Based on facility policy, record review, and interview, the facility failed to notify the State Agency after potential abuse concerns were identified, failed to investigate allegations of potential abuse, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 1 of 4 incidents reviewed for abuseFacility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property last revised 10/2018 states Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. Under Section E: Investigation, Subsection A. Investigation of Abuse When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with assistance of appropriate personnel. The investigation will include: who was involved .resident statements . For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident. Complete an evaluation of resident behavior, affect and response to interaction, and documentation . Resident's roommate statements .involved staff and witness statements of events .A description of the resident's behavior and environment at the time of the incident . Injuries present including a resident assessment . Observation of resident and staff behaviors during the investigation .Environmental considerations. On 8/21/24 the Division of Licensing and Certification received a facility reported incident in which a Certified Nursing Assistant (CNA) #4 reported by way of a written letter on 8/19/24, that on 8/18/24 she witnessed the following: between 8:30 a.m. to 9:00 a.m., CNA #5 brushed Resident #31's hair, did not stop when he/she stated ouch. CNA #4 stated you are hurting him/her be easy, CNA #5 then stated, watch this and brushed Resident #31's hair again causing the resident more pain. CNA #5 proceeded to laugh and apply blue hair dye to the ends of Resident #31's hair. When the resident left the area, CNA #5 stated I don't like him/her. Around 12:30 p.m.- 12:45 p.m., CNA #4 observed CNA #5 transfer Resident #25 to his/her bed with a stand and pivot machine, the bed was not at appropriate level at the time, causing the resident to cry out in pain upon transfer. Per the letter Resident #25 voiced he/she did not want CNA #5 to provide him/her care. CNA#5 proceeded to climb into bed with Resident #25 and lay down with him/her. Resident #25 proceeded to freak even more stating get away from me and don't touch me. Resident #25 then attempted to hit CNA #5, but the CNA grabbed the resident's hand and proceeded to move it like a car shifter. CNA #4 told CNA #5 to leave the room, CNA#5 got up out of the bed and took the residents glasses away. Around 12:50 p.m.- 1:00 p.m., CNA #4 and CNA #5 were getting Resident #4 changed in bed. Resident #4 rolled toward CNA #5 and hit his leg, CNA #5 stated don't touch my privates. Resident #4 stated he/she did not touch him there and felt CNA #5 was upset with him/her. CNA #4 needed to provide reassurance. Review of the facility investigation lacked evidence that the abuse allegations were reported immediately by CNA #4, the facility failed to report the allegations of abuse to the State Agency within 24 hours, failed to conduct a thorough investigation, and failed to report the results of the investigation within 5 days of the incident. On 7/8/25 at 9:20 a.m., during an interview, the above information was confirmed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 1 sampled resident reviewed for PASRR (Resident #14).Review of Resident #14's Minimum Data Set 3.0 (MDS) revealed an Annual Comprehensive Assessment, dated 11/14/24 that indicates an active primary diagnosis of Dementia and an active diagnosis of Post-Traumatic Stress Disorder (PTSD). Resident #14's most recent Quarterly MDS, dated [DATE], also includes an active diagnosis of mood disorder and indicates Resident #14 exhibited Physical behavioral symptoms directed towards others and Verbal behavioral symptoms directed toward others.Resident #14's Care Plan, last reviewed 5/8/25 revealed, . at risk for alteration in thought process r/t [related to] use of psychoactive medication for management of depression, PTSD, and mood d/o [disorder] . and .at risk for anxiety/behaviors, decreased psychosocial well-being and increased isolation related to PTSD, depression, and mood d/o . Further record review revealed a pre-admission Notice of PASRR Level I Screen Outcome, dated 11/15/22, that indicated Level II screening was not required and states, No mental health diagnosis is known or suspected .There are no known mental health behaviors .no known recent or current mental health symptoms . and lacked evidence that a new screen was submitted for the above diagnoses and symptoms. On 7/8/25 at 11:43 a.m., during an interview, the Director of Social Services stated tracking updated diagnoses and behavioral changes is a team approach with the Director of Nursing (DON) and sometimes the MDS Coordinator, and that it is discussed in the facility's daily morning meeting. After reviewing Resident #14's diagnoses, the Director of Social services stated Resident #14 needs an updated PASRR screening and that she does not even recall the resident being discussed for having mental health diagnoses. On 7/8/25 at approximately 12:00 p.m., the above finding was discussed with the DON. At this time, the DON stated Resident #14 does need a new PASRR, and she will initiate the screening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of respiratory care for 2 of 5 residents reviewed for respiratory needs (#45 and #10) and in the area of accidents for 1 of 1 reviewed for falls (#43).1. Review of Resident #45's medical record stated he/she was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease with acute exacerbation and obstructive sleep apnea requiring the use of Continuous positive airway pressure (CPAP) machine and nebulizers. The medical record lacked evidence that a comprehensive care plan had been developed in the area of a respiratory to include the use of the CPAP and nebulizer. On 7/8/25 at 10:12 a.m., during an interview the above was discussed with the Director of Nursing 2. On 7/7/25 at 9:27 a.m., a surveyor observed Resident #10 wearing oxygen via nasal cannula with the oxygen concentrator set at 3 liters.On 7/8/25 at 1:07 p.m., a surveyor observed Resident #10 asleep and wearing oxygen via nasal cannula with the oxygen concentrator set at 2.5 liters.A review of Resident #10's medical record revealed a physician's order, dated 8/22/24 for Oxygen (O2) at 2 liters per minute via nasal cannula without humidification. May use as needed for complaints of cluster headaches (effective historically per resident).A review of Resident #10's current care plan, dated 6/23/25, did not include Resident #10's use of oxygen.On 7/8/25 at 1:33 p.m., in an interview with the [NAME] President of Quality Improvement & Nursing Services, the surveyor discussed the observations of Resident #10 and that the care plan did not include the use of oxygen as per physician orders. 3. On 6/26/25 the Department of Licensing received a complaint indicating Resident #43 had a lot of falls and had a fall mat on the wrong side of the bed. Review of Resident #43's medical record included a diagnoses of dementia, vertigo, anxiety, osteoporosis, and a history of fall with fracture. The current care plan last updated on 5/8/25, lacked evidence to include use of a floor mat as an intervention. On 7/7/25 at 1:25 p.m., observation of Resident #43 to have a fall matt on the right side of bed. On 7/7/25 at 3:30 p.m., during an interview, the Director of Nursing confirmed Resident #43 used a fall mat and stated it should be care planned.

Based on observation, record review and interview, the facility failed to ensure a care plan was accurately revised for 1 of 2 residents reviewed for intravenous (IV) antibiotic use and transmission-based precautions (Resident #24).On 7/7/25 at 10:16 a.m., a surveyor observed Resident #24 receiving an IV infusion of the antibiotic Vancomycin. Resident #24 stated he/she had an infection of the right leg and was receiving 2 IV antibiotics. A review of Resident #24's clinical record noted a history of MRSA (methicillin resistant Staphylococcus aureus), a multidrug resistant organism, and recurrent lower extremity cellulitis. The record noted Resident #24 had been treated with IV antibiotics in May, 2025. The record noted on 6/25/25, Resident #24 had a PICC (peripherally inserted central catheter) line placed at the local hospital and was started on IV vancomycin and cefepime. A review of Resident #24's current care plan, last revised on 6/19/25, included the problem area: risk for infection. Resident #24's need for IV antibiotics was not included in the care plan. One intervention stated use standard precautions unless otherwise indicated. On 7/9/25 at 9:30 a.m., a surveyor observed an Enhanced Barrier Precautions sign had been placed on Resident #24's door. This replaced a previous sign which stated see nurse for instructions.On 7/9/25 at 10:00 a.m., in an interview with a surveyor, the Nurse Manager stated Resident #24 frequently receives IV antibiotics for recurrent wound infections.On 7/9/25 at 12:30 p.m., in an interview with the Director of Nursing, the surveyor discussed that the current care plan had not been revised to address Resident #24's need for IV antibiotics. In addition, the care plan instructed staff to use standard precautions, while a sign on the resident's door advised of the need for Enhanced Barrier Precautions. The Director of Nursing confirmed that Contact Precautions were indicated while Resident #24 was being treated for an active infection.

