**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a personal funds statement was provided quarterly for 1(Resident #55) of 2 Residents (Resident #30 and Resident #55) reviewed for personal funds out of a total sample of 19 Residents. Findings: Review of the Facility's Policy titled Accounting and Records of Resident Funds read in part: Policy statement-Our facility maintains accounting records of resident funds on deposit with the facility. 5. Individual accounting records are made available to the resident through quarterly statements and upon request. Review of Resident #55's Medical record revealed she was admitted to the facility on [DATE], with diagnoses that included in part . Cerebrovascular Accident, Hypertension, Type 2 Diabetes Mellitus, and Depression. Review of Resident #55's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/15/2023 revealed Resident #55 had a BIMS (Brief Interview for Mental Status) of 11 (moderately impaired cognition). Resident #55 answered all questions appropriately. Interview with Resident #55 on 05/07/2023 at 10:10 a.m. revealed the facility managed her money. Resident #55 stated she was admitted to the facility approximately 6 months ago and had not received an account statement. Observation on 05/08/2023 at 8:00 a.m. revealed Resident #55 awake, alert and oriented. Resident #55 stated she had no family and her husband (Resident #30) was not able to manage her money. Resident #55 stated the facility managed her money. Resident #55 stated she was able to get money from the office whenever she needed to purchase cigarettes. Resident #55 stated she had not received an account statement since she was admitted to the facility and would like to know how much money was in her account. Interview on 05/08/2023 at 9:07 a.m. with S3 Business Office Manager stated Resident #55's finances were managed by the facility. S3 Business Office Manager stated resident account statements were printed and mailed out quarterly to the resident(s) responsible party. She stated Resident #55 had no family and was her own responsible party. She stated Resident #55's quarterly statement was printed; placed in a folder; filed in the facility's business office; and not hand delivered to her. She stated she was not aware that she had to issue a quarterly statement to Resident #55 since the resident came and asked about her account balance. S3 Business Office Manager confirmed that Resident #55 was not provided with a quarterly financial statement and should have been.

Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week for 5 of 92 days reviewed for RN staffing hours. This deficient practice had the potential to affect all 60 Residents residing in the facility, according to the facility's Resident Census and Conditions Form. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1 - December 31, revealed the submitted weekend staffing data was excessively low. Review of the Time Card Report for 10/01/2022 - 10/31/2023 revealed the following: On 10/08/2023 the RN time card revealed 8.05 hours, and according to interview with S1 ADM, the RN actually worked 7.55 hours; on 10/09/2023 the RN time card revealed 8.27 hours, and according to interview with S1 ADM, the RN actually worked 7.77 hours; on 10/16/2023 the RN time card revealed 7.5 hours, and according to interview with S1 ADM, the RN actually worked 7.0 hours; and on 10/30/2022 the RN time card revealed 8.18 hours, and according to interview with S1 ADM, the RN actually worked 7.68 hours. Review of the Time Card Report for 12/01/2022 - 12/31/2022 revealed the facility RN worked 7.38 hours on 12/25/2022, and according to interview with S1 ADM, S8 RN worked 2.38 hours and S2 DON worked 5.0 hours. Interview on 05/08/2023 at 10:34 a.m. with S1 ADM revealed the facility required the RN to provide coverage for 8.5 hours per day for 7 days per week, with the 0.5 hours indicating a required unpaid 30 minute lunch break. S1 ADM revealed he pays the nurses for the exact hours worked. S1 ADM stated that the Time Card Report for the 10/2022 and 12/2022 time frame does not include the 30 minutes of time that is deducted from the nurse's lunch break time. S1 ADM confirmed the facility did not have RN coverage