Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1, the facility failed to ensure its Minimum Sata Set (MDS) Assessments accurately reflected the status of 1 of 1 sampled residents, (Resident [R] 8).The findings include: Review of a statement provided by the facility, dated 08/01/2025 and signed by the Director of Nursing (DON), Minimum Data Set Nurse (MDS) 1, and the Administrator, revealed the facility does not have a specific policy on MDS, we follow state/federal guidelines and the RAI. Review of the CMS RAI 3.0 User's Manual Version 1.19.1, Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0, revealed the definition of a fall was the unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g. onto a bed, chair, or bedside mat). Per review, the rationale of assessing falls, as related to health-related quality of life was: falls were a leading cause of morbidity and mortality among nursing home residents; falls resulted in serious injury, especially hip fractures; and previous falls, especially recurrent falls and falls with injury, were the most important predictor of future falls and injurious falls. Additional review revealed identification of residents who were at high risk of falling was a top priority for care planning. Review of R8's electronic medical record (EMR) revealed the facility admitted the resident on 02/19/2025, with diagnoses to include: unspecified fracture of left femur, adult failure to thrive, and chronic atrial fibrillation. Review of the Prospective Payment System (PPS) Part A Discharge MDS Assessment, with an ARD of 07/08/2025, revealed the facility assessed R8 to have a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the resident had severe cognitive impairment. Review of the facility report titled, Incidents by Incident Type (Fall Incidents), revealed R8 sustained a fall on 03/13/2025 at 12:00 AM. However, review of the Quarterly MDS Assessment, with an ARD of 04/11/2025, revealed the question J1800 stating, Has the resident had any falls since admission/entry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent, had been answered as 0 (which indicated No) even though R8 sustained the fall on 03/13/2025. Continued MDS review revealed J1800 being answered 0, inactivated question J1900 which addressed extent of injury resulting from a fall. Review of the facility report titled, Incidents by Incident Type (Fall Incidents), revealed R8 sustained a fall on 04/17/2025 at 6:08 AM. However, review of the Discharge Return Anticipated MDS Assessment, with an ARD of 05/05/2025, revealed for question J1800, Has the resident had any falls since admission/entry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent, was answered as 0 (which indicated No) even though R8 sustained the fall on 04/17/2025. The 0 for J1800 inactivated question J1900 which addressed extent of injury resulting from a fall. Review of the facility report titled, Incidents by Incident Type (Fall Incidents), revealed R8 sustained a fall on 06/13/2025 at 5:00 PM and on 06/17/2025 at 12:46 AM. However, review of the End of PPS Part A Stay MDS Assessment, with an ARD of 07/08/2025, revealed the question J1800, Has the resident had any falls since admission/entry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent, was answered as 0 (No) even though R8 sustained falls on 06/13/2025 and 06/17/2025. The 0 for J1800 inactivated the question J1900 which addressed extent of injury resulting from a fall.In interview on 08/01/2025 at 6:30 PM, MDS Nurse 2 stated she had been in her position for three years, and said she interviewed the residents and reviewed the nurse's notes when completing a MDS Assessment. She reported after the State Survey Agency (SSA) Surveyors asked for copies of R8's MDS Assessment, she reviewed them. MDS Nurse 2 said when reviewing the MDS Assessment she saw the inaccuracies related to R8's falls in section J of the MDS Assessments with ARD's of 04/11/2025, 05/05/2025, and 07/08/2025, and made corrections. When the SSA Surveyor asked the MDS Nurse what had happened when the MDS Assessments were originally completed, she stated they probably just fell through the cracks. In interview on 08/01/2025 at 8:02 PM, the Administrator stated communication with the staff and the staff following the facility's policies was how residents were kept safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 of 3 residents sampled for accidents/falls, (Resident (R)8). The findings include: Review of R8's electronic medical record (EMR) revealed the facility admitted the resident on 02/19/2025, with diagnoses that included: chronic atrial fibrillation, unspecified fracture of left femur, and adult failure to thrive. Review of the Prospective Payment System (PPS) Part A Discharge MDS Assessment, with an ARD of 07/08/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. Review of the facility's Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 experienced falls on the following dates: 03/13/2025 at 12:00 AM; 04/17/2025 at 6:08 AM; 06/12/2025 at 5:00 PM; 06/17/2025 at 12:46 AM; 07/18/2025 at 9:30 AM; and 07/22/2025 at 11:58 PM. Review of R8's Comprehensive Care Plan (CCP), last revised on 07/18/2025, revealed a focus statement for Risk for falls related to the resident's history of falls, injury, and multiple risk factors of: functional capabilities, Impaired mobility, bowel incontinence. Per review, R8 also had a decline in functional status from: a recent hospitalization due to a right femur neck fracture; osteoporosis; dementia; left hip fracture, thoracic compression fracture; falls; and the resident's preference to be in floor. Continued review revealed the Interventions included: keeping the resident in high traffic areas when up in the wheelchair for higher visibility from staff to ensure safety, initiated 04/17/2025; resident to be up in wheelchair during daytime hours to prevent injury from resident climbing out of bed; initiated 06/13/2025; and Non-skid strips to bedside; initiated 06/17/2025. Observation on 07/29/2025 at 10:45 AM, revealed R8 sitting in a wheelchair in his room with a staff member speaking to him. Per observation, the staff member exited the room leaving R8 unsupervised. Further observation revealed there were no non-skid strips on the floor to R8's bedside. Observation on 07/29/2025 at 4:30 PM, revealed R8 was not in his room and there were no non-skid strips on the floor to his bedside. Observation on 07/30/2025 at 8:20 AM, revealed R8 lying on his bed resting, with no non-skid strips on floor to the bedside. Observation on 08/01/2025 at 9:48 AM, revealed R8 lying on the bed with bolsters in place in his room (room [ROOM NUMBER]); however, there were no non-skid strips on floor to the resident's bedside. Observation on 08/01/2025 at 2:05 PM, revealed R8 up in the wheelchair facing towards the end of the hallway, between rooms [ROOM NUMBERS] with no staff member present. The State Survey Agency (SSA) Surveyor observed R8 for three minutes without seeing a staff member with him or near him. Observation on 08/01/2025 at 5:15 PM, revealed R8 lying on the bed with bolsters in place; however, with no non-skid strips on floor at bedside. Observation on 08/01/2025 at 6:45 PM, revealed R8 lying on the bed with bolsters in place; In interview on 07/30/2025 at 1:35 PM with Family Member (FM) 5, son of R8, he stated his only concern with his father's care was, it seems he has had a lot of falls recently. FM 5 stated he wonders what is going on with that (the falls). In interview on 08/01/2025 at 5:15 PM, Certified Nurse Aide (CNA) 11 stated the aides had a care guide sheet they referred to for caring for the residents. She reported R8 was supposed to be located at the nurse's desk when up in his wheelchair and not in his room. CNA 11 said R8 needed to have his bed in the lowest position; his call light within reach; and needed to have on non-skid socks. She further stated she was not aware R8 needed to have non-skid strips on the floor by his bed. In interview on 08/01/2025 at 5:20 PM, Registered Nurse (RN) 7 stated if a resident was to have non-skid strips on the floor by their bed, that would be listed on the resident's care guide and care plan. She reported she did not have it in R8's care guide that he was supposed to have non-skid strips on the floor by his bed. RN 7 further stated non-skid strips usually were for when people have falls as one of their interventions. She additionally stated a negative outcome of not following (implementing) a resident's care plan could be for an injury from a fall. In interview on 08/01/2025 at 7:30 PM, the Director of Nursing (DON) confirmed there were no non-skid strips beside R8's bedside until earlier today when the SSA Surveyor started asking questions. She said daytime was defined as day shift, or the 7:00 AM - 7:00 PM shift, as allowed by the resident (in reference to R8's care plan interventions to be up in the wheelchair during daytime hours.) The DON further stated the care plan for R8 meant he was, to be in a highly visible area when he is in his wheelchair instead of in his room. She clarified the nurses' desk was an example of a highly visible area and not meant to be the only place he could be located. In interview on 08/01/2025 at 8:02 PM, the, Administrator stated the residents were kept safe through communication with staff; staff following the facility's policies; and immediate action.