Based on observations, record review, and interviews, the facility failed to ensure that the resident's environment was free of accident hazards by failing to maintain a clutter-free pathway in the resident's room for 1 of 1 sampled resident reviewed for accidents (Resident #14).On 7/7/25 at 9:02 a.m. and 7/8/25 at 8:33 a.m., a surveyor observed a clear plastic bag containing two siderails, located on the floor next to Resident #14's bed, two wheelchair footrests and multiple pairs of shoes on the floor next to Resident #14's recliner, and a pair of shoes on the floor in front of the recliner. A review of Resident #14's most recent Fall Risk Screen, dated 4/30/25, indicated he/she is at high risk for falls. Review of Resident #14's care plan, updated 5/8/25, includes, .at risk for falls .keep environment free from clutter and pathways clear of obstacles, and .frequently incontinent .implement safety measures (keep path to bathroom clear and well lit .), and .ability to see in adequate light is impaired .Keep areas free of obstructions to reduce the risk of falls or injury . On 7/8/25 at 9:48 a.m., a surveyor and the Director of Nursing (DON) observed the siderails, footrests, and shoes on Resident #14's floor. The DON stated Resident #14 gets out of bed and transfers himself/herself to the chair at times and the environment was cluttered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book [a logbook used to record medication] Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts on 2 of 3 units observed for medication storage (Embden and [NAME] Control log).1.On 7/7/25 at 8:35 a.m. a review of Embden and [NAME] unit control log with Certified Nursing Assistant/Medication Technician (CNA-M) #3 revealed the following: -control log lacked evidence of oncoming signature during the day shift on 7/4/25 at 06:00, on 6/6/25 at 06:00, on 6/10/25 at 06:00, on 6/27/25 at 06:00, on 6/24/25 at 14:00, and on 6/29/25 at 14:00. -control log lacked outgoing signature on 6/27/25 at 18:00, on 6/29/25 at 22:00, on 6/6/25 at 1:30 p.m., on 6/10/25 at14:00, on 6/11/25 at 11:00, on 6/27/25 at 22:00, on 6/30/25 at 18:00, and on 6/29/25 at 22:00.At this time CNA-M #3 stated that everytime the keys are handed over at the end of shift, the incoming and outgoing staff are supposed to sign the narcotic count book.On 7/7/25 at 9:07 a.m., the above was discussed with Director of Nursing

Based on observations, record reviews, and interviews, the facility's quality assurance committee failed to ensure that the Plan of Correction (PoC) for identified deficiencies from the Recertification Survey, dated 7/9/25, were implemented/effective. The facility remains non-compliant with deficiencies F0695 (Respiratory Care), F0755 (Pharmacy Services/Procedures/ Pharmacist/Records), and F0880 (Infection Prevention & Control) which were recited at the re-visit survey on 9/9/25.Findings: 1. On 07/09/25 during the Long-Term Care Survey process (LTCSP), a deficiency was cited at F0695 for the failure to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care. The facility's plan of correction for F0695, signed on 8/7/25, indicated that education regarding Cpap, Bipap, oxygen and nebulizer storage will be provided to nursing staff by August 18th, 2025. 2. On 07/09/25 during the Long-Term Care Survey process (LTCSP), a deficiency was cited at F0755 for the failure failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book [a logbook used to record medication] Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts. The facility's plan of correction for F0755, signed on 8/7/25, indicated that Nursing staff education will be provided, education regarding correct counting procedures by August 18th, 2025. The DNS or designee will auditor narcotic count log weekly for 12 weeks. 3. On 07/09/25 during the Long-Term Care Survey process (LTCSP), a deficiency was cited at F0880 for the failure to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to conduct ongoing surveillance, tracking and educations to prevent the spread of Infections, failed to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). The facility's plan of correction for F0880, signed on 8/7/25, indicated that the nursing staff will receive education regarding Enhanced Barrier Precautions (EBP) and correct Personal Protective Equipment (PPE) by August 18, 2025. On review of the education given on 8/7/25, only 20 out of 40 nursing staff received the education. On 9/9/25 at 4:00 p.m., during an exit interview with three surveyors present, the Administrator, the [NAME] President of Clinical Services and the Director of Nursing, a surveyor discussed that the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, and that education was received by staff. Deficient practices were identified at the time of the revisit, after the PoC's anticipated date of compliance.

Based on record review and interview, the facility failed to ensure a resident who had elected to receive a Pneumococcal immunization received the immunization, for 1 of 5 resident records reviewed for immunizations (Resident #25)Review of Resident #25's clinical record revealed a signed Immunization Consent Form, dated 7/24/24, indicating Resident #25's legal representative consented to the Pneumococcal immunization. Further review of the clinical record lacked evidence that Resident #25 received or refused the Pneumococcal immunization.On 7/9/25 at 12:52 p.m., during an interview with two surveyors, the Infection Preventionist stated the Director of Nursing handles immunization tracking. On 7/9/25 at 12:57 p.m., two surveyors reviewed the above findings with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 4 Wings (Lakewood, Embden, [NAME]) and the common area/hallway for 2 of 3 days of survey.1. On 7/7/25 at 9:14 a.m., and on 7/8/25 at 8:11 a.m., observation of room [ROOM NUMBER]B to have trash/debris including tissues, a pen, papers, food and a sticky layer of a dried substance under the bed. 2. On 7/8/25 from 2:41 p.m. through 2:58 p.m., an environmental tour was conducted with Director of Nursing and the Maintenance Director for which the following was observed:Lakewood unit:- room [ROOM NUMBER]A had a stained ceiling tile above the bed and marred wallpaper at the head of the bed- room [ROOM NUMBER]'s windowsill had chipped paint and was separated from the brick below the window. - room [ROOM NUMBER]'s windowsill had chipped and peeling paint.- The hallway near room [ROOM NUMBER] and 108 had several cracked tiles spanning the width of the hallway. Embden unit:- room [ROOM NUMBER] the cabinet door below the sink has a chunk of missing laminate and the wall next to the bathroom has a large area of marred wall with exposed sheetrock.- The hallway railing had chipped and peeling paint on the wood. - The shower room had several missing tiles around the drain; the edge caulking is brown and orange in color with rust and multiple broken tiles along the shower perimeter. [NAME] Unit:- room [ROOM NUMBER]'s bathroom ceiling tiles above the toilet appear dirty/stained and chipped.- room [ROOM NUMBER]'s heater cover was off exposing the sharp metal fins. The common area across from the nurse's station has multiple areas of marred walls exposing sheetrock. The right corner of the nurse station wall has missing laminate exposing raw wood. The dining room entrance door panel has missing plastic with exposed wood leaving sharp edges, 2 stained ceiling tiles and multiple windowsills with chipped and peeling paint.On 7/8/25 at 2:58 p.m., the Director of Nursing and Maintenance Director confirmed the above concerns.

