice last week on the sticky strips. At 9:00 AM, V15 (Therapy) stated the mice are everywhere in the building and confirmed he caught a mouse in the therapy room on the glue strip this morning that he disposed of. V15 stated the traps do attract mice and they are not as bad as they were the last few weeks. V15 stated he puts bread on the strip because he wants to catch the mice to try and prevent them from running all over the desks and equipment in the therapy room. V15 stated he sanitizes everything each morning, and before staff leave for the day, they do a walk through and try to ensure there are no food or snacks left in the open to further attract mice. V15 stated he knows it doesn't stop it from happening but believes it helps. V15 stated it might take some money but the building would have to be gone over and repaired to take care of the issue completely. V15 stated his fear is that one day a resident will be bitten by a mouse. At 9:51 AM, V11 (Housekeeping) stated he had seen mice mainly in the laundry room. On 06/28/23 at 11:47 AM, V17 (Pest Control) was left a message for a return phone call. On 06/28/23 at 9:51 AM, V12 was no longer in the facility so this surveyor accompanied V11 for the purpose of measuring various locations throughout the facility observed to have cracks, holes, and gaps and are described as follows - Three separate exterior double glass doors leading directly into the facility from the outside had a visible gap down the middle of the doors to the ground when closed, measuring 1/2 inch at the widest point at the bottom of the doors/floor, making it accessible for rodents to enter the facility. These doors were located at the South entrance into the lobby, East resident hall doors, and the East resident dining room doors. V11 measured the exterior door to the laundry room which had a hole at the base of the wooden door/frame also measuring 1/2 inch. The rubber baseboard strip was detached from the wall at the floor and V11 was able to pull the strip completely away from the door frame exposing a large hole to the outside. Lastly, the door leading from the laundry room into the facility's [NAME] resident hallway was severely gapped at the bottom measuring 1/2 inch and traveling along the bottom of the door to the largest gap measuring 1 1/2 inches. This would allow rodents access from the exterior laundry room door, through the laundry room, and into the resident hallway. On 06/28/23 at 1:45 PM, this surveyor walked around the outside perimeter of the facility. Along the front of the facility hugging the brick, was a line of tall grass approximately 10 inches in height that was obviously too close for a lawn [NAME] to cut but would be easily accessible by finishing up with a weed eater. The back of the building had sporadic tall weeds. The exterior door to the laundry room was in disrepair, observed to have a large area of rotten, broken/splintered wood with some missing chunks where the door meets the frame and a visible hole at ground level leading into the laundry room. This too, would be easy access for rodents. On 06/28/23 At 1:55 PM, stored in the unoccupied room beside R2-R4's room were 7 beds, 4 storage cabinets, a loveseat, a chair, 2 trash cans, a shop-vac, 1 bedside table, 2 televisions, with one of the 7 beds being full of books, puzzles, mirrors, and other decorative items. Also, stored in the room beside R1's room were 5 beds, five 5-gallon paint tubs, 1 paint can, 4 storage cabinets, 1 dresser, a box fan, 3 chairs, a floor slider, a vase, a wheelchair pedal, and other miscellaneous items. On 06/28/23 at 3:25 PM, the door in the kitchen leading to the outside had a gap along the bottom of the door and some chipped areas in the wood that would allow access for pests/rodents. The widest gap in this area was 1/2 inch. On 06/28/23 at 4:00 PM, V1 stated she had repeatedly asked management to provide additional maintenance for the facility, had asked for the damaged doors to be replaced, and had asked that the overwhelming number of cracks, holes/gaps in the building be fixed as they were the source allowing pests and rodents access to the entire facility. V1 stated she was told by management that she and her team needed to step up, work harder, and put out more bait traps. V1 stated they were already doing everything that could be done, but until the building was properly repaired it would not alleviate pests and rodents entering the facility and having access to residents. On 06/29/23 at 1:15 PM, V1 confirmed V18 (Corporate Maintenance) had been to the facility last year at which time a new exterior laundry door and exterior kitchen door was requested. V1 stated the last and most recent time these same two doors were requested was in March of 2023 and nothing had been done to date. The website - https://www.victorpest.com/articles/how-do-mice-fit-in-such-small-spaces - indicates mice are able to fit into a space as small as a number 2 pencil, which is approximately 1/4 inches. The Resident Council