Based on interview, record review and review of facility policy, the facility failed to ensure that 2 of 2 residents reviewed for care plan participation were afforded the opportunity to participate in the development of their care plan (Resident (R)1 and R6). The findings include: Review of the facility's Care Plan Invitation and Documentation Guidelines policy, dated 08/2019, revealed that, To comply with regulatory requirements, invitations are extended to attend the care plan meetings to the resident, resident's representative, or other family members as/if when applicable. Per policy review, documentation of a resident, resident's representatives' or family member's attendance or nonattendance at the care plan meeting was to be placed in the Care Plan General Progress Notes. Continued review revealed Frequently, the facility sends out invitations that are in the form of cards or letters to enhance the participation of the residents and their representatives in the care planning process. Review revealed the following guidelines should be followed as necessary . These steps included a follow up call to the resident resident's representative, offering alternate dates/time if either the resident and/or their representative could not attend at the time the facility initially scheduled the meeting, and documenting names, times, and dates of those contacts. Further policy review revealed, If the [care plan] review occurs in person, the resident, the resident's representative as applicable, and the team members should sign the Signature page of the care plan to denote their attendance and review of the care plan. 1) Review of R1's admission Record revealed the facility initially admitted the resident in 2016. Review of R1's Minimum Data Set (MDS) Assessments, revealed an Annual MDS, with an Assessment Reference Date (ARD) of 03/28/2025, and a Quarterly MDS with an ARD of 06/20/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Review of R1's care plan generated after the Annual MDS Assessment revealed a start date of 04/04/2025, and a care plan with a start date of 07/07/2025, after the 06/20/2025 MDS Assessment. Review of R1's clinical record, including, but not limited to, the Progress Notes section, revealed no documented evidence the resident attended care plans meetings for neither of the two care plans reviews completed in 2025. Review of the Social Service (SS) Progress Notes dated 02/24/2025, revealed a note that stated, SS met with resident and/or RR [resident representative] on file in person or via phone and letter mail [sic] to provide information for resident care plan meeting for March. Per review, SS also offered resident and/or RR a copy of resident care plan at this time as well. Care plan was offered to be held in person, via phone conference, or via telehealth. No concerns voiced at this time. SS to f/u [follow up] as needed. Continued review revealed however, the Note did not detail whether it was actually the resident, a representative, or both, who was contacted regarding the care plan, nor did it specify which of the three ways listed (in person, via phone, or by mail) the facility actually provided the information. Review revealed although it noted there was to be a care plan meeting in 03/2025, no specific date, time, or location for the meeting was documented. Review of the Social Services Progress Note dated 05/20/25, revealed the same, non-specific information was documented as in the previous Note, with the only change being it referenced a June care plan meeting (instead of March). Review of the care plan signature pages and Progress Notes, including the Care Plan General Progress Notes, revealed no documented evidence the resident, a representative, and/or a family member had been present for either care plan review (in March or June), and there was no documentation indicating why their participation would not have been practicable. In interview on 07/30/2025 at 8:37 AM, R1 stated she was able to speak, and both her short and long-term memory were intact. R1 reported she had not regularly been invited to the scheduled care plan meetings where she was able to discuss and provide input on the services she was receiving. R1 said she was a nurse and was her own guardian. The resident further stated she felt she had lost her autonomy, and said she, would like to go to at least one [care plan meeting] to see how it goes. In interview on 07/31/2025 at 9:58 AM, the SSD reviewed R1's records and stated he could not find evidence of the resident being informed of the specific date and time of her care plan meetings. The SSD stated he could not find where a signature sheet for R1 resident was recorded, and he did not recall attending care plan meetings with R1 since he began his position (in March, 2025). He further stated he could find no documentation in R1's chart to explain why the resident and and/or representative had not attended the care plan meetings. 2) Review of R6's clinical record, including, but not limited to, the Progress Notes section, revealed no documented evidence the resident attended care plans meetings for either of the two care plans reviews completed for him in 2025. in interview on 07/31/2025 at 9:57 AM, MDS 1 stated at one time, their department was responsible for running the care plan meetings and issuing invitations. MDS 1 further stated however, currently, SS staff was responsible for scheduling the residents' care plan meetings. In interview on 07/31/2025 at 11:09 AM, R6 stated he had not been invited to any care planning meetings and did not know anything about them. In continued interview on 07/31/2025 at 9:58 AM, the Social Services Director (SSD) stated he just started his position in 03/2025. He said care plan meetings were to be documented in the facility's EMR system for residents. He stated his assistant was supposed to go and talk with the residents about attending their care plan meetings, and if the resident was alert and oriented, a letter was given to the resident. The SSD provided the State Survey Agency (SSA) Surveyor a copy of the letter referenced for review. Review of the letter revealed, During and after admission, you or a loved one may have been evaluated, and care plan was developed to meet required needs. If you are ever interested in reviewing this care plan, please reach out to our facility to schedule a care plan meeting with our team. If you plan to attend, please let us know in advance by calling. Continued review of the letter revealed it did not provide a specific date, time, or location for the care plan meeting, and indicated the care plan had already been developed, and the meeting was to review the care plan (rather than for the resident to participate in its development.) In further interview on 07/31/2025 at 9:58 AM, the SSD reported he could provide no evidence of the residents having been informed of the logistics (time and location) of their care plan meetings however. He stated SS staff scheduled the care plan meetings based on a calendar of scheduled assessments and placed a check on the calendar after they had talked to the resident. The SSD reported however, he could provide no evidence of such a system having been completed, as they discarded the calendars at the end of the month. He explained he could provide no evidence the resident, their representative, and/or family had, in fact, attended the care plan meeting and participated in the development of the care plan. In an additional interview on 07/31/2025 at 11:28 AM, the SSD stated R6 had just been invited to his care planning meeting within the hour that morning, and had not had a care plan meeting prior to that. The SSD reported there was a sign in page signed by all present when they completed a resident's care planning; however, there was no evidence of a sign in sheet for R1 and R6. In interview on 08/01/2025 at 7:48 PM, the Director of Nursing (DON) confirmed SS staff ran the resident care plan meeting process. She stated residents and family members were supposed to be asked to those meetings. The DON reported her expectation was for the SS staff to follow the facility's policy, including keeping a record of who attended the care plan meetings, obtaining signatures, and recording the date of the meeting. She further stated she was aware there needed to be documentation in the residents' medical records if the resident and/or their RP's participation was not practicable for some reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 483.25 Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure the safety of its residents for 1 of 5 residents, (Resident (R)8). The findings include: Review of the facility's electronic medical record (EMR) for R8 revealed the facility admitted him on 02/19/2025, with diagnoses including: adult failure to thrive; unspecified fracture of left femur; and chronic atrial fibrillation. Review of the Discharge Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/08/2025, revealed the facility assessed R8 to have a Brief Interview for Mental Status (BIMS) of 7 out of 15, indicating he was severely cognitively impaired. 1. Review of the facility document titled, Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 sustained a fall on 03/13/2025 at 12:00 AM. Review of the facility's document, Incident Report dated 03/13/2025, revealed a the Interdisciplinary Team (IDT) performed a Root Cause Analysis (RCA) and determined R8 got up unassisted without turning on his call light, attempted to ambulate with the walker to the recliner and lost his balance and fell. Per review, R8 was not able to ambulate without assistance. Further review revealed the immediate intervention was for red tape to be placed to his call light to serve as a visual reminder to R8 to call for assistance before attempting to transfer or ambulate on own. Review of the facility's document titled, Fall Risk Evaluation (FRE), signed 03/14/2025, revealed R8 had a history of falls in the past 31-180 days instead of the past 30 days. Additional review revealed a total score of 10 or higher indicated R8 was at risk for falls and follow-up was required. Further review revealed a score of 14 for R8; however the question for follow-up required, had been answered no, therefore, no follow-up comments or actions taken were documented in the space provided. 2. Review of the facility's FRE document, signed 04/15/2025, revealed no falls in the past 30 days was documented. 3. Review of the facility's document titled, Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 experienced a fall on 04/17/2025 at 6:08 AM. Review of the facility's document, Incident Report, dated 04/17/2025, revealed a RCA had been performed by IDT that determined R8 got up from his wheelchair in the hallway and attempted to ambulate without staff assist and fell backwards. Per review, the immediate intervention was noted for when R8 was up in a wheelchair, to keep him in high traffic areas such as by the nurses' station for higher visibility from staff to ensure his safety. Further review revealed the IDT agreed that intervention would work best for R8 as he was not safe to ambulate on his own. In addition, review revealed that intervention would also be best for R8 because if he was in a higher traffic area when he was in the wheelchair and attempted to get up on his own, staff would have a higher chance to see him and assist him to ensure no major injury occurred with a fall. Review of the facility's care plan for R8 revealed a focus for risk for falls characterized by history of falls/actual falls, injury, multiple risk factors . Continued review of the risk for falls focus, revealed an intervention for when resident is up in wheelchair, keep in high traffic areas such as nurses station for higher visibility from staff to ensure safety that had been initiated on 04/17/2025. Review of the facility's FRE document for R8, signed 04/17/2025, revealed falls in the past 31-180 days, instead of fall in past 30 days being noted. 4. Review of the facility's FRE document for R8, signed 05/15/2025, revealed, no falls in the past 30 days was documented instead of fall in past 30 days. 5. Review of the facility's FRE document for R8, FRE, signed 06/04/2025, revealed, no falls in the past 30 days was documented instead of fall in past 31-180 days. 6. Review of the facility's FRE document for R8, signed 06/05/2025, revealed the resident's gait was noted as chairfast - total assist with transport instead of as, ambulates with gait problem and device. Additional review revealed a total score of 10 or higher indicated R8 was at risk for falls and follow-up was required. Review further revealed R8's score was 13 indicating the resident was at risk for falls. In addition, review revealed the question for, follow-up required, was answered yes; however, no there was no documented evidence of follow-up comments or actions taken noted in the space provided. 7. Review of the facility's document titled, Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 sustained a fall on 06/12/2025 at 5:00 PM. Review of the facility's document, Incident Report, dated 06/13/2025, revealed the IDT performed RCA and determined R8 rolled out of his bed. Per review, the IDT noted R8's bed had been in the lowest position at the time of the fall and bolsters had been in place which the resident rolled right over. Continued review revealed R8 had not had his call light at time of rolling out of his bed, the lighting had been good in his room, and he had just been toileted and assisted to lie down. Further review revealed the IDT's immediate intervention was for R8 to be up in his wheelchair during the daytime hours to prevent injury from the resident climbing out of bed. Review of care plan with a focus of risk for falls characterized by history of falls/actual falls, injury, multiple risk factors . revealed an intervention of Resident to be up in wheelchair during daytime hours to prevent injury from resident climbing out of bed was initiated on 06/13/2025. Review of the facility document, FRE, signed 06/14/2025, revealed R8's gait was documented as bedfast, and the history of falls was documented as no falls in the past 30 days. As a result of those answers, the score of this evaluation was assessed as a 6, which indicates the resident is not at risk for falls. 