Based on observations, record reviews, interviews and the facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 4 of 5 residents reviewed for respiratory care (Resident #45, #151, #29 and #35). In addition, the facility failed to ensure physician orders were followed for 1 of 5 residents receiving oxygen therapy (Resident #10)Oxygen use & Storage Policy last revised on 6/25 states under respiratory care A Sanitary environment must be maintained to prevent the transmission of disease and infection. A. Nasal Cannula's will be discarded and changed every 2 weeks. The respiratory set up bag will be labeled with resident's name and the date the equipment was changed or the date changed can be directly labeled on the cannula with a piece of tape. When the nasal cannula is not in use, on both the concentrator and portable tank, the cannula will be stored in a plastic bag to avoid the risk of it becoming contaminated.B. Nebulizer parts should be rinsed after each use, allowed to air dry while being covered with a paper towel and placed in respiratory set up bag once dried. Respiratory set-ups for nebulizers will be changed every 2 weeks. Nebulizer filters will be rinsed every 2 weeks and changed on a monthly basis.D. Staff changing the tubing should document on the Treatment Administration Record (TAR) when the tubing has been changed following this policy.E. When the tubing is changed, the filter in the concentrator must also be removed and rinsed off to ensure the filter remains free from dust.Continuous positive airway pressure (CPAP)/ Bilevel positive airway pressure (BIPAP) Management policy last revised on 6/25 states under Daily Cleaning RecommendationsMask and/or nasal pillows wash in warm soapy water, allow to air dry, out of direct sunlight or wipe down with a recommended CPAP wipe. Once completed, place clean equipment into plastic bag. Water chamber empty any remaining water after treatment. 1. On 7/7/25 at 10:01 a.m., and on 7/8/25 at 8:11 a.m., observations of Resident #151's nasal cannula with foam protectors taped to the tubing, unlabeled and stored on the bedside dresser. Review of the medical record lacked evidence of nursing changing the nasal cannula every 2 weeks. 2. On 7/7/25 at 9:20 a.m., and on 7/8/25 at 8:11 a.m., observations of Resident #45's nebulizer pipe and tubing, unlabeled and stored on top of the bedside dresser and a Continuous positive airway pressure (CPAP) mask draped over the CPAP machine. There was no respiratory set up bag for storage observed.Review of Resident #45's Treatment Administration Record lacked evidence of the changing and/or cleaning of the Nebulizer tubing/pipe and CPAP mask.On 7/8/25 at 10:12 a.m., during an interview, the above was observed and confirmed with the Director of Nursing (DON).On 7/8/25 at 2:58 p.m., an additional observation of Resident #45's CPAP mask draped over the machine and hanging between the wall and the bedside dresser. At this time, it was again confirmed with the DON 3. On 7/7/25 at 9:27 a.m., a surveyor observed Resident #10 wearing oxygen via nasal cannula with the oxygen concentrator set at 3 liters.On 7/8/25 at 1:07 p.m., a surveyor observed Resident #10 asleep and wearing oxygen via nasal cannula with the oxygen concentrator set at 2.5 liters.A review of Resident #10's medical record revealed a physician's order, dated 8/22/24 for Oxygen (O2) at 2 liters per minute via nasal cannula without humidification. May use as needed for complaints of cluster headaches (effective historically per resident).A review of Resident #10's Treatment Administration Records (TAR) for June and July, 2025, noted no documentation for the use of oxygen, though the oxygen tubing was changed every 2 weeks per facility policy.On 7/8/25 1:33 p.m., in an interview with the [NAME] President of Quality Improvement & Nursing Services, the surveyor discussed the observations of Resident #10 and the lack of documentation for Resident #10's oxygen use. The [NAME] President of Quality Improvement and Nursing Services confirmed the findings did not reflect the physician's order and stated she would clarify the correct order at this time. 4. On 7/7/25 at 9:03 a.m. and on 7/8/25 at 10:15 a.m., observation of Resident #29's unbagged nebulizer mask and tubing on the bedside table dated 1/21. Review of Resident #29's clinical record indicated an active physician order for Albuterol Sulfate Inhalation Nebulization Solution 2.5 mg/3 mL (0.083 %) with directions to use every 6 hours as needed. Review of the medication administration record/treatment administration record indicated that his/her last time using the nebulizer was on 5/26/25.On 7/8/25 at 10:15 a.m., the above information was confirmed with the DON. 5. On 7/7/25 at 8:57 a.m. and on 7/8/25 at 8:26 a.m., Resident #35's unbagged nebulizer mask was observed hanging on the nebulizer machine on his/her nightstand. Review of Resident #35's active physician orders revealed an order for, ipratropium 0.5mg-albuterol 3mg (2.5mg base)/3mL .Nebulization As Needed . Review of Resident #14's Treatment Administration Record lacked evidence of when the nebulizer tubing has been changed. On 7/8/25 at 9:56 a.m. a surveyor observed Resident #35's unbagged nebulizer mask with the DON. At this time, the DON stated after a nebulizer treatment is administered, the mask should be rinsed and air dried, then stored in a bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked for 1 of 1 medication refrigerator reviewed (nurses station), and failed to ensure controlled medications were stored appropriately for 1 of 3 medication carts observed (Embden and [NAME] medication cart), in addition, the facility failed to ensure treatment carts were locked when unattended on 1 of 1 unit ([NAME] Chase [NAME] Unit) for 1 of 3 days of survey.1. During a review of Embden and [NAME] medication cart with Certified Nursing Assistant/Medication Technician (CNA-M) #3 on 7/7/25 at 8:35 a.m., CNA-M #3 confirmed the cart contained controlled medications and proceeded to open the metal box with a lock on the top, using her pinky fingernail, sticking it under the lid and popping the lid open. The metal box contained approximately 15 cards of controlled medications. At this time, CNA-M #3 stated she did not close the lid all the way, which would engage the lock and she should have. 2. During an observation of medication storage refrigerator with Registered Nurse (RN) #2 on 7/7/25 at 8:42 a.m., 4 boxes of liquid Lorazepam were observed in the bottom draw of the refrigerator, not in a permanently fixed compartment. At this time RN #2 stated this is her first day at the facility, and she thought it was odd that the controlled medications weren't in a fixed compartment but had not asked about it yet. On 7/7/25 at approximately 2:45 p.m., the above was discussed with the Director of Nursing. 3. On 7/7/25 at 9:41 a.m., a surveyor observed an unlocked and unattended treatment cart on the [NAME] Chase [NAME] Unit, at this time the surveyor opened the treatment cart, which contained multiple vials of insulin, blood thinners, and Narcan. Approximately 3 minutes later, the surveyor observed Registered Nurse #3 coming out of room [ROOM NUMBER] where she was then made aware of the unlocked and unattended treatment cart. On 7/7/25 at 10:11 a.m. the above information was discussed with the Director of Nursing.