Minutes from 05/23/23 document residents' concerns regarding mice as - Maintenance: Mice . wish maintenance was here throughout the day. Comments/Suggestions: Need a full-time maintenance man . The Resident Council Minutes from 06/13/23 document residents' concerns regarding mice as - Maintenance: (V12's name) needs to step game up, fix building, mice, grass. Comments/Suggestions: New maintenance man . The facility Pest Control Summary of Service dated 05/30/23 included - Recommendations: Area/Device - Perimeter Inspection: Door gap/damage noted that allows pest access. Please repair to prevent pest entry. Severity: Medium. Status: Pending. Date: 03/07/23. Area/Device - Kitchen Inspection: Door gap/damage noted that allows pest access. Please repair to prevent pest entry. Severity: Medium. Status: Pending. Date: 03/07/23. General Comments: I serviced and inspected the areas with rodent activities. There were rodent activities found in the kitchen. I spoke with (V1 name) about the facility and service today. I replaced and added monitoring devices in the facility for rodents. I will follow-up with this situation . The facility Pest Control Summary of Service dated 06/20/23 included - Recommendations: Area/Device - Laundry Inspection: Door gap/damage noted that allows pest access. Please repair to prevent pest entry. Severity: High . ILT (Insect Light Trap) 001. Insect light trap of not working properly. We suggest purchase of new bulbs for effective control. Severity: Medium. Exterior: Door gap/damage noted that allows pest access. Please repair to prevent pest entry. Severity: High. Exterior: Weeds/grass in area need to be treated to eliminate. Severity: High . Kitchen Inspection: Door gap/damage noted that allows pest access. Please repair to prevent pest entry. Severity: Medium. Pending: 03/07/23 . General Comments: I serviced and inspected the areas with rodent activities and insect activities. There have been reports of rodent activities in the facility and there was a mouse reported in the dining area by the kitchen door. I placed monitoring devices in the kitchen area for such issues. During the service today, I noticed the door to the sprinkler room need repaired. I highly recommend having the door repaired. During the service today I noticed a mouse run under the door into the laundry room. This door also has gaps. I highly recommend having this door fixed as well. I spoke with (V2's name) about the facility and he will pass the findings on to (V12's name). (V12's name) was not at the facility today . An undated facility policy titled, Physical Plant and Environmental Policy and Guidelines includes - Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well-maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (National Fire Protection Association) codes . Policy Implementation: The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Under Maintenance/Approved Contractors: the policy states . Routine care and repairs to interior finishings - repairing ceiling/wall damage, painting, floor; . Insect and rodent control; Secured and organized mechanical rooms and storerooms; . Routine grounds clean-up of litter, maintaining landscaping, and lawn mowing; Secured exterior doors; . Maintain essential supplies and parts . An undated facility policy titled Insect and Pest Control Policy documents: It is the policy of (Name of Corporation) to contract with a duly licensed exterminating service to protect and/or control against infestations of insects and rodents. A preventative treatment, both interior and exterior, shall be applied at least once every month. Treatments will be applied more often if required. Chemicals, materials and equipment used to control insects and rodents will be provided by the Vendor and will be in accordance with current Federal and State specifications for use in nursing homes. Methods of application shall be in accordance with current Federal and State regulations and manufacturers recommendations. The Vendor shall provide the facility with Material Safety Data Sheets for all products used. Under Procedure: The following procedures shall apply regarding pest control: 1. Any employee observing insects or rodents of any kind shall inform their supervisor giving the exact location and type of infestation. 2. The employee shall fill out a work order form and give it to the maintenance person. 