8. Review of the facility document, titled Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 experienced a fall on 06/17/2025 at 12:46 AM. Review of the facility document, Incident Report, dated 06/17/2025, revealed an RCA by the IDT determined R8 attempted to get out of bed without assistance. Resident has dementia and is not able to understand that he cannot ambulate on his own which is the root cause of the fall. The immediate intervention was that non-skid strips were to be placed at bedside so that if resident does attempt to stand without staff assist hopefully the non-skid strips will keep him from slipping and falling. Review of R8's care plan with a focus of, risk for falls characterized by history of falls/actual falls, injury, multiple risk factors . revealed an intervention for non-skid strips to bedside which had been initiated on 06/17/2025. Review of the facility's FRE document, signed 06/17/2025, revealed a total score of 10 or higher indicated the resident was at risk for falls and follow-up was required. Per review, a score of 13 for R8, which indicated he resident was at risk for falls. Further review revealed however, the question for follow-up required, was answered as no. Additional review revealed In the space provided for documentation of follow-up comments and action taken, only the score of 13 was documented. 9. Review of the facility's FRE document, signed 07/05/2025, revealed fall in past 31-180 days was documented instead of fall in past 30 days. Per review, a total score of 10 or higher indicated R8 was at risk for falls and that follow-up was required. Additional review revealed a score of 11 for R8; however, the question, follow-up required, was answered no, with no follow-up documentation. 10. Review of the facility's document titled, Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 experienced a fall on 07/18/2025 at 9:30 AM. Review of the facility's document, Incident Report, dated 07/18/2025, revealed the IDT performed a RCA that determined R8 slid out of bed onto the floor. Per review, R8 had been noted to have increased confusion over the past day which was determined as the root cause of the fall. Per review, a room assessment showed all previous interventions were in place; however, the resident did not have his call light at time of the fall. Continued review revealed R8's clothing had been well fitting with his non-skid socks in place. Further review revealed as an immediate intervention, labs were ordered to rule out a medical cause of R8's fall related to his increased confusion. Review of the facility's FRE document signed 07/18/2025, revealed fall in past 31-180 days was documented instead of fall in past 30 days. Continued review revealed a total score of 10 or higher indicated R8 was at risk for falls and follow-up was required. Additional review revealed a score of 15 which indicated the resident was at risk for falls; however, the question for follow-up required, was answered as no. 11. Review of the facility's document titled, Incidents by Incident Type, Fall Incidents, with a date range of 01/01/2025 through 07/31/2025, revealed R8 sustained a fall on 07/22/2025 at 11:58 PM. Review of the facility's document, Incident Report, dated 07/22/2025, revealed the IDT performed RCA of R8's fall and determined the resident slid out of bed and landed on his bottom on floor. Per review, R8's call light had not been activated at time of the fall. Continued review revealed R8's bed was in the lowest position; and the resident had on properly fitting clothing and non-skid socks at the time of the fall. Further review revealed R8 was currently being treated for a Urinary Tract Infection (UTI), and was receiving intravenous (IV) antibiotics and had experienced increased confusion from the infection which was the root cause of the fall. In addition, review further revealed as an immediate intervention, red tape had been placed on R8's call light to serve as a visual reminder for him to call for assist before attempting to get up. Review of R8's care plan with the focus for risk for falls characterized by history of falls/actual falls, injury, multiple risk factors . revealed an intervention for red tape to call light to remind resident to call for assistance before attempting to get up that was initiated on 07/23/2025. Review of the facility FRE document, signed 07/23/2025, revealed R8's history of falls was documented as no falls in the past 30 days. Further review revealed as a result of that being the answer, R8's score was evaluated as a 5, which indicated the resident was not at risk for falls. Observation on 07/29/2025 at 10:45 AM, revealed R8 sitting up in a wheelchair in his room (room [ROOM NUMBER]) with a staff member present speaking to him. Continued observation revealed the staff member left R8's room leaving the resident unsupervised. Further observation revealed R8's bed was in the low position with the right side against the wall, and bolsters in place. Additional observation revealed however, there were no non-skid strips on floor at R8's bedside. Observation on 07/29/2025 at 4:30 PM, revealed R8 was not in his room and there continued to be no non-skid strips on floor at his bedside. Observation on 07/30/2025 at 8:20 AM, revealed R8 lying on his bed with eyes closed, and no non-skid strips on floor beside the bed. Observation on 08/01/2025 at 9:48 AM, revealed R8 lying on his bed with the bolsters in place; however, with no non-skid strips on floor by the bed. Observation on 08/01/2025 at 2:05 PM revealed R8 sitting up in his wheelchair located towards the end of the hallway, between rooms [ROOM NUMBERS], which were in the opposite direction of his room (room [ROOM NUMBER]) and near the end of the hallway, with no staff member present near the resident. Continued observation of R8 for a continuous three minutes revealed no staff member was by or near R8. Observation on 08/01/2025 at 5:15 PM and at 6:45 PM, revealed R8 lying on his bed with the bolsters in place, but with no non-skid strips on the floor at bedside. In interview on 07/30/2025 at 1:35 PM, R8's son, Family Member (FM) 5, stated his only concern with his father's care was, it seems he has had a lot of falls recently, and said wondered what was going on with that. In interview on 08/01/2025 at 5:15 PM, Certified Nurse Aide (CNA) 11 stated the aides had a care guide sheet to refer to when they cared for the residents. The CNA reported R8 when up in his wheelchair was supposed to be at the nurse's desk when not in his room. She said R8 needed to have his bed in the lowest position; have on non-skid socks; and have his call light within reach. CNA 11 further stated she was not aware R8 needed non-skid strips on the floor by his bed though. In interview on 08/01/2025 at 5:20 PM, Registered Nurse (RN) 7 stated if a resident was to have non-skid strips on the floor by the bed, that information would be listed in the resident's care guide and on the care plan. RN 7 said she did not have it on R8's care guide for him to have non-skid strips on the floor by his bed. She reported non-skid strips usually went in steps when people had falls as one of their interventions. RN 7 further stated a negative outcome of not following a resident's care plan could be an injury from a fall. In interview on 08/01/2025 at 7:30 PM, the Director of Nursing (DON) gave confirmation of there being no non-skid strips beside the bedside of R8. She said there were no non-skid strips until earlier that day when the State Survey Agency (SSA) Surveyor started asking questions. The DON said the falls risk care plan for R8 meant he was to be in a highly visible area when he is in his wheelchair instead of in his room. She clarified the nurses' station as an example of a highly visible area, but not meant to be the only place he could be. The DON explained the FREs were to be completed at admission for each resident, after a fall, and quarterly. When asked by the SSA Surveyor who was responsible for educating nursing staff on how to complete the FRE's, she stated, after you asked for copies, I reviewed them and it appears no one was providing education related to the FRE. She further stated education had begun and about half the staff had completed it, with the remainder to be finished the next week. In interview on 08/01/2025 at 8:02 PM, the Administrator stated the residents were kept safe through communication with staff; staff following policies; and immediate action.

483.45Based on observation, interview, record review, and facility policy review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation of 300 hall medication refrigerator revealed expired medications for 2 residents (Resident (R)19, R115).The findings include: Review of the facility's policy titled, Medication Storage, dated 09/2020, revealed no information pertaining to expiration dates or discarding expired medications. 1. Review of R19's facesheet revealed the facility admitted the resident on 09/20/2024, with diagnoses that included: second degree burn of lower back, chronic pain, and autistic disorder. 2. Review of R115's facesheet revealed the facility admitted the resident on 09/03/2020, with diagnoses that included: type 2 diabetes mellitus, allergy status to other antibiotic agents, muscle weakness, and chronic kidney disease. Observation of 300-hall medication room refrigerator on 08/01/2025 at 8:55 AM, revealed four elastomeric ball pumps (medical device used for administering medications), containing 3.375 grams of the antibiotic piperacillin/tazobactam that expired on 07/27/2025, and were labeled for R19. Further observation of the medication room refrigerator revealed six additional elastomeric ball pumps containing 100 milligrams of gentamicin that were expired (one expired on 07/24/2025 and five expired on 07/27/2025) labeled for R115. During interview with Certified Medication Technician (CMT) 8 on 08/01/2025 at 9:00 AM, she stated the nurses were responsible for removing expired medications from the refrigerator and medication rooms. She stated a negative outcome of giving expired medications could be the resident experiencing an allergic reaction. In interview on 08/01/2025 9:03 AM, the Assistant Director of Nursing (ADON) stated the expired antibiotic medications in the refrigerator might have been discontinued. The ADON said or the antibiotic medications might have been a medication requiring peak and trough levels (laboratory level indicating high and low levels of a medication) and might not have been infused due to the resident having a high trough level. She explained the nurses and pharmacy technician were responsible for removing and discarding any expired medications. The ADON stated the pharmacy technician came once a month and typically discarded expired medications. She further stated negative outcomes of giving expired medications, especially intravenous (IV) antibiotics could be the resident having an adverse reaction to the medication and/or the medication might not be as effective. During interview with the Director of Nursing (DON) on 08/01/2025 at 7:21 PM, she stated if medications were expired, she expected her staff to return them or destroy them if applicable. She stated she also expected the unit managers to do checks and audits of the medication rooms and refrigerators. The DON said pharmacy also did weekly checks for expired medications in medication rooms. She further stated negative outcomes of giving residents expired medications were them experiencing adverse effects and decreased effects of the medications. During interview with the facility's Administrator on 08/01/2025 at 8:06 PM, he stated the DON took care of expired medications as well as the pharmacy. He reported he expected his staff to monitor the medication rooms for expired medications and discard or return the medications to the pharmacy that were beyond their expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 483.60Based on observation, interview, record review, and review of facility documents and policy, the facility failed to ensure each resident received food that accommodated the resident's allergies, intolerances, and preferences for 4 of 4 residents reviewed for accommodation of preferences (Resident (R)1, R38, R68, R5). [NAME], [NAME] (1) [NAME], [NAME] (27868) - Food No Notes [NAME], [NAME] (1) [NAME], [NAME] (27868) - RESIDENT NOTE No Notes The findings include: Review of the facility's policy titled, Initial Comprehensive assessment dated 08/2013, revealed residents were to be assessed for nutritional status, their likes and dislikes and was to include clinical considerations. 1) Review of R1's comprehensive care plan dated 07/07/2025, revealed the resident was to be assessed for and provided had food preferences and those preferences updated as indicated. Review of the Nutritional Screen assessment for R1 dated 06/19/2025, revealed no listed preferences. Per review, in area titled, Food Preferences/ Allergies/ Religious or Cultural Considerations revealed resident's meal preferences reviewed and updated per resident request and will follow up PRN (as necessary) with no further specific instructions. Observation during the hall lunch tray pass on 07/30/2025 at 11:57 AM, revealed Certified Nurse Aide (CNA) 13 delivering R1's meal tray. Per observation, R1 only had one (1) single serving of vegetables; however, her meal card noted she was always to receive a first and second choice vegetable. In interview, at the time of observation, R1 stated she had requested extra vegetables and although she received dialysis, she often had potatoes on her tray with an occasional banana, which the resident said was contraindicated for her dialysis. Additionally, in interview on 07/30/2025 on 11:57 AM , CNA 13, was asked by the State Survey Agency (SSA) Surveyor what R1's second vegetable was as indicated on the meal card. CNA 13 reported she could not identify a second vegetable on R1's meal tray, and could not explain why there was no second-choice vegetable present. 2) Observation on 07/29/2025 at 11:53 AM, of the lunch tray pass and review of the meal cards, revealed R5 was missing the resident's preferred almond milk. Continued observation revealed R38 was missing a can of lemon lime soda, and chocolate milk. Further observation revealed although R38's meal card stated, “No Straws” the resident had a straw in his coke. In addition, observation further revealed R68 was ordered a ground diet; however, received a dessert that was not ground. In interview on 08/01/2025 at 8:06 PM, the Administrator stated physician diet orders were to be followed as written. He further stated they tried to get what a resident preferred, and he expected the residents' preferences to be accommodated within their ordered diet.