Based on observations, record review and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors and walls for 1 of 3 days of survey (7/7/25) and failed to monitor refrigerator, freezer and the steam table/tray line temperatures for 3 of 4 months reviewed.1. On 7/7/25 from 8:33 a.m. to 9:00 a.m., a surveyor conducted a kitchen tour with the Food Service Director in which the following findings were observed and confirmed: -There was trash and food debris on the floor under the equipment and around the edges of the floor.-The first-floor food storage room had a hole in the wall exposing sheetrock, making the surface uncleanable. -In the kitchen by the fire extinguisher there was exposed sheetrock, making the surface uncleanable.2. On 7/8/25 a surveyor reviewed the facilities Freezer and Refrigerator Temperatures Form which indicates temperatures are to be taken in the morning and at night. Further review showed the following missing temperatures: May 2025:- The diet kitchen freezer and refrigerator showed 5 out of 31 days missing. - The dairy cooler, upright freezer, and chest freezer showed 8 out of 31 days missing.- The bread freezer showed 9 out of 31 days missing.- The true freezer showed 4 out of 31 days missing.- The upright refrigerator (veg) showed 10 out of 31 days missing.- The dietary refrigerator showed 6 out of 31 days missing.- The cooks freezer showed 1 out of 31 days missing.- The cooks refrigerator showed 2 out of 31 days missing.April 2025:-The Bread freezer, true freezer, upright freezer, chest freezer, and upright refrigerator showed 8 out of 30 days missing. - The dairy cooler showed 9 out of 30 days missing. - The dietary refrigerator showed 11 out of 30 days missing. 3. On 7/8/25 a surveyor reviewed April 2025 through June 2025 facilities Steam Table and Tray Line Temperature Record which indicates temperatures are to be taken 3 times daily with meals. Further review showed the following missing meal temperatures: - Breakfast 26 out of 91 days are missing. - Lunch 26 out of 91 days are missing. - Dinner 41 out of 91 days are missing. On 7/8/25 at 12:30 p.m., the above was reviewed and confirmed with the Food Service Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to conduct ongoing surveillance, tracking and educations to prevent the spread of Infections, failed to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP), and failed to develop and implement elements of a Legionella Water Management Program. This has the potential to affect all 47 residents.Infection Control: Multidrug-Resistant Organism (MDRO's) policy, last revised 4/18/24 states Enhanced Barrier Precautions (EBP): gowns and gloves are worn during high-contact resident care activity. Examples of high-contact activity are: Preforming ADLS (activity of daily living) - bathing, dressing, transfers and toileting. Providing device care and/or wound care. Device are would include central lines, catheters . Under procedure states, Residents being treated for an active MDRO infection will be placed on Contact precautions. Residents who have competed treatment for MDRO's will then be placed on Enhanced Barrier Precautions (EBP). Gloves and Gowns will be used when preforming high-contact care activities. 1. On 7/7/25 at 9:14 a.m., observation of Resident #45's room door with a small Stop see nurse for instructions sign posted on the door frame, no directions on what Personal Protective Equipment (PPE) to utilize prior to entering the room. Directly inside the room was a cart containing Personal Protective Equipment (PPE). Resident #45 was receiving an Intravenous (IV) antibiotics via a peripherally inserted central catheter (PICC) line. At this time, the resident stated he/she has an infection in the wound on the coccyx which requires daily dressing changes and is followed by infectious disease. On 7/8/25 at 8:11 a.m., an additional observation of resident #45's room to have only a stop see nurse for instructions sign posted on the door frame. There were no additional directions on what type of precautions or what PPE to wear prior to going into the room. Review of the medical record confirmed he/she has a diagnosis of an unstageable coccygeal pressure ulcer with osteomyelitis containing Methicillin-resistant Staphylococcus aureus (MRSA) and Extended-Spectrum Beta-Lactamases (ESBL) Klebsiella, both a Multidrug - Resistant Organism (MDRO's) with an active order for a dressing to the coccyx wound daily. On 7/8/25 at 2:58 p.m., both the Director of Nursing (DON) and the Surveyor observed Resident #45 room to have the small Stop see nurse for instructions sign on the door frame. The surveyor asked the DON what precautions were needed and why when caring for resident #45. The DON stated, he/she is being treated for an active infection involving MDRO's and contact precautions should be utilized when providing wound care and enhanced barrier precautions when providing IV care. At this time, the surveyor asked why the precaution is not posted and which precaution is to be used, being that they are 2 very different types i.e., Contact requires appropriate PPE when entering the room while EBP requires PPE using gowns and gloves during specific high-contact resident care activities. The DON did not have an answer. On 7/9/25 at 11:14 a.m., observation of Resident #45's room to now have an EBP sign posted on the door instructing staff to use gloves and gowns when performing high-contact resident care activities. At this time, Registered Nurse (RN #1) stated he/she is on EBP for both the wound and the IV line, has an active infection and is on 2 different antibiotics to treat 3 different bugs since admission. The surveyor asked what organism or bug he/she is being treated for. RN #1 stated, I'm not sure, one is MRSA, I think. The surveyor asked what type of precautions he/she should be on while being treated for an MDRO. RN#1 stated, EBP and originally I had put [resident #45] on contact precautions when [he/she] came to us and she is not sure why or when it was changed. At this time, the surveyor discussed the facilities policy of when a resident has an active MDRO infection, they are to be Contact precautions. RN #1 did not have response. 2. On 7/7/25 at 10:23 a.m., and on 7/8/25 at 10:20 a.m., observation of Resident #47 to have bilateral feet wrapped in kerlix and wearing orthopedic shoes. At this time in an interview, he/she confirmed both feet had surgical wounds which required dressing changes.Review of the medical record states Resident #47 was admitted [DATE] with diagnosis of chronic osteomyelitis resulting in amputation of toes on both feet and surgical wounds requiring treatments every other day. In addition, he/she has a stage 2 pressure ulcer on the right hip requiring treatment three times daily. The room lacked notification/posting of Enhanced Barrier Precautions and available personal protective equipment. 3. On 7/7/25 at 9:14 a.m., a surveyor observed a small red and white Stop, See Nurse for Instructions sign on Resident #16's door frame. There was no Personal Protective Equipment (PPE) outside or inside the room, and there was no additional signage on the door. At this time, Certified Nurse Medication Aide (CNA-M) #3 was exiting the room, and a surveyor asked about the sign. CNA-M #3 stated the sign indicates precautions, but she is not sure what type of precautions this resident is on because today is her first day back as agency staff. On 7/7/25 at 10:53 a.m., during an interview, Registered Nurse (RN) #2 stated today is her first day at the facility and she is agency staff and is not sure if Resident #16 is on precautions. RN #2 then checked Resident #16's clinical record and stated Resident #16 has MRSA (methicillin-resistant staphylococcus aureus), and that she is not sure where PPE is located but thinks she was told in the closet next to the nurses' station. On 7/7/25 at 2:14 p.m., during an interview, CNA #1 stated today is her first day as a permanent staff member and that she is not sure if any residents on the [NAME] unit are on precautions and that she was not told where to find PPE but that she is training with CNA #2. On 7/7/25 at 2:52 p.m., during an interview, CNA #2 stated no residents on the [NAME] unit are on EBP or TBP and that there are gowns in the linen closet and trash cans in the supply closet, and trash cans get put in front of the door for residents on precautions. On 7/7/25 at 2:58 p.m., during a follow-up interview, CNA-M #3 stated she worked here as an agency staff member from December 2024-June 2025, and typically, residents have the red and white Stop signs hanging outside the door but no signage is posted indicating what type of precautions the resident is on, and if a resident on precautions, a trash can and a 3-drawer bin with gowns and gloves is placed outside the door. CNA-M #3 then stated residents with Foley catheters or wounds are not placed on EBP and that there are no residents on the [NAME] unit on EBP or TBP but she knows Resident #14 has a foot wound and Resident #7 has a Foley catheter. 