for 8 consecutive hours per day for 7 days per week; and the weekend RN hours provided were less than required 8 hours on 10/08/2022, 10/09/2022, 10/16/2022, 10/30/2022 and 12/25/2022. S1 ADM stated the One Star Staffing will trigger on the PBJ when RN coverage of 8 hours is not provided for 2 days in a quarter. Interview on 05/08/2023 at 1:30 p.m. with S1 ADM confirmed the Facility had not provided the minimum required hours on 10/08/2022, 10/09/2022, 10/16/2022 and 10/30/2022 and 12/25/2022 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure garbage and refuse was properly contained as evidenced by one dumpster lid not closed. Findings: Observation upon arrival to the facility on [DATE] at 7:45 a.m. revealed the facility's dumpsters were clearly visible by the surveyor from the road as the surveyor drove up to the facility. One of the two dumpsters was not properly contained and was open at the time of observation. The surveyor asked the owner of the nursing facility on 05/07/2023 at 8:57 a.m. the best way to go to the dumpsters. S4 CNA Supervisor was in the office at the time of the conversation with the owner. Observation on 05/07/2023 at 9:00 a.m. revealed the surveyor observed S7 Dietary Manager pushing S5 Kitchen Staff through the dining room door that lead to the outside where the dumpsters were located. The surveyor exited the dining room door immediately behind S5 Kitchen Staff and witnessed S5 Kitchen Staff closing one of the two flaps on the dumpster. The Surveyor asked S5 Kitchen Staff what was he doing, and he stated he had just closed one of the flaps on the dumpster. S5 Kitchen Staff stated the dumpster was open prior to him closing the flap. Observation at that time revealed the other flap to the dumpster remained open. Interview with S7 Dietary Manager on 05/07/2023 at 10:00 a.m. confirmed she instructed S5 Kitchen Staff to go and close the dumpster. Interview with S5 Kitchen Staff on 05/07/2023 at 10:05 a.m. revealed S7 Dietary Manager instructed him to close the dumpster, and confirmed that one of the two dumpsters were not properly contained.

Based on observation and interview the facility failed to provide a safe environment to help prevent the development and transmission of communicable diseases and infections by failing to screen all visitors entering the facility. This had the potential to affect all residents in the facility. Findings: Review of the facility policy titled Coronavirus Disease (COVID-19) - Visitors revealed the following including: Policy Statement For the safety of residents and staff, visitation policies during the COVID-19 public health emergency (PHE) are in compliance with current recommendations from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services Policy Interpretation and Implementation 1. Residents are permitted to receive visitors of their choice as long as: a. Visitors will be asked to use the front entrance. b. Core Principles of COVID-19 prevention and best practices to reduce COVID-19 transmission are adhered to at all times Observation conducted on 05/08/2023 at 8:45 a.m. in Area 1 revealed a man enter the facility through a door from the outside at the end of the hall and go into Resident #2's room. S6 LPN followed him into the room and was asking questions about Resident #2. Interview on 05/08/2023 at 8:49 a.m. with S6 LPN confirmed the visitor entered the Facility without being screened. S6 LPN stated he was not supposed to do this. At this time another visitor entered the Facility through the same door and was stopped by S6 LPN and instructed to go through the front door. The visitor ask through the front door or through the front, front door by the office? S6 LPN instructed her to enter by the office so she could be screened. Interview on 05/08/2023 at 8:55 a.m. with S2 DON revealed all visitors to the facility should be screened prior to entering the building. She stated all doors in the Facility require codes to obtain entrance. She stated the codes have been changed, but visitors learn them and enter the building without being screened. She confirmed the visitor should have entered the facility through the entrance door by the offices so that screening could have been done.