Based on observation, interview, record review, and review of facility policy, the facility failed to maintain an effective infection prevent program to help prevent the development and transmission of communicable infections for 2 of 7 residents reviewed for infection control (Resident (R)106 and R6). Staff failed to implement Enhanced Barrier Precautions (EBP) by wearing gowns during high contact resident care activities for the two residents, who had clinical indications which required EBP. The findings include: Review of the facility's Enhanced Barrier Precautions policy, revised 04/01/2024, revealed EBP are used in conjunction with Standard Precautions to reduce the risk of MDRO [Multidrug Resistant Organisms] transmission during high-contact resident care activities. Per review, EBP included the use of both gown and gloves, and was meant to be in place for the duration of the resident's stay or until resolutions of a wound or discontinuation of an indwelling medical device occurred. Continued review revealed EBP applied to residents with any of the following…Wounds with or without the presence of an MDRO infection…Presence of indwelling medical devices with or without the presence of an MDRO infection or colonization. 1. Review of R106's admission Record revealed the facility admitted the resident in 2017, with diagnoses that included gastrostomy tube (g-tube or feeding tube) and dementia. Review of R106's current physician orders, as well as the facility's, Care Plan Report, initiated 11/24/2017 for the resident, revealed she had orders for a g-tube and to be on EBP. Observation during the initial tour of the facility, on 07/29/2025 at 10:30 AM, revealed a container of personal protective equipment (PPE), including gloves and gowns, hanging from the door to R106's room. Continued observation revealed however, no sign on R106's door indicating what type of precautions were to be used or which of the two residents residing in the room (R106 in Bed A, or R99 in Bed B) was to be on precautions. Further observation revealed R106 was lying on her bed with eyes closed, and did not respond to the State Survey Agency (SSA) Surveyor's knocking on her door. In interview on 07/30/2025 at 10:20 AM, Registered Nurse (RN) 2 confirmed R106, the resident in Bed A, was on the EBP. Observation on 07/30/2025 at 1:38 PM, revealed a sign on the door indicating the resident in Bed A (R106) was on EBP. Observation of the sign which stated, Stop – Enhanced Barrier Precautions, revealed, All Healthcare Personnel must wear gloves and gown for the following high contact resident care activities .Providing hygiene. Observation on 07/30/2025 at 1:38 PM, revealed R106's door was closed, and no response received when the SSA Surveyors knocked. Observation revealed upon entering the room Certified Nurse Aide (CNA) 2 was observed in R106's room providing personal care and stated to the SSA Surveyors, Patient Care and the Surveyors then exited the room. During the observation of CNA 2 providing personal care for R106 revealed the CNA had not been wearing a gown. Further observation at 1:39 PM, revealed while the SSA Surveyors were standing outside R106's door, the resident's door opened a small amount, and a hand came out and pulled a gown from the PPE holder on the resident's door into the room, and then closed the door. Observation on 07/30/2025 at 1:48 PM, revealed CNA 2 exited the room. In interview, at the time of observation, CNA 2 stated when the SSA Surveyors observed her providing R106's care, she had been cleaning under the resident's breasts because the resident got sweaty there. The CNA said she then put on powder the area to keep it dry. She reported she had not been wearing a gown while providing personal care/hygiene to F106, because the other resident in the room (R99), was who was on the EBP. When the SSA Surveyor asked how she knew which resident was on EBP, CNA 2 stated it was on the care guide used by direct care staff to know how to care for the residents. Per observation, CNA 2 went to the nurse's station and obtained a copy of the care guide document. In review of the facility's, Resident Care Guide with CNA 2, confirmed R106 (not R99) was on the EBP. In continued interview, CNA 2 stated, Well, it used to be on the door. Further observation revealed CNA 2 went with the SSA Surveyors and observed the door showed Bed A (R106) was the resident on the EPB. In further interview, CNA said she should have donned a gown when providing personal care/hygiene to R106. In interview on 08/01/25 at 10:20 AM, Assistant Director of Nursing (ADON) 1, who also served as the facility's Infection Preventionist (IP), stated she was aware of the incident with R106, explaining that CNA 2 had told her that she had not donned a gown prior to providing the resident's care, but should have. ADON 1 confirmed in the interview that a gown should have been worn during R106's care since the resident had orders for EBP related to her indwelling feeding tube placement. 2. Review of the current physician orders for R6 revealed orders to treat R6's sacral pressure wound. Review of the facility's Care Plan Report, for R6 revealed a care plan with the orders for the wound care treatment and for the resident to be on EBP. During observation of a wound dressing change for R6 on 08/01/2025 at 9:39AM, revealed no signage observed designating EBP was required, and the room did not have PPE available for use hanging on the door. Per observation, the treatment nurse did not don a gown, and initiated wound care for R6. Continued observation revealed after removing the soiled dressing, fecal material was observed under the dressing nearest to the resident's anus. Observation revealed the treatment nurse positioned the clean dressing on the sacral area of the buttock; however, did not place the dressing in a way to seal fecal material from getting under the dressing. In interview at the time of observation, the Treatment nurse stated EBP was not needed due to the wound having been cultured and found not to be colonized with infectious organisms. In interview by telephone on 08/01/2025 at 10:49 AM, the Medical Director stated any resident with a feeding tube, as well as other care issues such as wounds, were to be on EBP. In interview on 08/01/2025 at 7:16 PM, the Director of Nursing (DON) stated the potential consequences related to failure to use EBP as required included transmission of different disease and infections to residents as well as staff. In interview on 08/01/2025 at 8:10 PM, the Administrator stated his expectation was for staff to use EPB as indicated and/or ordered and follow the facility's policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 483.90Based on observation, interview, record review, and facility policy review, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system (call light system) for 2 residents (Resident (R)98, and R117). The findings include: When asked to provide a policy pertaining to residents' call lights, the Director of Nursing (DON) provided a signed statement dated 07/30/2025, stating the facility did not have a specific call light policy. 1. Review of R98's facesheet revealed the facility admitted the resident on 01/28/2025, with diagnoses that included: occlusion and stenosis of left carotid artery, morbid obesity, chronic diastolic heart failure, and chronic obstructive pulmonary disease. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R98 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Observation on the 300-hall of room [ROOM NUMBER] on 07/29/2025 at 11:00 AM, revealed the call light malfunctioning. Further observation revealed R98 had a cow bell sitting on her bedside table and her roommate (R117) had no type of an alternative device to call for assistance. Observation on the 300-hall on 07/29/2025 at 11:20 AM, revealed the door to room [ROOM NUMBER] was closed and R98 was ringing her cow bell. Further observation revealed the cow bell could not be heard unless one was within approximately 15 feet of room and it was unclear which room the cow bell sound was coming from. During interview on 07/29/2025 at 11:07 AM, R98 stated her call light had been out since Friday afternoon. She stated that no one came to check on her and her roommate. R98 said staff had been running around labeling stuff since state had been there at the facility. She reported she did not have a way to get a hold of anybody, and one day no one even entered their room to check on them for over four hours. R98 explained on Sunday, the Registered Nurse (RN) on duty called the Director of Maintenance and told him about the malfunctioning call light. She stated the RN and Maintenance Director also told the Administrator on Sunday as well; however, the part needed still had not been ordered. R98 said she and her roommate had no way of communicating their needs to staff. She reported the face plate on the call light panel had just been replaced that morning and had been replaced at least twice in a matter of two weeks. RN 98 further stated it (call light panel) had been leaking water and she got squirted with water when she pressed the call light button. 2. Review of R117's facesheet revealed the facility admitted the resident on 12/04/2023, with diagnoses that included: type 2 diabetes mellitus, muscle weakness, bipolar disorder, and chronic obstructive pulmonary disease. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R117 to have a BIMS score of 15 out of 15, indicating intact cognition. Observation on 07/29/2025 at 11:00 AM of room [ROOM NUMBER], revealed the residents' call light was malfunctioning, and R117 had no alternative device for requesting assistance from staff. During interview with R117 on 07/29/2025 at 11:08 AM, she stated her call light had not been working since last Friday. She stated she had been living here (facility) for two years, and it was hard to get anyone to help them (her and her roommate). R117 reported she had a hard time getting ice water and it took staff two to three hours to bring them something that they asked for. She further stated she did not like this place. During interview with the Maintenance Assistant (MA) on 07/29/2025 at 11:30 AM, he stated he had worked here for about 10 months now. He stated the reason R98's and R117's call light kept malfunctioning was because of the condensation leaking into the call light box and that had been an issue. The MA reported they were trying to get the facility's air conditioning system replaced, and they had put dehumidifiers in the attic. He explained they usually tried to dry the call light box out first and if that did not work then they would replace the call light board. The MA said when the resident (R98) pressed the call light it sprayed her with water. He further stated when a resident's call light system was not working, they had cow bells they gave the residents to use. During interview with the Director of Maintenance on 07/29/2025 at 2:15 PM, he stated a new call light board had just been put in R98's and R117's room. He said the residents kept it so cold in that room, that condensation formed causing the problem. The Director of Maintenance further stated he replaced the board on Friday and then again today. During interview with Certified Medication Technician (CMT) 8 on 08/01/2025 at 8:55 AM, she stated if a resident's call light malfunctioned staff were supposed to call maintenance to fix it. She said in the meantime (while waiting for it to be fixed), if there were extra call lights they gave the resident(s) another call light to use or gave them a cow bell. CMT 8 further stated both roommates in room [ROOM NUMBER] should have been given a cow bell so they could call for help. She also said staff were supposed to check on the residents with malfunctioning call lights more often. During interview with CMT 9 on 08/01/2025 at 9:15 AM, she stated she had worked at the facility for almost two years. She reported if a resident's call light was not working staff were supposed to get them another call light to use, or another way of calling for assistance. CMT 9 further stated both roommates in room [ROOM NUMBER] were supposed to have a way to call for help. During interview with Registered Nurse (RN) 5 on 08/01/2025 at 9:25 AM, she stated when a resident's call light was not working, staff were to attempt to switch out the call light with a different call light if available and/or give the resident a cow bell to use to call for help. She reported last week there had been one room where the bathroom call light had been malfunctioning. RN 5 reported both roommates in a semi-private room, such as room [ROOM NUMBER], were to have a way of calling staff for assistance. She explained negative outcomes could occur with not having a working call light. The RN said a resident might need something or need to go to the bathroom and if their call light was broken and constantly blinking, staff would ignore it, and the resident might try to get up without the assistance they needed and fall. During interview with the Director of Nursing (DON) on 08/01/2025 at 7:21 PM, she stated when a resident's call light was malfunctioning, she expected staff to let maintenance know so they could replace the call light. She said she also expected staff to provide the resident with another way of calling for help, like the cowbell in use. The DON reported both roommates (in room [ROOM NUMBER]) were to have a way of calling for help. She further stated negative outcomes of residents not having a functioning call light were they would not be able to call for assistance if they needed it. During interview with the facility's Administrator on 08/01/2025 at 8:06 PM, he stated his expectation if a call light was out, for staff to give the resident a cow bell so they could call for assistance. He said they would use that approach until they could figure out how to fix the residents' call light system. The Administrator reported one of the plans was to definitely watch and make sure the residents were not having any other issues at the moment. He further stated they were looking at other things and talked to the call light manufacturer to find out if there was anything they could do to get the air flow going better to reduce the moisture in the call light box.