4. Review of Resident #14's clinical record indicated Resident #14 has a right lateral midfoot diabetic ulcer. Further record review revealed an active physician order for Right lateral foot Cleanse wound for at least 1 minute Apply Medihoney to wound bed .Apply Mepilex .Dressing change daily . On 7/8/25 at 8:30 a.m., a surveyor entered Resident #7 and Resident #14's shared room, and there was no Stop sign or other signage on the door and no PPE outside or inside the room. At this time, Resident #7 stated he/ she has a Foley catheter, and when the Certified Nursing Assistants (CNAs) empty the drainage bag or the nurses change the catheter, they wear gloves but he/she has not noticed anyone wearing a gown or other PPE. On 7/8/25 at 1:08 p.m.-1:45 p.m., during an interview, the above concerns were discussed with the DON and Infection Preventionist (IP), and the DON stated Stop signs are placed outside a resident's door but no signage indicating what type of precautions or what type of PPE is required is placed on the resident's door. The surveyor asked how new staff are educated on infection control upon hire, as CNA #1, CAN-M #3, and RN #2 were day 1 staff on the [NAME] unit yesterday and could not tell a surveyor the location of PPE or if residents were on precautions and what type. The DON then stated Infection Control education is provided as part of a comprehensive orientation, but that does not take place on day 1 and is provided within the first week of employment. At this time, a surveyor requested additional evidence of the facility's ongoing surveillance and tracking for EBP and TBP and evidence of staff education on infection control measures. Review of the provided Educational Program Sign-In Sheet .Topic: Infection Control Enhanced Barrier Precautions, dated 6/24/25 indicates 23 staff members attended, and of those, only 9 were nursing staff (8 CNAs, IP). Review of the provided f Enhanced Barrier Precautions surveillance census was dated 7/9/25 (after survey start date) and indicates 10 residents in the facility are on EBP. The census did not indicate Resident #14 and Resident #47 were on precautions, despite a surveyor previously discussing this with the DON and IP.On 7/9/25, at 12:03 p.m., during a follow-up interview with the DON, a surveyor discussed concern with recent EBP education only including 9 nursing staff and no evidence of EBP/TBP surveillance prior to the survey. The DON stated she posts a monthly calendar of mandatory annual training offerings, but if all required staff does not attend, she posts another calendar the following month offering the training again. At this time the DON confirmed the facility did not have ongoing EBP and TBP surveillance, tracking, and education in place. 5. Review of policy, Legionnaires Prevention Program Policy, dated 7/19, states, .Establish a water management team .The following employees will be on the Water Management Team . The Administrator .The Infection Control Specialist .The Maintenance Director .Corporate Plant Manager .Describe Your Building Water Systems Using a Flow Diagram .Identify Areas Where Legionella Could Grow & Spread on the flow diagram .Decide where Control Measures should be applied & how to monitor them .You will need to monitor to ensure your control measures are performing as designed Staff, residents and their representatives will be informed of the in place to keep the building water systems safe. A copy of the plan will be shared upon request . Further review of the policy lacked evidence of the description of the water system or a flow diagram and did not specify control measures or how the control measures are being monitored.On 7/8/25 at 1:08 p.m., during an interview with the Director of Nursing (DON) and Infection Preventionist (IP), a surveyor requested evidence of the facility's water management program. The DON stated she had asked the Administrator about water testing but could not provide a written plan.On 7/9/25 at 2:01 p.m., during a follow-up interview and after multiple surveyor requests, the DON stated she could not provide evidence of the facility's Legionella Water Management Program.

Based on record review and interview, the facility failed to ensure that a resident's choice in the area of bathing was followed for 1 of 3 sampled residents [Resident #1 (R1)]. Finding: On 12/11/24 at 12:30 p.m., during an interview with a surveyor, R1 stated he/she had not been offered a shower since they broke their leg. R1 stated my hair is long overdue for a washing. On 12/11/24, clinical record review indicated R1 fell from a Hoyer lift resulting in a fracture to the left leg on 11/20/24. R1 had a brief interview for mental status (BIMS) score of 15 on 12/2/24, which indicates the resident is cognitively intact. The care plan states, [R1] has a self care deficit related to [Multiple Sclerosis (MS)] as evidenced by residents inability to perform [activities of daily living (ADLs)] without assist. The orthopedic provider signed orders on 12/4/24 stating 1. Continue [left] knee brace, may remove for hygiene and 2. May transfer [from] bed to chair with brace in place as comfort allows. The record lacked evidence that the resident was offered, provided, or refused a shower after 11/20/24. On 12/11/24 at 1:55 p.m., during an interview, a surveyor and the Director of Nursing reviewed R1's clinical record. At this time the surveyor confirmed the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure a care plan was updated in order to meet the physical needs of a resident for 1 of 2 residents reviewed during a complaint investigation [Resident #1 (R1)]. Finding: R1 was admitted on [DATE] with a diagnosis of Multiple Sclerosis (MS). On 11/20/24 R1 experienced a fall from a Hoyer lift resulting in a fracture of the left knee. The provider order dated 11/21/24 states wear left knee immobilizer as tolerated. On 12/4/24, the orthopedic physician signed an order stating (1) Continue [left] knee brace, may remove for hygiene. (2) May transfer [from] bed to chair with brace in place as comfort allows. (3) While in chair should have [left] leg supported. (4) Strictly [non weight bearing] on [left] leg. (5) [follow-up] 4 weeks for re-[check] xray. On 12/11/24, review of R1's care plan indicated, [R1] has a self care deficit related to MS as evidenced by residents inability to perform [activities of daily living (ADLs)] without assist. The surveyor was unable to locate a care plan for the management of a left knee fracture or use of a knee immobilizer. On 12/11/24 at 1:55 p.m., during an interview with a surveyor, the Director of Nursing stated the knee immobilizer should be addressed in the care plan. At this time the surveyor confirmed the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy, the facility failed to ensure care plans were updated/implemented for 2 of 3 residents reviewed during a complaint investigation. Findings: 1. Resident #1 was admitted to the facility on [DATE], with diagnoses including: history of heart attack; cerebral infarction; hemiplegia and hemiparesis; dysphagia; and morbid (severe) obesity. Review of Resident #1's care plan, updated 5/2/24, states, Interventions: Supervision/assistance is required at meal and snack times. Open all items .cut into small pieces . Review of Resident #1's active orders, dated October 2024, revealed diet order dated 6/14/24 for, Consistent carbohydrate, regular texture, continuous. Further review of Resident #1's clinical record lacked evidence of the need to cut food into small pieces. During an interview with 2 surveyors, on 10/28/24 at 10:41 a.m., Director of Nursing (DON) stated it was her expectation that a resident's care plan should reflect their personal goals and interventions because they are supposed to be individualized. DON further stated that Resident #1 does not have his/her food cut up and is unsure why it's in his/her care plan. At this time, DON reviewed Resident #1's care plan and confirmed his/her care plan was last reviewed on 8/1/24 and should not include cut into small pieces. 2. Resident #2 was admitted to the facility on [DATE], with diagnoses including dementia; dysphagia. Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 4 out of 15, indicating he/she is not cognitively intact. Review of Resident #2's care plan, updated 9/26/24, states, .uses upper dentures (partial)- assist him with cleaning and putting them in daily as tolerated and as needed . During a lunch observation on 10/28/24 at 12:05 p.m., Certified Nursing Assistant (CNA) 1 was observed providing feeding assistance to Resident #2 in the dining room. Resident #2 did not appear to be wearing any dentures. At this time a surveyor asked CNA 1 if Resident #2 was wearing dentures. CNA 1 indicated that Resident #2 was not wearing dentures but knows Resident #2 has them because there's a cup for them in his/her room. CNA 1 stated Resident #2 doesn't really wear them anymore. During an observation of Resident #2's room on 10/28/24 at 3:37 p.m., CNA 2 confirmed that she has never put dentures in for Resident #2. At this time, CNA 2 located an empty denture cup labeled [Resident #2] in a drawer by the sink. During an interview with 2 surveyors on 10/28/24 at 3:23 p.m., DON confirmed Resident #2 has not been wearing his/her dentures for a while and will ensure the care plan is updated appropriately. Review of facility policy, Comprehensive Person-Centered Care Planning, dated January 2019, states, The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with Resident Rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy, the facility failed to assess a resident for self-administration of medications (Resident #20). Review of facility policy Self-Administration of Medications dated 11/28/16 states .Facility . should assess and determine, . whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition .To ensure safe and appropriate Self-Administration, Facility should educate residents to ensure that a resident is able to; State the name, dose, strength, frequency, and purpose for use of his/her medications; Understand the possible side effects of his/her medications and that he/she should notify Facility staff if he/she experiences any such side effects; correctly administer .his/her medications . Facility should ensure that orders for Self-Administration list the specific medication(s) the resident may Self-Administer Facility should document in the Self-Administration of medications in the residents care plan Review of Minimum Data Set (MDS) dated [DATE] reveled Resident #20 had a Brief Interview for Mental Status (BIMS) of 12 of 15 indicating [he/she] moderate impairment. On 4/16/24 at 6:41 a.m., two surveyors observed Resident #20 lying in bed, a small medication cup containing vitamin D3, lopid (cholesterol medication), ferrous sulfate (iron), allopurinol (gout medication), Vitamin C, garlic oil, milk [NAME], senna and pantoprazole (9 pills). Resident #20 indicated I can't take my pills until I've had my breakfast. Review of entire clinical record lacked evidence that a self-administration assessment was completed for Resident #20. On 4/16/24 at 7:43 a.m., during an interview, CNA-M#2 indicated that Resident #20 likes to take [his/her] medications after breakfast so they leave them at bedside. On 4/17/24 on 10:05 a.m., during an interview, LPN#1 indicated that medications should not be left at bedside. On 4/17/24 at 10:08 a.m., during an interview, CNA-M#3 indicated Resident #20 likes to take [his/her] medications after breakfast but they don't leave them at bedside. On 4/17/24 at 10:56 a.m., during an interview, DNS indicated that a resident needs to have an order and an evaluation to self-administer medications. DNS further indicated that medications are not to be left at Resident #20's bedside. At this time, the above findings were confirmed.

Based on interviews and record review, the facility failed to follow a resident's schedule for bathing and to ensure that a resident has a choice about his/her care in the area of bathing for 1 of 1 resident (Resident #11). On 4/17/24 at approximately 10:00 a.m. ,during an interview with a surveyor, Resident #11 voiced his/her frustration that he/she has not been receiving his/her showers on a weekly basis. Further, Resident #11 stated he/she prefers a whirlpool twice a week because it helps make his/her joints feel better and helps with his/her chronic pain. On 4/17/24, a surveyor reviewed the facility's Whirlpool & Shower List which indicates the resident is scheduled to have a shower and/or whirlpool on Wednesday during the day shift. In a review of the resident's electronic bath record from 3/1/24 through 4/17/24 indicates that resident had a shower on 3/27/24 and 4/10/24. The resident did receive a bed bath on the days a shower and/or whirlpool was not provided. On 4/17/24, at approximately 11:30 a.m., during an Interview, the Director of Nurses (DON) confirmed the above findings. In an interview with the Licensed Practical Nurse, (LPN), Minimum Data Set Coordinator (MDS Coordinator) he/she stated that the care plan should be updated to reflect Resident #11's preferences for bathing. Further, she stated when a resident refuses bathing/and or a shower, the refusal should be reported to the charge nurse as to the reason of the Resident's refusal so that it can be documented. On 4/17/24, at approximately 2:15 p.m., the LPN, MDS Coordinator confirmed that these concerns will be addressed, and the care plan will be updated.

Based on observation, record review and interviews, the facility failed to ensure the resident representative was notified of an injury of unknown origin and failed to follow its own Notification of Changes policy and procedure for 1 of 1 sampled resident reviewed for injury of unknow origin (Resident #9). Findings: The Facilities Notification of Changes policy and procedure, developed September 2018 states, The nurse will immediately notify the resident, residents physician and the residents representatives for the following: An accident involving the resident, which results in injury and has the potential for requiring physician intervention and The nurse will notify the resident, resident physician and the resident representatives for non immediate changes of condition on the shift the changes occurs unless otherwise directed by the physician. On 4/16/24 at 7:15 a.m., observations were made of Resident #9 to have purple bruising around his/her left eye. At this time in an interview, surveyor asked how the bruise was obtained, Resident #9 stated, I don't know, while touching his/her face. The residents medical record contains a face sheet which indicates Resident #9 has a family representative and an Advanced Directive that was signed by the resident representative on 4/18/18. Review of nursing documentation dated 4/15/24 at 5:58 a.m., states, Resident woke up this morning with a large bruise under [his/her] left eye of unknown origin and a note on 4/15/24 at 2:03 p.m., states, I went to see [Resident] due to staff stating he/she was fine when he/she went to bed last night and this am has a left superficial bruise under his/her eye, no bruising in or around the eye more on his/her upper cheek toward eye. No swelling or documented falls. [Resident] does have a habit of sitting in his/her recliner and falling asleep with bedside table being on that side of him/her. Will monitor when in chair. When I asked [Resident] what happened to his/her eye he/she replied, I don't know it happened yesterday complaints of no pain. On 4/16/24 at 8:46 a.m., during an interview, the Director of Nursing (DON) stated she was made aware of Resident #9's bruise yesterday in the morning. The surveyor requested the state reportable incident for the injury of unknown origin. On 4/16/24 at 9:26 a.m., the DON provided the surveyor with the State reportable incident form which indicated N/A for the family/guardian notification. On 4/16/24 at 10:06 a.m., in an additional interview, the DON was asked why the state reportable incident for the injury of unknown origin, states N/A for the family/resident representative notification. The DON stated, the resident doesn't have any family then stated, the resident representative never comes in to see the resident but she will attempt to call the representative now. On 4/16/24 at 10:22 a.m., during an interview with the Licensed Social Worker she confirmed Resident #9 has a representative however, when they try to contact the representative, they leave a voice message but do not get a return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related linen handling, urinary collection devices for 3 of 3 days of survey on 2 of 3 units ([NAME] and Lakewood). Findings: 1. The facility's Linen Handling Policy notes under handling laundry: Soiled linen is considered to be potentially contaminated and standard precautions will be used when being handled. Gloves will be worn when handling soiled linens. Linens will be bagged (a pillowcase may be used) at the point of collection (resident room) and then soared linens are transported to laundry bins. On 4/16/24 at 7:23 a.m., a surveyor observed Certified Nursing Assist (CNA) #4 carrying soiled linen on the [NAME] unit from resident room [ROOM NUMBER] to the soiled utility room. CNA #4 was not wearing gloves and the linen was not bagged as per the facility's Linen Handling Policy. At this time, CNA #4 confirmed that she had transported the linen to the soiled linen room unbagged and that she was not wearing gloves. On 4/16/24 at 9:20 a.m., the surveyor discussed the finding with the Director of Nursing (DON). 2. On 4/17/24 at 8:11 a.m., and on 4/18/24 at 8:27 a.m., observation of Lakewood Unit, room [ROOM NUMBER]/108 shared bathroom had a urinal hanging on the side of the trash can next to the toilet. This was discussed with the Administer on 4/18/24 at 10:34 a.m. 3. On 4/16/24, 4/17/24, and 4/18/24., observation of [NAME] Unit, room [ROOM NUMBER]/425 shared bathroom had an unlabeled bed pan and an unlabeled urinal stored on the floor beside the toilet. On 4/18/24 at approximately 9:30 a.m., in an interview with a surveyor, the Director of Nurses confirmed the above observations did not support good infection control practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 6 of 6 residents reviewed for advanced directives (Resident's #7, #23, #27, #39, #304 and #306). Findings: Review of facility policy Advanced Directive Policy and Procedure dated 10/18 states POLICY .Upon admission, the facility will inform and provide the resident/and/or resident's representative with information about advanced directive. PROCEDURE: Upon admission, identify if the resident has an advance directive and if not, determine if the resident wished to formulate an advance directive . All advance directive document copies will be obtained and located in the resident's medical record . 