Based on interview and record review, the facility failed to ensure that alleged violations of staff to resident physical abuse were reported to the State Survey Agency within 2 hours for 2 (Resident #2 and Resident #5) of 6 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6). Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revealed in part . Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #2 Review of Resident #2's clinical record revealed an admit date of 05/03/2021 with diagnoses that included: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Generalized Anxiety Disorder, and Vascular Dementia without Behavioral Disturbance. Review of Resident #2's Quarterly MDS with an ARD of 10/19/2022 revealed a BIMS score of 10, indicating moderate cognitive impairment. Resident #2 required one person physical assist with dressing, toilet use, personal hygiene, and bathing. Review of a document titled Continuous Quality Improvement Corrective Action Plan revealed in part . Date: 07/09/2022 1. Problems Identified: Resident #2 complained of a CNA grabbing her by the throat and pushing her on the bed. Review of Resident #2's Incident Witness Statement revealed in part Date/Time: 07/09/2022 10:42 a.m. Statement: Resident #2 I was getting up and she grabbed me by my throat and pushed me back down on the bed. Resident #2 states the CNA held her neck down for a little while. Review of a progress note for Resident #2 documented by S7 LPN on 7/09/2022 at 1:27 p.m. revealed in part . Late entry 9:30 a.m. - Resident reported to this nurse that she was getting up to go take her bath and S8 CNA grabbed her by the neck and pushed her on the bed. Interview on 10/31/2022 at 2:57 p.m. with S1 ADM revealed he was not at the facility when Resident #2 complained of S8 CNA grabbing her by the throat and pushing her on the bed. S1 ADM reported he was not notified of the allegation immediately. S1 ADM confirmed he did not report the allegation of abuse to the State Survey Agency, but should have. Resident #5 Review of Resident #5's clinical record revealed an admit date of 03/17/2021 with diagnoses that included: Acute on Chronic Combined Systolic and Diastolic Heart Failure; Type 2 Diabetes Mellitus with Neuropathy; Unspecified Psychosis not due to a substance or known physiological condition; and Pain. Review of Resident #5's Quarterly MDS with an ARD of 10/12/2022 revealed a BIMS score of 14, indicating intact cognition. Resident #5 required two plus persons physical assist with toilet use and one person physical assist with bed mobility, transfer, unit, dressing, personal hygiene and bathing. Review of an Incident Report for Resident #5 revealed in part . Date of Incident: 10/25/2022 Time of Incident: 8:30 p.m. If injury occurred, describe type of injury and body part involved: Noted small bruise to resident's left hand 0.2 cm x 0.3 cm light purple in color and between left middle and ring finger light green/yellow 0.3 cm x 0.2 cm. Description of the incident: Resident states that when nurse tried to take her medicine from her on 10/25/2022, the nurse tried to take the medicine out of her hand and that is what caused the bruise. Interview on 11/02/2022 at 11:20 a.m. with S1 ADM revealed he received a text message on 10/25/2022 from S6 PTA that Resident #5 wanted him to call, so he called to see what was going on. S1 ADM reported Resident #5 told him S3 LPN forcefully pried medication out of her hand. S1 ADM reported he called S2 DON to go to facility to do investigation since she lived closer. S1 ADM confirmed he did not report the allegation of abuse to the State Survey Agency, but he should have within 2 hours of the allegation.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #46 and #69) of 23 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly changed, labeled and stored. Findings: Facility's Policy on Oxygen Administration reads in part .Essential points: Nasal cannula or mask and oxygen tubing must be dated and changed every seven days and PRN. The humidifier container will be refilled every 7 days or PRN with distilled water. The container must be dated when distilled water is changed or added. Resident #69 Record review of Resident #69's Medical Record revealed resident had a diagnoses of Chronic Obstructive Pulmonary Disease and received Ipratropium Bromide/Albuterol Sulfate 0.5/3MG/3ML vial (breathing treatment). Give one vial by mouth per nebulizer three times a day. Interview and observation on 05/09/2022 at 1:51 p.m. revealed Resident #69's nebulizer mask was stored inside a Ziploc bag with a date of 04/29/2022 on it. Resident stated he used the nebulizer for his breathing treatments. Observation on 05/10/2022 at 8:46 a.m. revealed Resident #69's nebulizer mask was stored inside a Ziploc bag with a date of 04/29/2022 on it. Interview and observation on 05/10/2022 at 12:07 p.m. with S2 DON in attendance