Based on observation and interview, the facility failed to ensure a functional, sanitary, environment for residents, staff and the public. Observation of the facility's back 300 Hall revealed water damage to the ceilings, which affected two residents (Resident (R)99 and R106) and had the potential to affect any of the 28 residents residing on the hall.The findings include: 1. Observation on 07/29/2025 at 3:06 PM, revealed Licensed Practical Nurse (LPN) 1 was in the 300 Back Hall, which housed 28 residents. Per observation, a large wet spot was noted on the carpet, and a bucket filled with water and a soiled glove were on the floor, directly under an approximately 2-inch-long hole in the hallway's ceiling. Continued observation revealed the ceiling surface was broken with white bits of ceiling debris littering the floor. In interview, at the time of observation, LPN 1 stated there had been condensation in the ceiling, and it cracked. In addition to the 2-inch-long hole in the ceiling, observation revealed a water stain approximately 10-inches, which ended at an overhead light fixture. Observation on 07/29/2025 at 3:40 PM, revealed staff had removed the overhead light fixture. In interview with the Maintenance Director on 07/29/2025 at 4:21 PM, he stated he had to remove the light fixture due to water in the ceiling and was screwing a metal plate over where the missing fixture had been. He said his belief was the water issues were coming from condensation problems in the attic. Observation on 08/01/2025 at 3:52 PM revealed that the light was still missing from the ceiling and water stains were still present on the ceiling. Interview with the Maintenance Director, who was present during this observation, revealed that the water problems had been caused because the condensation drain to the pan that goes outside had build-up in it. Further interview with the Maintenance Director revealed he believed the issue was taken care of, as the drain had been cleaned and ceiling repairs were scheduled for the next week. 2. Observation during initial tour on 07/29/2025 at 10:30, revealed R99 and R106 shared a room. Per observation, the ceiling in each resident's portion of the room had water damage. Observation on 07/29/2025 at 4:35 PM, revealed R99 had large water stains on the ceiling, which were dotted with a dark grey/green moldy looking substance on the ceiling above the resident's bed in two areas, approximately 6-inches across. Observation on 07/30/2025 at 8:22 AM, revealed R99's ceiling continued to have evidence of water damage. Per observation, R106 also had an approximate 9 x8 inch water stain on the ceiling, and a 4-inch hole in the middle of the stain was cut out of the ceiling. Continued observation revealed a fuzzy, dark grey/green substance indicative of mold was visible where the textured ceiling spackling was missing. Additional observation on: 07/30/2025 at 8:26 AM, 10:20 AM and 2:00 PM; 07/31/2025 at 8:42 AM; and 08/01/2025 at 3:52 PM, revealed the water damage and mold-appearing substance remained on the ceiling in R99's and R106's room. During the observation on 08/01/2025 at 3:52 PM, the Maintenance Director had been present, he confirmed the size and appearance of each of the areas, and stated the ceiling area appears wet. Per observation, the Maintenance Director, using a flashlight, he shone his light on the ceiling areas, which appeared to glisten as if wet. He inspected the areas with the fuzzy, greenish/grey substance and stated the areas could be mold. In continued interview the Maintenance Director stated he was unaware of the issues in that room prior to the State Survey Agency (SSA) Surveyor's notification and said no work order had been initiated. He reported, in addition to the issues identified in Example 1, the facility needed to determine the cause of the problems in that room so that it could also be corrected. The Maintenance Director said the water stains on the ceiling, the missing portions of ceiling, and the mold-like substance on the ceiling all appeared to be located on the same water line and they would need to figure out what the problem was. He further stated, Condensation has been my enemy this year, adding that, This appears to be a water issue in the ceiling which has no place to go. In interview with the Administrator on 08/01/2025 at 8:10 AM, he stated the issue with the water damage on the 300 Hall was from condensation and he thought they were on the way to fixing the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to protect one (1) of forty-seven (47) sampled residents from physical abuse. Resident #75 had a history of wandering and wore a Wanderguard bracelet. Per Patient Care Assistant (PCA)'s #2 documented interview, completed on 02/04/2022 by the former Director of Nursing (DON), Resident #75 was in Resident #64's room, and Resident #64 began yelling at the PCA to get Resident #75 out of his/her room. According to the facility investigation, PCA #2 witnessed Resident #64 touch Resident #75's right shoulder to attempt to guide the resident toward the door. However, after the incident, Resident #75 continued wandering into other residents' rooms and picking up their belongings. On 03/30/2022, Resident #46 struck Resident #75. Per the facility's Investigational Summary, dated 04/01/2022, completed by the facility's former Director of Nursing, (DON), revealed it as documented as Resident #46 made contact with Resident #75's right side. However, when the State Agency Survey (SSA) Representative interviewed Housekeeper (HK) #1 on 07/01/2022, she stated she witnessed Resident #46 shove Resident #75, and hit him/her in the stomach and the impact caused Resident #75 to hit the wall, but he/she did not fall. The facility interviewed Resident #46 after the incident and he/she stated Resident #75 had been in his/her room looking at his/her belongings. The findings include: Review of the facility policy titled, Abuse, Neglect Or Misappropriation, revised 03/10/2017, revealed the resident had a right to be free from mistreatment, neglect, and abuse. In addition, the facility would identify residents whose personal histories render them at risk for abusing other residents, and would develop intervention strategies to prevent occurrences, would monitor for changes that would trigger abusive behavior, and ensure reassessment of the interventions on a periodic basis. 1. Review of the facility's investigation of the incident dated 02/04/2022, revealed Patient Care Assistant (PCA) #2 stated he was near Resident #64's room doorway when Resident #64 started calling out for him to get Resident #75 out of his/her room. The PCA's documented interview revealed when he entered Resident #64's room, he/she began yelling and pointing at Resident #75, and with his/her left hand, he/she touched Resident #75's right shoulder to attempt to guide him/her toward the door. Per the PCA's written account, Resident #64 continued to yell for the PCA to get Resident #75 out of his/her room, so the PCA redirected Resident #75 from the room. Continued review of the facility's investigation, revealed the 100 Hall Unit Manager (UM) assessed both Resident #75 and #64, but did not find any injuries for either resident. The investigation revealed there were no additional inappropriate actions between the residents, and no changes in either resident's daily activities after the incident. Per the investigation, upon agreement from Resident #64's resident representative, the resident was moved to the 300 Hallway on 02/04/2022. In addition, the facility placed signage (a picture of a cat) at Resident #75's door, to cue/remind the resident of his/her room's location on the 200 Hallway. Review of Resident #75's medical record revealed the facility admitted the resident on 05/07/2021 with diagnoses including Arteriosclerotic heart disease, Osteoarthritis, History of Falls, Unsteadiness on feet, Generalized muscle weakness, Cognitive communication deficit, and Dementia with behavioral disturbance. Observation, on 06/28/2022 at 9:21 AM, revealed Resident #75 was sitting on the side of the bed eating breakfast. The resident was wearing a gray helmet, and was noted to also have a Wanderguard bracelet on his/her left ankle. On 06/28/2022 At 9:40 AM, Resident #75 was walking along the 200 hallway and was wearing a gray helmet, but was not using any type of assistive device. Review of the Annual MDS assessment, dated 01/03/2022, completed for Resident #75, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fourteen (14) out of a possible fifteen (15), indicating the resident was cognitively intact. Review of the Nursing Progress Note, dated 02/04/2022 at 2:50 PM, documented by Licensed Practical Nurse (LPN) #6, revealed Resident #75 walked into another resident's room, and the other resident pushed Resident #75 on the shoulder to get him/her to leave the room. No bruising or redness noted. The resident's Medical Provider and Resident Representative were notified. Review of Resident #75's Social Services Progress Note, dated 02/04/2022 at 2:29 PM, revealed the social services staff made a sign with the resident's first name, and a photo of a cat. Further, this was per the resident's request, to assist him/her with finding his/her room. Review of a Social Services Progress Note, dated 03/24/2022, completed by the Director of Social Services, revealed the resident continued to have increased confusion, and wandering. Resident appeared very happy and calm, but had difficulties finding his/her personal room. Review of Resident #75's Nursing Progress Note, dated 03/26/2022 at 4:18 PM, documented by Licensed Practical Nurse (LPN) #6, revealed Resident #75 was walking into other residents' rooms trying to take their water pitchers and belongings. Resident was redirected back to his/her room. The nurse documented she explained to Resident #75 that he/she was to please not take other residents' belongings, and the resident voiced he/she understood. Review of Resident #75's Nursing Progress Note, dated 03/28/2022 at 8:00 AM, revealed Registered Nurse (RN) #2 documented the resident continued to go in and out of other residents' rooms. Further review revealed the resident was continuously redirected which did not help, but would continue to monitor. Review of Resident #64's medical record revealed the facility admitted the resident on 04/19/2019 with diagnoses including Cerebral Infarction, Type 2 Diabetes, Cognitive Communication Deficit, Other Speech Disturbances, Anxiety Disorder, and Depression. Review of Resident #64's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of a possible fifteen (15) indicating intact cognition. Observation, on 07/02/2022 at 2:57 PM, revealed Resident #64 was self-propelling in his/her wheelchair near the 100 Hallway nurses' station. The resident looked calm, with no overt indication of anxiety. Attempted interview with Resident #64, revealed he/she felt safe at the facility. Initially, the resident indicated he/she had not had any problems with other residents. However, when asked if he/she remembered Resident #75, the resident started waving his/her hands back and forth in a [NAME]-cross fashion. Resident #64's speech was very difficult to understand related to existing diagnoses. Interview, on 07/02/2022 at 6:50 PM, with Licensed Practical Nurse (LPN) #6, revealed on 02/04/2022, she heard Resident #64 yell out. She stated before she got to his/her room, two (2) male staff working on the Hallway had removed Resident #75 from Resident #64's room. She further stated the male staff reported Resident #64 touched Resident #75 on his/her right shoulder, and yelled at him/her, but did not hit the resident. LPN #6 stated the incident occurred right around shift change, about 6:00 PM. LPN #6 further stated she assessed both residents, but found no redness or bruising, or any other indications of injury. Per interview, within an hour of the incident, Resident #64 was was moved to the 300 Hallway. 