1. Resident #7 was admitted to facility on 3/5/19 with diagnoses to include multiple sclerosis. Review of annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) of 14 of 15 indicating he/she is cognitively intact. Review of Resident 7's clinical record lacked evidence that the facility provided resident/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 4/17/24 at 9:00 a.m. Resident #7 indicated that he/she doesn't remember ever being asked or offered an advanced directive. 2. Resident #23 was admitted to facility on 7/18/23 with diagnoses to include cerebral infarction, morbid obesity and the presence of a cardiac pacemaker. Review of Resident 23's clinical record lacked evidence that the facility provided resident/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 4/17/24 at 9:30 a.m., Resident #23 indicated that he/she doesn't remember ever being asked any questions regarding an advanced directive. 3. Resident #27 was admitted on [DATE] with diagnoses to include vascular dementia, and depression. Review of admission MDS dated [DATE] revealed Resident #27 had a BIMS of 5 of 15 indicating that he/she is cognitively impaired. Review of Resident #27's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. 4. Resident #39 was admitted to the facility on [DATE] with diagnoses to include multiple myeloma, and atrial fibrillation. Review of quarterly MDS dated [DATE] revealed Resident #39 had a BIMS of 14 of 15 indicating he/she is cognitively intact. Review of Resident #39's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. 5. Resident #304 was admitted on [DATE] with diagnosis to include diabetes mellitus, major depressive disorder, and post-traumatic stress. Review of admission MDS dated [DATE] revealed Resident #304 had a BIMS of 4 of 15 indicating he/she is cognitively impaired. Review of Resident #304's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. 6. Resident #306 was admitted on [DATE] with diagnosis to include anxiety, and history of stroke. Review of admission MDS dated [DATE] revealed Resident #306 had a BIMS of 15 of 15 indicating he/she is cognitively intact. Review of Resident #306's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. During an interview on 4/17/23 at 12:15 p.m., Resident #306 stated that he/she could not recall being asked or offered an advanced directive. On 4/16/24 at 12:56 and 4/17/24 at 8:14 a.m., during an interview, the Licensed Social Worker confirmed the clinical records lacked evidence the above residents were offered/refused the opportunity to formulate an advanced directive upon his/her admission. On 4/17/24 at 10:54 a.m., during an interview the above was discussed with the Director of Nursing. Surveyor: [NAME], [NAME] L

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for the 3 of 4 units (Lakewood, [NAME] Chase [NAME] and [NAME]), a common area and the Laundry room for 1 of 1 facility tours (4/18/24). Findings: On 4/18/24 from 8:40 a.m. to 9:00 a.m., a surveyor, the Administrator, the Maintenance Director and the District Manager for Health Care Services conducted a tour of the facility in which the following findings were observed: Lakewood - Resident room [ROOM NUMBER] (bed 2) - The wallpaper was peeling on the wall underneath the overhead bed light and next to the floor by the head of the bed. [NAME] Chase [NAME] - Resident room [ROOM NUMBER] - The wall, by the bed on the right side of the room, was marred and had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The walls by the sink were marred and had chipped/missing paint, the drawers had chipped laminate and the bathroom wooden hand rail had a worn surface exposing untreated wood all of which created uncleanable surfaces. [NAME] Unit - Resident room [ROOM NUMBER] - The bathroom electric wall heating unit had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The bathroom electric wall heating unit had chipped/missing paint creating an uncleanable surface. Nurse's station (common area) - The corner of the Nurse's station, facing the hallway, had a missing/broken piece of laminate near the bottom. Laundry Room - The cement floor had chipped/missing paint creating an uncleanable surface. - There were approximately 10 broken/cracked floor tiles. - The wooden shelving, under the stored chemicals and chemicals in use behind the washing machines, had chipped/ missing paint creating uncleanable surfaces. On 4/18/24 at 9:00 a.m., in an interview, the Administrator, the Maintenance Director, and the District Manager of Health Care Services confirmed the findings.

Based on record reviews, interviews, and facility policy the facility failed to update/implement goals and interventions in the areas of enteral feeding (Resident #37), and mobility (Resident #41) for 2 of 14 care plans reviewed. Findings: Review of facility policy Comprehensive Person-Centered Care Planning dated 1/19 states The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with Residents Rights, which includes measurable objectives and timeframes to meet a residents medical nursing, mental, and psychosocial needs . Review of facility policy Vital Signs/Height And Weight Measurements Policy last revised 3/19 states: Procedure: B. Weights will be obtained weekly and documented for the first four weeks after admission (to obtain a baseline) and on a monthly basis unless otherwise ordered by the resident's physician . E. A weight that indicates a variance of +/-3 lbs. from the last obtained weight will necessitate a re-weigh of the resident. a. The original and 2nd weight should be obtained on the same shift and documented. F. The charge nurse will be made aware of the differences in the resident's weight. G. The weight loss/gain will be discussed with the Nutrition and Food Services Director for further dietary interventions. 1. Resident #37 was admitted to facility on 3/6/23 with diagnoses to include amyotrophic lateral sclerosis and peripheral vascular disease. A physician order instructs nursing staff to obtain Weight 2 Times Weekly. The residents current care plan, last reviewed and updated on 2/14/24, states Obtain and document weight as ordered (report a loss or gain greater than 3 pounds to provider and dietician). Adjust tube feeding order as needed. A review of the documented weights reveal the following weighs gains/losses +/- 3 pounds(lbs.): On 2/12/24 weight was 159.50. On 2/16/24 weight was 147.80(11.7 lbs. weight loss and no re-weigh of resident). On 2/22/24 weight was 157.60(9.8 lbs. weight gain and no re-weigh of resident). On 2/26/24 weight was 154.40(3.2 lbs. weight loss and no re-weigh of resident). On 4/1/24 weight was 158.60. On 4/4/24 weight was 150.70(7.9 lbs. weight loss and no re-weigh of resident). On 4/8/24 weight was 157.80( 7.10 lbs. weight gain and no re-weigh of resident). On 4/18/24 at 11:34 a.m., in an interview, the Director of Nursing confirmed that the facility did not implement Resident #37's care plan for weights as written and that he/she was not re-weighed as the facility policy stated. 2. On 4/16/24 at 7:26 a.m., during an interview, Resident #41 stated I don't get my walking, nobody walks me. Surveyor asked if he/she is walked daily, Resident #41 stated, they say but they don't . I can walk by myself, but they don't let me. On 4/16/24 at 12:26 p.m., Resident #41 was observed eating lunch in his/her bedroom. On 4/17/24 at 8:16 a.m., Resident #41 was again observed in his/her bedroom with a breakfast tray on the table. At this time, the resident stated that he/she always eats in his/her bedroom. Review of Resident #41's Activities of Daily Living (ADL) care plan initiated on 5/12/23 states, Restorative Nursing Program(RNP), Ambulation Deficits: [Resident] will maintain his/her ability to ambulate at least 160ft, two times per day with interventions of RNP Walk: Use gait belt, front-wheeled walker, verbal cues and contact guard assist x1. Further, review of the ADL verification worksheet documentation for walking from 2/1/24- 4/16/24, (79 day period), indicated on 25 days the resident was not walked and on 39 days the resident was only walked once a day. On 4/17/24 at 8:22 a.m., during an interview, the Director of Nursing (DON) stated, since COVID they do not have RNP program and no longer have a RNP aid but have started a walking program, Walk to Dining. The DON provided the surveyor with a list of residents who participate in the Walk to Dining program which included Resident #41. On 4/17/24 at 10:13 a.m. during an interview, the facilities Operation Education Coordinator confirmed Resident #41 is not participating in the walk to dining program and has not been walked twice a day as per the individualized care plan.