3. The maintenance person shall contact the contracted pest control company for eradication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a recapitulation of stay at the facility for 1 of 1 resident (R26) reviewed for discharge in a sample of 22. The Findings Include: R26 profile face sheet documents that R26 was admitted on [DATE] with a diagnosis of acquired absence of left leg, below knee. R26's nursing progress notes document that on 3/21/23 R26 was discharged from facility and left with husband in personal vehicle at 12:05. Discharge instructions and medications reviewed and sent with resident. A Discharge Evaluation was found in R26's medical record but was blank. On 5/11/23 at 10:00 AM, V2 (Minimum Data Set Coordinator) stated that there was not a completed discharge evaluation on R26. On 5/12/23 at 9:30 AM, V1 (Administrator) stated R26 was admitted for a very short time and was here for her home to be made handicap accessible, and when she found out she could leave there was not a lot of notice. V1 confirms the only information on R26's discharge is in the progress note dated 3/21/23. V1 stated at this time that she expects all discharged residents to have the discharge summary completed by all departments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess residents blood sugar prior to administering fast-acting insulin for 1of 1 resident (R23) reviewed for insulin administration a sample of 22. The findings include: R23's document labeled Profile Face Sheet notes that R23 was admitted to the facility on [DATE]. R23's Profile Face Sheet documents diagnoses including: Type 2 Diabetes Mellitus without Complications, Chronic Kidney Disease, Stage 3, unspecified open wound, left lower leg. R23's Physician's Orders note an order dated 4/3/23 for Insulin Lispro 100 units/ml Inject 5 units Sub Q (subcutaneous) three times daily 6am, 11am, 4pm. R23's Physician's Orders dated 4/3/23-4/30/23 and 5/1/23 to present do not document any orders to check R23's blood sugar. R23's facility progress note dated 4/4/23 written by V8 (Physician) document under Plan .will monitor blood sugars closely and adjust insulin as necessary. On 5/9/23 at 11:15am, R23 was observed being administered 5 units of Humalog insulin without a blood sugar test being performed. R23's MDS (Minimum Data Set) dated 4/10/23 documents in Section C, that R23 has a BIMS (Brief Interview of Mental Status) of 15 which indicates R23 is cognitively intact. On 5/12/23 at 11:10am, R23 said that the nurses did check her blood sugars at the hospital before she was admitted to the facility but does not remember how often or what they were. R23 said she was more focused on her pain and the wound on her leg. On 5/12/23 at 11:40am, V10 (RN/Registered Nurse) said she was the nurse that admitted R23 on 4/3/23. V10 said she faxed the orders to the physician (V8) and just did not think about asking about getting an order to get R23's blood sugars checked. On 5/12/23 at 2:15pm, V3 (RN) said they are not doing blood sugar checks on R23. When asked how they know what R23's blood sugar is she responded, We don't. On 5/11/23 at 2:45pm, V9 (Regional Quality Assurance Nurse) said she is a nurse and would not feel comfortable giving a resident Humalog insulin without knowing what the resident's blood sugar is. On 5/11/23 at 2:25pm, V2 (MDS/Minimum Data Set Coordinator) said V8 (Physician) did not want any blood sugars ordered and that he was asked on the resident's admission and declined. V2 said that they do labs on R23 every 3 months. On 5/12/23 at 11:20am, V2 said he took report from the hospital prior to R23's admission and was told that R23 received blood sugar checks ac (before meals) and hs (bedtime) and received 5 units of Lispro (Humalog) insulin with each meal. On 5/11/23 at 2:36pm, V8 (Physician) said he thought that R23 was getting blood sugar checks prior to insulin being given and that R23 should be getting blood sugar checks prior to the administration of the insulin. V8 said he was going to call the facility and get them ordered. A document is R23's Medical Record labeled with the local laboratory company and the facility name document that a Glyco-HgbA1C lab test was collected on 4/25/23 and a result of 5.8, with a documented normal range of 4.1-6/1%. The website https://www.humalog.com/fast-acting-mealtime-insulin#about-mealtime-insulin, documents under the section titled Managing Blood Sugar that when using mealtime insulin like Humalog, you must test your blood sugar (glucose). For example, you may need to test before and after meals and at bedtime. Your doctor will tell you when and how often you should test.

Based on interview and record review, the facility failed to provide a Director of Nursing for the facility. This failure has the potential to affect all 23 residents residing in the facility. Findings Include: On 05/9/23 at 10:20 AM, V1 (Administrator) stated the facility currently does not have a Director of Nursing (DON) and has not since December 2022. V1 states the facility has sought to hire a DON but been unsuccessful. V1 verified the accuracy of nursing schedules provided and stated the facility does not have any nursing waivers. On 5/11/23 at 2:00 PM, V10 (Registered Nurse) stated that they do not currently have a DON on staff. On 5/9/23 at 1:00 PM, V2 (MDS) stated that they have not had a DON for quite some time but that they are interviewing for the position. During the survey from 5/9/23 to 5/12/23, there was no DON observed working at the facility. The Resident Census and Conditions of Residents form provided by the facility on 5/9/23 documents 23 residents reside at the facility.