2. Review of the facility's investigation, dated 04/01/2022, completed by the facility's former Director of Nursing, (DON), revealed at approximately 8:05 AM on 03/30/2022, Resident #75 was ambulating (walking) down the 200 Hallway past Resident #46's room. Resident #46 was sitting at his/her room doorway, and as Resident #75 passed, Resident #46 struck out at Resident #75 making contact with Resident #75's right side. The incident was witnessed by Housekeeper #1. Further review revealed the residents were immediately separated and assessed after the incident, and neither resident sustained injury from the incident. Both residents were placed on one on one (1:1) observation until they both were transferred to a local Hospital Emergency Department (ED) on 03/30/2022 for a psychiatric evaluation. According to the DON's interview documented in the investigation, Resident #75 did not recall the incident. The DON's interview with Resident #46 revealed he/she was upset because Resident #75 had wandered into his/her room earlier that morning before the incident. Per the investigation, after Resident #46 returned from the ED evaluation, he/she was moved to a room on the 300 Hallway. Further review of the investigation, revealed the facility's conclusion was the allegation of resident-to-resident altercation was substantiated, although no negative outcomes occurred as a result of the interaction. Review of Resident #75's Nursing Progress Note, dated 03/30/2022 at 10:07 AM, completed by the former Assistant Director of Nursing (ADON), revealed the resident was assessed to have no injuries, and reported no pain at the time of the assessment. Review of Resident #75's Nursing Progress Note, dated 03/30/2022 at 10:10 AM, revealed due to the resident's increased confusion, the 100 Hallway Unit Manager (UM) notified the Advanced Practice Registered Nurse (APRN). Orders were received to transfer Resident #75 to the hospital Emergency Department (ED) for evaluation. Review of the Hospital Emergency Department (ED) Discharge summary, dated [DATE], revealed Resident #75 did not sustain injuries as a result of the incident, and returned to the facility that day. Review of a Document titled, Greenwood Nursing and Rehabilitation Resident Location, dated 03/30/2022 to 04/01/2022, revealed the facility implemented every fifteen (15) minute checks on Resident #75's whereabouts in the facility after he/she returned from the hospital. However, there were no staff signatures or initials that identified who completed the resident observations for that period of time. Review of Resident #46's medical record revealed the facility admitted the resident to room [ROOM NUMBER]-B on 12/24/2020, with diagnoses of Depression unspecified, Anxiety Disorder, Cerebral Infarction, Aphasia following Cerebral Infarction, Unsteadiness on feet, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #46's Quarterly MDS Assessment, dated 03/03/2022, revealed the resident scored a zero (0) out of a possible fifteen (15), on the Brief Interview for Mental Status indicating severe cognitive impairment. Interview on 07/01/2022 at 9:13 AM with Housekeeper (HK) #1, revealed she was cleaning near Resident #46's room on 03/30/2022 and Resident #46 was sitting in a wheelchair at his/her room door. HK #1 stated Resident #75 was walking in the hall and walked up to Resident #46 like he/she wanted to talk to the resident. However, she stated Resident #46 was not going to have it, and he/she shoved Resident #75, and hit him/her in the stomach. HK #1 stated the impact caused Resident #75 to hit the wall, but he/she did not fall. Further, Resident #46 did not hit Resident #75 in the head. HK #1 stated she immediately redirected Resident #75 to his/her room and reported the incident to the direct care staff. She further stated the Unit Manager (UM) initiated a report and moved Resident #46 to the 300 Hallway. Continued interview revealed she thought both residents were sent to the Hospital Emergency Department ED for evaluation. HK #1 stated this was the first time she had seen Resident #46 hit someone. Interview on 07/02/2022 at 8:10 PM, with Registered Nurse (RN) #2, revealed Resident #75 was often awake at night, and would wander to the nurses' station. She stated the resident would go in and out of residents' rooms, and would sometimes pick up other residents' belongings. The RN stated the other day, Resident #75 took a puzzle book from the room of a from a resident who lived on the Upper Side of the 200 Hallway, but it was returned to the resident. RN #2 could not remember that resident's name. RN #2 stated staff tried to keep the resident on his/her side of the 200 Hallway, but he/she wandered to the 100 and 300 halls, as well, and staff from the other halls brought him/her back to the 200 Hall. Further interview revealed RN #2 heard about the incident of 03/30/2022 between Residents #75 and Resident #46, and she was not sure Resident #75 was living in the type of facility that was best for him/her due to his/her frequent wandering behaviors. She stated she thought a locked/Alzheimer's Unit would be a more suitable setting. RN #2 further stated it may be hard for the other alert/oriented residents to understand why Resident #75 entered their rooms, and picked up their things. Per interview, the residents probably felt like it was an invasion of their privacy and space. RN #2 stated staff tried to give Resident #75 some activities to entertain him/her, but they only held his/her attention for a few minutes. Interview, on 07/02/22 at 04:01 PM, with Certified Medication Aide (CMA), #1 revealed staff had to frequently redirect Resident #75 from other residents' rooms. She stated, on 03/30/2022, she was on the 200 Hall, and saw Resident #46 raise his/her hand to hit Resident #75. Per interview, she called out and stated, Don't you hit {him/her}, and then she redirected Resident #75. However, she stated HK #1 told her Resident #46 had already hit Resident #75. She stated she may have not seen that because she was standing by the Medication Cart, and turned around when she heard HK #1 say something about it. CMA #1 stated she immediately redirected Resident #75 back to his/her room. Interview with Resident #75, on 06/28/2022 at 9:21 AM revealed the resident did not remember the incident, but stated he/she felt safe, and digressed to another topic, asking about chocolate milk. Attempted interview with Resident #46, on 06/29/2022 at 1:25 PM; however, the resident's speech was difficult to understand. He/she stated, yes, when asked if he/she felt safe at the facility. The resident denied any confrontation with Resident #75. Continued Interview, on 07/02/2022 at 9:13 AM with HK #1, revealed there had been one additional incident prior to 03/30/2022, when Resident # 64, who also lived on the 200 Hallway, yelled at Resident #75, because he/she was in his/her room. She stated Resident #64 wanted Resident #75 to get out of his/her room, but he/she did not hit the resident. HK #1 stated Resident #64 was transferred to the 300 Hallway, and now, Resident #46 and Resident #64 lived in the same room. She stated staff knew to keep Resident #75 off the 300 Hallway to avoid any further incidents. Interview, on 07/02/2022 at 11:50 AM, with the Social Services Director (SSD), revealed she remembered the incidents that occurred on 02/04/2022 and 03/30/3022 that involved Resident #75 and two separate residents (Residents #46 and #64). She stated the similarity between the two (2) incidents was that Resident #75 had apparently been in both residents' rooms. She further stated, Resident #46 reported in interview that Resident #75 had been in his/her room prior to the incident where he/she hit the resident. Further, she viewed hallway camera footage of the incident involving Resident #75 and #46, and also interviewed residents and staff during the investigation. She stated both Residents #46 and #64 were moved to the 300 Hallway, and were now roommates. She further stated both residents were agreeable to the move and seemed to get along with each other. Per interview, she did not think Resident #75 wandered around the facility in recent months as much as he/she once did. However, further review of Resident #75's medical record revealed the resident continued to wander in and out of residents' rooms: Review of the Nursing Progress Note, dated 06/19/2022 at 5:51 AM, documented by Registered Nurse (RN) #2, revealed the resident was up and down all through out the shift. and continued to go in and out of residents' rooms. Per the Note, the resident was redirected continuously, which did help somewhat, but within five (5) to ten (10) minutes the resident was again exhibiting the same behaviors. Review of Resident #75's Nursing Progress Note, dated 06/27/2022 at 2:09 AM, documented by RN #2, revealed the resident was going in and out of residents' rooms and taking things that did not belong to him/her. Per the Note, the resident gave her the items, and she returned them to the owner. RN #2 documented she educated Resident #75 about not taking other residents' belongings. Interview, on 07/03/22 02:37 PM, with the Director of Nursing (DON), revealed after the 03/30/3022 incident involving Residents #75 and #46, both were placed on one on one (1:1) supervision until Emergency Medical Services (EMS) arrived. She stated upon their return from the hospital, Resident #75 was placed on every fifteen (15) minute checks for three (3) days, and Resident #46 was moved to a room on the 300 Hall. Per interview, the residents had psychiatric evaluations, and she thought the incident was handled fine, because things just happen. Further interview revealed the cause of the incident could have been that Resident #75 was a wanderer, and Resident #46 was having some health changes at the time of the incident. The DON stated that she, and other management staff made daily rounds, observed the residents, and asked them if they felt safe and if they were having a good day. Interview, on 07/04/2022, 3:50 PM, with the Administrator, revealed he thought staff were very aware of Resident #75's behaviors and worked hard to redirect and protect him/her. He stated the DSS had been exploring potential transfer options for the resident to a facility with a closed/Dementia Unit, but so far, she had not found one willing to accept the resident. He further stated their reasons have been no bed availability and staffing challenges. Further interview revealed per the facility investigation findings, the allegation of abuse was substantiated by the facility.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who has an indwelling urinary catheter receives the appropriate treatment and services to prevent urinary tract infections for one (1) of forty-seven (47) sampled residents (Resident #68). Observation on 06/28/2022, revealed Resident 68's indwelling urinary catheter drainage bag was anchored near the head of the bed and not below the bladder. The findings include: Interview with the Director of Nursing (DON), on 07/05/2022 at 3:57 PM , revealed the facility did not have a policy related to indwelling urinary catheter drainage bag positioning/placement. Further interview revealed nursing staff was to follow the resident's care plans related to indwelling urinary catheter. Review of Resident #68's medical record revealed the facility admitted the resident on 06/09/2020 with diagnoses which included Heart Failure, Hypertension, and Type 2 Diabetes Mellitus. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 05/20/2022, revealed Resident #68 scored eleven (11) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The indwelling urinary catheter was not addressed on the MDS Assessment, as the Foley catheter was ordered after this assessment. Review of Resident #68's Comprehensive Care Plan, dated 06/14/2022, revealed a focus of an altered pattern of urinary elimination with an indwelling catheter and risk for infection. Further review of the care plan, revealed indwelling catheter to bedside as an intervention. Observation, on 06/28/2022 at 1:29 PM, revealed Resident #68 resting in bed, with his/her indwelling urinary catheter drainage bag positioned near the head of the bed and not below the level of the bladder. Interview with Certified Nurse Aide (CNA) #3, on 06/28/2022 at 1:31 PM, revealed the indwelling urinary catheter drainage bag should be secured lower on the bed frame and below the level of the bladder to keep the urine from backing up into the bladder. She further stated she had not noticed the position of the urinary drainage bag when she was in the resident's room earlier and she wasn't sure who assisted the resident to bed. Interview with Registered Nurse (RN) #3, on 06/28/2022 at 1:37 PM, revealed the CNAs should ensure the indwelling urinary catheter drainage bags were secured below the level of the bladder to allow the urine to drain and decrease the risk of urinary tract infections. She further stated both nurses and CNAs did walking rounds to monitor residents and the urinary drainage bag should have been moved below the bladder if staff noticed it. RN #1 stated she was in the resident's room earlier and if she had noticed the position of the urinary drainage bag, she would have anchored it lower on the bed frame. Interview with the Director of Nursing (DON), on 07/05/2022 at 3:57 PM, revealed she expected the indwelling urinary catheter drainage bag to be placed below the level of the bladder to aid in urine flow and decrease the risk of infections. The DON further stated both nurse aides and nurses should be monitoring correct placement of indwelling urinary catheter drainage bags when providing care for the residents. Interview with the Administrator, on 07/05/2022 at 4:20 PM, revealed he expected nursing staff to do their walking rounds to ensure care guides are followed. He further stated he would expect nursing to ensure catheter drainage bags were kept below the level of the bladder.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation of the kitchen on 06/28/2022, revealed an unopened bag of Salisbury steaks which had not been dated when removed from the original box and placed in the freezer. The findings include: Review of the facility's policy and procedure titled, Purchasing and Storage, dated 08/2013, revealed the dietary manager or designated qualified employee were responsible for dating and rotating stored food items. Observation, on 06/28/2022 at 6:18 AM, of the kitchen walk-in freezer, revealed one (1) bag of unopened Salisbury steaks, which had not been dated when removed from the original box and placed in the freezer. Interview with the Dietary Manager, on 07/02/2022 at 3:05 PM, revealed any food or food items should be dated and labeled when placed in the freezer from the original box. He further stated it was important to date food items to ensure expired food items were not served to residents. Interview with the Administrator, on 07/05/2022 at 4:20 PM, revealed he expected the Dietary Manager and dietary staff to ensure food items were dated to ensure no outdated foods were served. He further stated the Dietary Manager would need to address this.