revealed Resident #69's nebulizer mask lying on his bedside table, stored in a Ziploc bag with a date of 04/29/2022 on it. S2 DON stated the date of 04/29/2022 was the date the respiratory equipment was last changed. S2 DON confirmed the nebulizer mask should be changed every 7 days and PRN and it had not been. Resident #46 Review of Resident #46's Care Plan dated 03/23/2022 revealed resident returned from the hospital with a diagnoses of Pneumonia. Interventions included: Oxygen at 2 liters per nasal cannula continuously and check oxygen saturation every shift and notify the doctor if less than 92%. Interview and observation on 05/09/2022 at 10:10 a.m. revealed Resident #46 in bed with oxygen per nasal cannula in nostrils. The oxygen tubing was running through a Ziploc bag lying on the floor with a date of 04/26/2022 on it. The humidifier bottle was not dated. Observation on 05/10/2022 at 11:15 a.m. revealed Resident #46 in bed with oxygen per nasal cannula in her nostrils. The oxygen tubing was running through a Ziploc bag lying on the floor with a date of 04/26/2022 on it. The humidifier bottle was not dated. Interview and observation on 05/10/2022 at 12:11 p.m. with S2 DON in attendance revealed Resident #46 in bed with oxygen per nasal cannula in her nostrils. The oxygen tubing was running through a Ziploc bag lying on the floor with a date of 04/26/2022 on it. The humidifier bottle was not dated. S2 DON stated the date of 04/26/2022 was the date the respiratory equipment was last changed. S2 DON confirmed the respiratory equipment should be changed every 7 days and PRN and it had not been.

Based on interview and record review the facility failed to ensure medications were available to be administered as ordered for 1 (#31) of 23 sampled residents. Findings: Review of the facility policy titled Medication Orders and Receipt Record revealed in part 4. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Review of Resident #31's clinical record revealed an admit date of 09/03/2021, with diagnoses that included: Hemiplegia and Hemiparesis following cerebral infarct affecting left non-dominant side, COPD, Hyperlipidemia, Hypertension, GERD without Esophagitis,and Constipation. Interview on 05/09/2022 at 1:34 p.m. with Resident #31 revealed she was not receiving her medications the way she needed to. She stated the facility ran out of her medications often and just last week she was told the facility was out of her Linzess. Review of the resident's May 2022 MAR revealed an order to give Linzess 145mcg capsule one by mouth every day. The medication administration was noted documented as (N) on 05/07/2022 and 05/08/2022 by S10 LPN. Further review of the MAR documentation revealed Linzess 145mcg capsule was documented as not available on 05/07/2022 and 05/08/2022 by S10 LPN. Telephone interview on 05/10/2022 at 11:12 a.m. with S10 LPN revealed she did not have Resident #31's Linzess to administer on 05/07/2022 or 05/08/2022. She stated she did not call the DON nor did she reorder the medications herself. She stated S11 LPN told her that she would reorder the medication. Review of the facility's pharmacy reorder fax transmission log revealed Resident #31's Linzess had not been reordered until 05/09/2022 at 12:22 p.m. by S11 LPN. Interview on 05/10/2022 with S2 DON revealed medications should be reordered when the resident has 1 week of medication remaining which is color coded in blue on the medication cards received from pharmacy. She stated nurses are supposed to call her if there is a medication needed that is not available on the weekend and they are then directed to call the on call pharmacy so the medication can be delivered the same day. Further interview revealed she was not notified that Resident #31's Linzess was not available for administration on 05/07/2022 or 05/08/2022 and should have been. She confirmed the resident's Linzess was not reordered until 05/09/2022 and was not available for administration on 05/07/2022 and 05/08/2022 and should have been.

Based on observation and interview the facility failed to ensure garbage was disposed of properly. Findings: Observation on 05/09/2022 at 9:30 a.m. of the facility's trash receptacles accompanied by S4 Dietary Manager revealed two large blue dumpsters. The lid to both dumpsters were open. The dumpster closest to the kitchen door was overflowing with trash. There was debris and dirty gloves on the ground in front of the dumpster. S4 Dietary Manager confirmed the dumpster was too full and the lids should be closed. S4 Dietary Manager further confirmed there was debris and dirty gloves on the ground in front of the dumpster closest to the kitchen and it should not have been. Interview on 05/11/2022 at 1:14 p.m. with S1 Administrator revealed trash is picked up once a week. He stated the lids being left open to the dumpsters had been an ongoing problem.

Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to provide clean bath linens that were in good condition for resident use in the facility and by failing to ensure 1 (Resident #49) of 23 sampled residents had space to store his personal belongings. Findings: Observation on 05/10/2022 at 6:54 a.m. revealed a facility CNA removing linen from a linen cart on a hall in the facility. Observation of the cart at that time revealed approximately 4 towels and 3 washcloths. The towels had dark stains on them, and were dingy, and the washcloths were threadbare and ragged. Interview on 05/10/2022 at 7:32 a.m. with S5 LPN confirmed the towels and washcloths on the above linen cart were stained and ragged. S5 LPN stated that the facility had recently bought new linens, but someone must have pulled these from the old batch of towels and washcloths. Interviews conducted on 05/10/2022 at 2:00 p.m. during the Resident Council meeting revealed Resident #48 stated that staff were using rags that had been cut from towels as washcloths, and that some of the linens were stained and were not washed well. She stated that some of the rags (washcloths) smelled like feces and the residents were expected to use these. Resident #44 agreed. Observation on 05/11/2022 at 9:15 a.m. of the clean linen closet in the hall near the nurses' station revealed 2 linen carts. Observation of the linen on one of the carts revealed 1 of 4 towels badly stained. Interview with S8 CNA revealed the linens on the cart were for residents use. S8 CNA confirmed the towel was badly stained, she pulled the towel from the cart and stated this should not be used on residents. Interview on 05/10/2022 at 9:00 a.m. with S6 Laundry Manager and S7 Laundry Worker revealed they pull stained and discolored towel/linens and discard them when doing laundry. S6 Laundry Manager confirmed items should not have been on the cart. Interview on 05/11/2022 at 9:30 a.m. with S1 Administrator confirmed there was a problem with the amount of linen in the facility. S1 Administrator confirmed that staff were having to cut washcloths from towels, so the facility had gone to local stores and purchased towels and washcloths. S1 Administrator stated that the facility had changed companies for purchase of linens and the order from the current company was on backorder, and has since arrived. Resident #49 Interview and observation on 05/09/2022 at 9:47 a.m. with Resident #49 revealed resident had one armoire filled with clothes and clothes folded and placed on the floor near the foot of his bed. Resident #49 stated his roommate had all the space in the room. Observation on 05/10/2022 at 8:50 a.m. revealed Resident #49's clothes were still on the floor near the foot of his bed. Interview and observation on 05/11/2022 at 8:50 a.m. with S9 CNA in Resident #49's room confirmed the clothes on the floor belonged to Resident #49. S9 CNA stated she did not know why his clothes were on the floor. Interview and observation on 05/11/2022 at 9:00 a.m. of Resident #49's room with S3 SSD in attendance revealed resident's clothes on the floor near the foot of his bed. S3 SSD stated Resident #49 had moved into that room last week and his dresser should have been moved too. SSD confirmed Resident #49's clothes should not have been on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Findings: Observation on 05/09/2022 at 9:00 a.m. accompanied by S4 Dietary Manager revealed: 1. A box of hamburger patties open and undated in freezer #2 2. A pack of [NAME] open and undated in freezer #2. 3. A container of barbecue sauce open and undated on pantry shelf. 4. A container of creamy cole slaw dressing open and undated on pantry shelf. 5. Pantry shelf littered with wasted mashed potato flakes from a Ziploc bag with a hole in it. Interview at the time of observation with S4 Dietary Manager revealed the staff who opens a food item should label and date it. S4 Dietary Manager confirmed the above listed items were not dated and they should have been and the pantry shelf was littered with flakes of mashed potatoes and it should not have been.