Based on observation, interview, and review of the Safety Data Sheet for the Super Sani-Cloth Germicidal Wipes, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. Observation on 06/28/2022, revealed a container of Super Sani-Cloth Germicidal Wipes was left unattended on a medication cart on the 200 hall; and there was also a container of Super Sani-Cloth Germicidal Wipes unattended on the 200 hall ledge of the nurses' station, with residents nearby. Additionally, observation on 07/01/2022, revealed a container of Super Sani-Cloth Germicidal Wipes was left unattended on a medication cart on the 200 hall with residents nearby. The findings include: Review of the Safety Data Sheet for the Super Sani-Cloth Germicidal Wipes, revised 06/03/2020, revealed the product should be kept out of reach of children and could be hazardous to humans. Further review of the document revealed the product could cause serious eye irritation. Observation, on 06/28/2022 at 6:30 AM, revealed a container of Super Sani-Cloth Germicidal Wipes was left unattended on a medication cart on the 200 hall; and there was also a container of Super Sani-Cloth Germicidal Wipes unattended on the ledge of the 200 hall nurses' station, with residents nearby. Observation, on 07/01/2022 at 10:01 AM, revealed a container of Super Sani-Cloth Germicidal Wipes was left unattended on a medication cart on the 200 hall with residents nearby. Interview with Licensed Practical Nurse (LPN) #5, on 07/01/2022 at 10:15 AM, revealed the Super Sani-Cloth Germicidal Wipes should be stored in the medication cart in order to be keep them out of residents' reach. She further stated the wipes could be harmful to residents if they were used them incorrectly. Interview with the Director of Nursing (DON), on 07/05/2022 at 3:57 PM, revealed she expected the Super Sani-Cloth Germicidal Wipes to be locked up inside the medication carts and not kept out on top of the carts or on the ledge at the nurses' station. She further stated the wipes could be harmful to residents. Interview with the Administrator, on 07/05/2022 at 4:20 PM, revealed the wipes were used to keep the surfaces clean and to minimize the spread of infection due to the COVID pandemic. He stated the facility had not had any instances of residents getting into the wipes. The Administrator further stated nursing staff should keep the wipes locked up inside their medication carts and out of residents' reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Observation, on 06/30/22 at 9:25 AM, revealed Registered Nurse (RN) #7 entered Resident # 21's room, washed her hands, and donned a pair of clean gloves to get ready to administer the resident's morning insulin medication. However, the nurse then proceeded to touch the room door to close it, and pull the privacy curtain with her clean gloved hands prior to administering both subcutaneous doses of insulin to the resident. Further, after administering the injections, RN #7 doffed the gloves, but did not perform hand hygiene prior to exiting the resident's room. In addition, upon returning to the nurses' station, RN #7 did not perform hand hygiene prior to touching the computer's keyboard. Interview, on 07/05/2022 at 10:51 AM, with RN #7, revealed she should have performed hand hygiene after she had closed the door and the privacy curtain, and prior to administration of the insulin to Resident #21. Further, she stated she should have performed hand hygiene after administering the resident's insulin. She stated hand hygiene should be performed after providing any type of resident care. She further stated staff should perform hand hygiene by washing hands or using hand sanitizer after removing soiled gloves and before exiting a resident's room. Further, if hand hygiene was not performed after resident care, there would be increased risk of cross-contamination/transmission of germs to other residents or staff. 9. Observation, on 06/30/2022 at 3:00 PM, revealed CNA #16 was standing in the hall near the 200 hall nurses' station, but was not wearing a mask. The CNA was holding the mask in her hand. She was talking to co-worker, Restorative CNA #7. Interview, on 06/30/2022 at 3:30 PM with CNA #16, revealed she was not wearing the mask, because Restorative CNA #7 would not be able to hear her talk to him with the mask on. However, CNA#16 admitted she was to wear the mask at all times in resident care areas, and could only remove it when in the break room, eating, or when outside of the facility. 10. Observation, of the 200 Hallway, on 06/30/2022 at 3:00 PM, revealed RN #8 was standing at the medication cart across from room [ROOM NUMBER] with her mask dangling from her right ear. The mask was not covering her nose or mouth. When the RN saw the State Agency Surveyor, she put on the mask, so that it covered her mouth and nose. Interview with RN #8, on 06/30/2022 at 3:00 PM, revealed she should have been wearing the mask properly, ensuring it covered her nose and mouth. Interview with the 200 Hall Unit Coordinator (UC), on 07/03/2022 at 10:33 AM, revealed staff was trained on ICP policy by the Staff Development Coordinator (SDC), to include hand hygiene, donning and doffing of Personal Protective Equipment (PPE), and Transmission- Based Precatusions (TBP). She stated she made rounds throughout the day to monitor staff for proper use of PPE and hand hygiene performance and the staff nurses were responsible for making rounds as well. Per interview, most staff carried Alcohol-Based Hand Rub (ABHR) in their pockets, and she and the nurses reminded staff to wash their hands after caring for each resident. Per interview, staff should be performing hand hygiene before and after providing resident care, after touching a contaminated surface, prior to exiting a resident's room and upon entering a resident's room. Additional interview revealed the UC was not sure of the policy regarding cleaning and disinfecting shared equipment such as BP cuffs, pulse oximeter monitors, the rolling vital sign machine stand, and the Hoyer lift. She stated she did not know who was responsible for cleaning this shared equipment or what cleaner/disinfectant was used to wipe it down. Per interview, she was unaware if these items should be cleaned before use for each resident. Further, respiratory supplies, including BiPAP tubing and masks, should be stored in a clean storage bag and put away in the resident's bedside table. Continued interview with the UC, on 07/03/2022 at 10:33 AM, revealed dirty linen should be placed in a clear plastic trash bag, tied, and staff should take the soiled linen to the dirty utility room on the unit and place it in the appropriate linen bin. Per interview, transporting and disposing of linen according to facility policy would prevent the spread of germs to residents and staff. Additionally, the UC stated the facility has an ample supply of PPE and staff was responsible for assuring the PPE bins were adequately supplied. She stated staff should gather supplies prior to entering a resident's room who was on TBP. Interview with the Quality Improvement/Infection Preventionist (QI/IP) Nurse, on 07/03/2022 at 11:45 AM, revealed she was transitioning into her current role as the QI/PI. She stated she was currently taking courses to obtain her IP certification. Further, she would continue to monitor infection control practices in the facility. The QI/IP stated it was her expectation all staff follow the facility infection prevention and control policies and practices. Interview with the Director of Nursing (DON), on 07/03/2022 at 11:45 AM, revealed she acted as the Infection Preventionist for the facility. The DON stated staff was trained to clean and disinfect shared equipment, such as BP cuffs, pulse oximeters, the rolling vital sign machines, and the Hoyer lift, after each use with Super Sani-Cloth Germicidal Wipes which were EPA approved wipes. Continued interview revealed it was not ideal for staff to use residents' gowns for PPE. She stated staff should stock PPE supplies prior to entering the TBP room. Additional interview revealed trash and dirty linen were to be bagged prior to exiting a resident's room and taken to the dirty utility room and placed in the proper receptacles. She stated contaminated linen bags should not be placed on the floor and staff should not take contaminated linen directly into the Laundry Room. Continued interview with the DON, on 07/05/2022 at 3:58 PM, revealed everyone in the facility was responsible to maintain IPC standards. According to the DON, indwelling urinary catheter drainage bags should never touch the floor in order to avoid cross contamination. Additional interview revealed respiratory equipment should be stored in a clean bag and placed in a drawer when not in use to avoid contamination. Further interview revealed all staff should follow facility policy with regard to wearing PPE. She stated masks should be worn at all times, and should fit properly to cover the nose and the mouth. Further, staff should ensure hand hygiene was performed prior to medication administration. Continued interview revealed nursing leadership and Unit Coordinators monitored staff for PPE and hand hygiene compliance while making rounds on the units and observing staff providing care for the residents. Additional interview revealed staff was educated upon hire and throughout the year by completing online education through the RELIAS education platform. She further stated clinical staff was trained and then expected to do a return demonstration of the skill or tasks. Per interview, it was her expectation for all staff to follow and maintain the facility's IPC protocols and policies to ensure a safe environment for residents and staff, and to prevent the spread of harmful diseases and infections. Interview with the Administrator, on 07/05/2022 at 4:48 PM, revealed all staff was responsible for ensuring they were utilizing proper infection control measures in order to prevent the spread of infection to residents and other staff members. He stated it was his expectation all staff follow the facility's infection control and prevention policies related to proper hand hygiene, laundry protocol, proper use of PPE, cleaning and disinfecting equipment, storage of masks and tubing for BiPAP machines, and ensuring urinary drainage bags were not touching the floor. Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Observation, on 06/28/2022, revealed Certified Nursing Assistant (CNA) #2 was working on the 200 Hall and took a rolling vital sign machine into room [ROOM NUMBER]. After using the blood pressure (BP) cuff and pulse oximeter monitor on Resident #85, she failed to clean and disinfect the equipment prior to entering Rooms 218 and room [ROOM NUMBER], and obtaining vital signs and oxygen saturation levels for Residents #21, #34, #57, and #68. Observation of room [ROOM NUMBER], on 06/28/2022, revealed Resident #82's BiPAP tubing and mask was lying directly on the bedside table. The tubing and mask were not properly stored inside a storage bag. Observation of room [ROOM NUMBER], on 06/28/2022, revealed one (1) clear plastic trash bag containing dirty sheets, towel and gown on the floor. Observation of room [ROOM NUMBER], on 06/28/2022, revealed Resident #56's indwelling urinary catheter drainage bag was attached to the bed frame and the bottom half portion, including the pour spout section, was touching the floor. Observation on 06/28/2022, revealed Certified Nursing Assistant (CNA) #2 and CNA #3 assisted Resident #97 into his/her wheelchair using a Hoyer lift. CNA #3 failed to clean and disinfect the lift prior to placing it outside the room into the hallway to be used for other residents. Observation of room [ROOM NUMBER], on 06/28/2022, revealed there was a sign on the door, stating contact precautions. However, there were no gowns available for staff to use in the PPE storage bin outside the resident's door. Further observation revealed CNA #1 was in room [ROOM NUMBER], providing care to Resident #15, wearing a resident's gown. CNA #1 proceeded to doff the gown and place it into a plastic bag. She then walked across the hall and entered the clean side of the Laundry Room, and placed the bag in the dirty laundry bin. Observation of Receptionist #1, on 06/29/2022 8:00 AM, revealed her mask was below her nose while checking in surveyors and staff. Observation, on 06/30/22, Registered Nurse (RN) # 7 entered Resident # 21's room, washed her hands, and donned a pair of clean gloves. However, the nurse then proceeded to touch the room door to close it, and pull the privacy curtain with her clean gloved hands prior to administering both subcutaneous doses of insulin to the resident. Furthermore, after administering the injections, RN #7 doffed the gloves, but did not perform hand hygiene prior to exiting the resident's room. Additionally, upon returning to the nurses' station, RN #7 did not perform hand hygiene prior to touching the computer's keyboard. Observation, on 06/30/2022, revealed CNA #16 was standing in the hall near the 200 hall nurses' station, but was not wearing a mask. The CNA was holding the mask in her hand while talking to co-worker, Restorative CNA #7. Observation, of the 200 Hallway, on 06/30/2022, revealed RN #8 was standing at the medication cart across from room [ROOM NUMBER], with her mask dangling from her right ear. The mask was not covering the nurse's nose or mouth. The findings include: Review of the facility's policy titled, Infection Control, revised 03/10/2020, revealed the purpose of an Infection Prevention and Control (IPC) program was to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable disease and infections. Continued review of the policy revealed the IPC program helped to prevent, detect, investigate, and control the spread of infections to residents, staff, and visitors in the facility. Per policy, IPC objectives ensured standard precautions were used by all staff to include following hand hygiene protocols and transporting of linen to prevent the spread of infection. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 03/10/2020, revealed hand hygiene/hand washing was the single most effective means of preventing transmission of infection from one person to another. Facility personal were required to wash their hands after each direct or indirect resident contact, for which hand washing was indicated by acceptable standards of practice. Hand hygiene should be performed after touching inanimate sources that are likely to be contaminated, between resident contacts, between tasks and procedures to prevent cross contamination, and when otherwise indicated to avoid transfer and microorganisms to other residents and environments. Review of the facility's policy titled, Standard Precautions, revised 03/10/2020, revealed the purpose of the policy was to reduce the risk of transmission of microorganisms for both recognized and unrecognized sources of infection in the facility. Per policy, staff was to wash hands after touching bloody body fluids, secretions, excretions and contaminated items, and between residents. Per policy, good hand hygiene was essential to prevent the spread of infection. Further review of the policy, revealed linens must be handled and transported in a manner that prevents contamination and avoids the transfer of microorganisms to other residents and environments. Review of the facility's policy titled, Cleaning and Maintenance of Equipment, revised 03/10/2020, revealed equipment in the facility will be cleaned and disinfected according to the manufacturer's recommendations. Resident care equipment will be cleaned and disinfected between resident uses. Further review of the policy revealed equipment will be cleaned of surface material by using soap and water and then decontaminated with an Environmental Protection Agency (EPA) approved disinfectant. Review of the facility's policy titled, Linen Handling, revised 03/10/2020, revealed all linen should be considered contaminated. When soiled, linen should be handled as little as possible and with minimum agitation to prevent microbial contamination of the air and of the staff handling the linen. Additionally, linen should be bagged or placed in containers at the location where it was used. Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, reviewed 01/08/2021, revealed hand hygiene reduced the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Continued review revealed there were multiple opportunities for hand hygiene to occur during a single care episode. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when hands were visibly soiled, and before preparing or handling medications. 1. Observation of the 200 Hall, on 06/28/2022 at 6:22 AM, revealed Certified Nursing Assistant (CNA) #2 took a rolling vital sign machine into room [ROOM NUMBER]. She used the blood pressure (BP) cuff and pulse oximeter monitor on Resident #85, then failed to clean and disinfect the equipment prior to entering Rooms 218 and room [ROOM NUMBER]. CNA #2 used the same contaminated shared equipment to obtain vital signs and oxygen saturation levels for Residents #21, #34, #57, and #68. Interview with CNA #2, on 06/28/2022 at 6:47 AM, revealed she had worked at the facility for three (3) months. CNA #2 stated she cleaned the BP cuff, and pulse oximeter monitoring equipment after taking all the vital signs on the floor. She stated she used purple top disinfectant wipes. that were located at the nurses' station. She further stated housekeeping was responsible for cleaning the actual rolling machine. Further interview revealed CNA #2 received IPC training related to Personal Protective Equipment (PPE), hand hygiene, and transmission based precautions (TBP), upon hire. She stated she was unaware of a facility policy stating shared equipment should be cleaned between each resident use. However, she stated it was important to clean shared equipment to prevent the spread of infection. Interview with Licensed Practical Nurse (LPN) #6, on 07/02/2022 at 2:51 PM, who worked the 200 Hall, revealed CNAs were responsible for cleaning shared equipment at the end of the shift using Super Sani-Cloth Germicidal Wipes. LPN #6 stated, upon hire she received IPC training related to PPE, hand hygiene, and TBP, but she was not aware of a facility policy to ensure shared equipment was cleaned between each resident use. She further stated cleaning and disinfecting shared equipment was important to prevent the spread of infection. Interview with LPN #5, on 07/02/2022 at 3:35 PM, revealed she was an agency nurse and usually worked the 200 Hall when assigned at the facility. She stated she received IPC training through her agency prior to her orientation at the facility, which included hand hygiene, PPE use, and TBP. Per interview, shared equipment needed to be cleaned and disinfected with an EPA approved cleaner between each resident use. She stated the facility used the purple topped wipes pointing to a container labeled as Super Sani-Cloth Germicidal Wipes. 2. Observation of room [ROOM NUMBER], on 06/28/2022 at 6:40 AM, revealed bilevel positive airway pressure (BiPAP) tubing and mask lying directly on Resident #82's bedside table. The tubing and mask were not stored inside the storage bag. Interview with CNA #4, on 07/02/2022 at 3:03 PM, revealed the BiPAP tubing, and face mask should be stored in a clean bag and put away in the bedside drawer when not in use. She further stated storing equipment properly helped prevent germs from spreading. Interview with LPN #5, on 07/02/2022 at 3:35 PM, revealed nursing staff was responsible to store respiratory equipment in the storage bag after use. According to LPN #5, an oxygen supply company came to the facility once weekly and was responsible for managing all respiratory supplies, including changing of oxygen filters, masks, humidifier bottles, and all tubing. 3. Observation of room [ROOM NUMBER], on 06/28/2022 at 6:43 AM, revealed one (1) clear plastic trash bag containing dirty sheets, towel and gown on the floor. Interview with the Unit Coordinator (UC), on 06/28/2022 at 6:45 AM, revealed she did not know why the bag of dirty linens was left on the floor. She stated staff was trained to place the dirty linen in a clear plastic trash bag, tie the bag closed, immediately take the bag to the dirty utility room and place it in the appropriate laundry container. She further stated placing contaminated linen on the floor was a breach in infection control practices. Per interview, she needed to talk to staff and provide education. 4. Observation of room [ROOM NUMBER], on 06/28/2022 at 6:51 AM, revealed Resident #56's indwelling urinary catheter drainage bag was attached to the bed frame and the bottom half portion, including the pour spout section, was touching the floor. Interview with LPN #6, on 07/02/2022 at 2:51 PM, revealed indwelling urinary catheter drainage bags should never rest on the floor as this was an infection control issue. Per interview, if she saw a urinary drainage bags bag on the floor, she would change out the collection bag, and call housekeeping to clean the floor. Interview with CNA #13, on 07/02/2022 at 3:25 PM, revealed urinary drainage bags should never rest on the floor as this was an infection control issue and could cause cross contamination. Further, she would alert the nurse if she found a urinary drainage bag on the floor. 5. Observation on 06/28/2022 at 7:20 AM, revealed CNA #2 and CNA #3 assisted Resident #97 into his/her wheelchair using a Hoyer lift. After using the Hoyer lift, CNA #3 wheeled the lift out into the hall. CNA #3 failed to clean the lift prior to placing it outside the room into the hallway to be used for other residents. Interview with CNA #3, on 06/28/2022 at 7:30 AM, revealed shared equipment such as Hoyer lifts were cleaned using a Super Sani-Cloth Germicidal Wipe at the end of the shift and she was unaware of the need to clean shared equipment after each resident use. However, she stated cleaning shared equipment was important to prevent the spread of infection 6. Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including Dementia. Further review revealed the resident was on Contact Precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in a wound. Observation of room [ROOM NUMBER], on 06/28/2022 at 7:20 AM, revealed there was a sign on the door, stating contact precautions. However, further observation revealed there were no gowns available for staff to use in the PPE storage bin. Observation, on 06/28/2022 at 7:25 AM, revealed CNA #1 was in room [ROOM NUMBER], providing care to Resident #15, wearing a resident's gown. CNA #1 took the gown off and placed it into a plastic bag. She then walked across the hall and entered the clean side of the Laundry Room, and placed the bag in the dirty laundry bin. Interview with Certified Nursing Assistant (CNA) #1, on 06/28/2022 at 7:30 AM, revealed she had to use the resident's gown because there weren't any disposable gowns available in the PPE bin located on the outside of the door. When asked if the facility was out of gowns, she stated, No, and further stated she should have gone and obtained PPE supplies prior to entering the room, but did not. CNA #1 revealed she bagged the gown in a clear plastic bag and took it to the laundry room and informed the laundry staff the bag held contaminated linen. She further stated she should have walked the bagged linen to the dirty utility room on the unit and placed it in the linen bin. Continued interview revealed transporting and disposing of linen according to facility policy would prevent the spread of germs to residents and staff. Observation, on 06/28/2022 at 8:00 AM, of the clean supply room, revealed there was an ample supplies of PPE available for staff. Interview with the Laundry/Housekeeper, on 07/01/2022 at 10:01 AM, revealed the Laundry Room had two (2) doors. One door led to the dirty area, where soiled linen was brought to be washed, and the other door led to the clean area, where clean linen was dried and folded. She stated staff was to bag all soiled linen inside of the residents' rooms and dispose of the tied bag in the appropriate laundry hampers located in the dirty utility rooms on each unit. Per interview, staff was not to walk into the laundry area with bagged linen, but stated, a lot of them do because it's closer than walking down the hall. She further stated entering the clean area of the laundry room with soiled linen, even bagged linen, could cause the spread of infection. 7. Observation of Receptionist #1, on 06/29/2022 8:00 AM, revealed her mask was below her nose when checking in surveyors and staff. Interview with Receptionist #1, on 06/29/2022 at 9:30 AM, revealed everyone who entered the building must wear a mask while in the facility. She stated her mask slipped down when she talked. She further stated it was important to wear PPE properly to prevent the spread of infection.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all drugs and biological's were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Observation of a medication pass revealed Registered Nurse (RN) #1 left a bottle of Flonase Nasal Spray on top of the medication cart in the hallway unattended. The findings include: Review of the facility's policy, titled Medication Storage, not dated, revealed the medication cart would be locked at all times, when not under the direct physical supervision of a licensed nurse or medication aide. Observation of a medication pass, on 10/09/19 at 9:00 AM, revealed RN #1 turned over a cup of medication on top of the medication cart which contained a narcotic, and left the medication cart to find another nurse to destroy the narcotic. RN #1 left a Flonase Nasal Spray she had prepared to administer sitting on top of the medication cart unattended. Interview with RN #1, on 10/09/19 at 10:30 AM, revealed she was aware she should not have left the medication on top of the medication cart unattended. Interview with the Director of Nursing (DON), on 10/11/19 at 8:38 AM, revealed she expected the nurse not to leave medication sitting on top of the medication cart unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled, Handwashing Procedure, last revised September 2014 revealed staff should wash their hands: 1. When reporting to work and before going home 2. Before and after contact with residents 3. After coming in contact with any body fluids 5. After handling contaminated items (soiled incontinent briefs, linens, trash, etc) 6. Before and after eating or drinking 7. After using the bathroom 8. After smoking 9. After coughing, sneezing, or blowing your nose 10. Whenever your hands are obviously soiled Record review revealed Resident #223 was admitted to the facility on [DATE] with diagnoses which included Persistent Vegetative State related to Anoxic Brain Damage and a history of Urinary Track Infections (UTI's). Observation of incontinent care on 10/09/19 at 1:01 PM performed by CNA #7 and CNA #8 revealed CNA #7 removed the resident's soiled brief, provided peri care, and was assisted by CNA #8. The two CNA's washed their hands and applied gloves. CNA #7 performed peri care, front and back using the proper technique. The two CNA's then preceded to apply a clean brief and adjust the cover without washing their hands and applying clean gloves. Interview with the CNA #7 and CNA #8 on 10/09/19 at 1:10 PM, revealed the CNA's realized they did not wash their hands or change their gloves prior to replacing the clean brief, and knew they should have. Interview with Charge Nurse/LPN #2 on 10/09/19 at 1:20 PM revealed when asked what should have been done different during peri care, she looked puzzled and was unable to answer. Interview with Unit Manager/LPN #3 on 10/09/19 at 1:25 PM revealed the CNA's should have changed gloves and washed hands prior to providing a clean brief and bed clothing. Interview with the Director of Nursing (DON) on 10/11/19 at 08:48 AM revealed she expected all staff to wash their hands and change gloves when going from dirty to clean. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-eight (28) sampled residents and (1) unsampled resident (Residents #37 and #223). Observation revealed Licensed Practical Nurse (LPN) #1 dropped a glove on the floor and picked it up and used it to administer medications through Resident #37's G-Tube; and, observation of Resident 223's peri care revealed two (2) Certified Nurse Aides (CNAs) failed to wash their hands and change gloves during the care. The findings include: Review of the facility's policy titled, The Infection Prevention and Control Program, last revised 01/22/18, revealed the infection prevention and control program of this facility was designed to establish and maintain an effective program that provided a safe, sanitary and comfortable environment and attempted to prevent the development and transmission of diseases and infections. The objectives of the program were to provide hand hygiene procedures to be followed by staff involved in direct patient contact. 1. Observation of a G-Tube medication pass for Resident #37, on 10/08/19 at 3:45 PM, revealed LPN #1 dropped a glove on the floor and picked it up and used it rather than replacing it with a clean one before administering medications to the G-Tube. In addition, she did not wash her hands after she picked up the contaminated glove. Interview with LPN #1, on 10/08/19 at 4:00 PM, revealed she should not have used the contaminated glove. LPN #1 stated she should have washed her hands after picking up the contaminated glove, and obtained a new glove prior to the medication administration. Interview with the Director of Nursing (DON), on 10/11/19 at 8:38 AM, revealed she expected the nurse to not have used a contaminated glove to administer the G-Tube medication or any medication. The DON stated she would have washed her hands and used a clean glove prior to the medication administration.