Based on interviews, record review and facility policy, the facility failed to provide residents with a continuous resident centered activities program for 3 of 4 residents reviewed for activity participation. (Resident's #12, #16, and #47). Findings: Review of facility policy Activities undated states .Activities Calendar: This is done monthly and posted in every room and bedside and beside the dining room door. This will include the daily and weekend scheduled activities and the birthdays for that month Review of activity calendars for June 2023 through April 2024 (11 months), lacked evidence that continuous resident centered activities were held on weekends. Review of Resident #12, #16, and #47's Resident Daily Activities Log dated March and April 2024 lacked evidence that activities were offered/refused on the weekend. During an interview on 4/18/24 at 10:24 a.m., Resident #12 indicated they only have activities on weekends if it's a holiday, because the activity director has no help. During an interview on 4/18/24 at 10:27 a.m., Resident #47 indicated [he/she] would like activities on weekends it gets very boring, During an interview on 4/18/24 at 10:29 a.m., Resident #16 indicated that it really bothers [him/her] that there are no scheduled activities on weekends. During an interview on 4/18/24 at 10:30 a.m., the Activity Director confirmed that there were no continuously scheduled activities on the weekends. During an interview on 4/18/24 at 10:45 a.m., the above was discussed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to electric wall heating units for 3 of 3 observations and failed to ensure that that a chemical was properly secured for 1 of 4 days of survey. (4/16/24) Findings: 1. On 4/16/24 at 7:00 a.m., a surveyor observed an electric wall heating unit in the hallway across from Administrator office that had the metal front cover hanging half off exposing hot, sharp metal fins. At this time, the Administrator confirmed in an interview that the broken and sharp electric heater was an accident hazard. Additionally, the Administrator confirmed that the facility had vulnerable and independent ambulating residents. 2. On 4/16/24 at 7:50 a.m., a surveyor observed the bathroom electric wall heating unit in Resident room [ROOM NUMBER]/104 to be missing the front cover exposing hot, sharp metal fins. On 4/16/24 at 7:55 a.m., the Administrator confirmed in an interview that the broken and sharp electric heater was an accident hazard. 3. On 4/16/24 at 9:10 a.m., a surveyor observed the bathroom electric wall heating unit in Resident room [ROOM NUMBER] to be missing the front cover exposing hot, sharp metal fins. On 4/16/24 at 9:15 a.m., the Maintenance Director confirmed in an interview that the broken and sharp electric heater was an accident hazard. 4. On 4/16/24 at 9:35 a.m., a surveyor observed a 1 pound 14 ounce container of Sani-Cloth Bleach Germicidal Disposable Wipes in a box on a small table in the Embden Shower room. The door to the shower room was open. The Safety Data Sheet for Sani-Cloth Bleach Germicidal Disposable Wipes notes the following: Section 4 first aid measures: Inhalation - Call a poison Control Center or doctor for treatment advice. Skin contact - Wash thoroughly with soap and water. Call the poison Control Center or doctor for treatment advice. Eye contact - If in eyes, hold eye open and rinse slowly and gently with water for 15-20 minutes. Remove contact lenses, if present, after the first 5 minutes, then continues rinsing eye. Call poison Control Center or doctor for treatment advice. Ingestion - If swallowed: rinse mouth. Do not induce vomiting. Call physician or poison Control Center immediately. Only induce vomiting at the instruction of medical personnel. Never give anything by mouth to an unconscious person. On 4/16/24 at 9:38 a.m., the Director of Nursing (DON) confirmed the bleach wipes were left in an unsecured place and an accident hazard. Additionally, the DON confirmed that the facility had vulnerable and independent ambulating residents.

Based on record reviews and interviews, the facility failed to complete performance reviews at least once every twelve months for 3 of 3 Certified Nursing Assistants selected for review (Certified Nursing Assistant's (CNA) (CNA's #7, #8 and #9). Findings: 1. CNA#7 was hired on 1/7/22. Review of CNA#7's personnel file lacked evidence that a performance evaluation was completed in 2023 and 2024. 2. CNA#8 was hired on 5/5/22. Review of CNA#7's personnel file lacked evidence that a performance evaluation was completed in 2023 and 2024. 3. CNA#9 was hired on 7/15/19. Review of CNA#7's personnel file lacked evidence that a performance evaluation was completed in 2023 and 2024. On 4/18/24 at 9:45 a.m. during an interview, the Director of Nursing confirmed staff have not received their annual reviews.

Based on observation, interview's, and record review, the facility failed to reconcile the narcotic book during shift change on 1 of 3 units (Emden Unit).,failed to monitor and record refrigerator temperatures containing biological's and vaccines in medicaion room (long term care medication room). Findings: 1. On 4/16/24 at 6:20 a.m., During review of long-term care controlled substance log with Certified Nursing Assistant/Medication Technician (CNA-M) #2 a surveyor noted the control substance log index was missing entries for page 49, 55, 59 and 60. At this time CNA-M #2 confirmed the index was missing entries. Review of untitled long term care narcotic log index on 4/17/24 revealed the following: -Index indicated page 48 belonged to Resident #304 for the medication lorazepam. Review of page 48 revealed it belonged to Resident #1 for medication Lyrica with received date 3/28/24. -Index indicated page 49 was missing a name but had quotations and arrows pointing down indicating it also belonged to Resident #304 for the medication lorazepam. Review of page 49 revealed it belonged to Resident #304 with received date 3/28/24. -Index indicated page 55 was blank. Review of page 55 revealed it belonged to Resident #17 for the medication tramadol received 4/6/24 -Index indicated page 59 was blank. Review of page 59 revealed it belonged to Resident #1 for the medication alprazolam with received date 4/11/24. -Index indicated page 60 was blank. Review of page 60 revealed it belonged to Resident #60 for the medication lorazepam with received date 4/12/24. On 4/17/24 at 11:43 a.m., Interview with Licensed Practical Nurse (LPN) #1 confirmed long-term care controlled substance log index was not filled out correctly. LPN #1 indicated that 2 nurses are supposed to enter new medications into the controlled substance log and should be in the index. On 4/17/24 at 10:49 a.m., Director of Nursing Service (DNS) indicated that when narcotics are delivered from pharmacy, the nurse signs them in, takes them out of package and immediately puts it in bound book on next blank page and should be putting them in index. At this time a surveyor confirmed the above findings. 2. Review of facility provided Maine Immunization Program Refrigerator Temperature logs dated February 2024 through April 2024 revealed the following: Review of facility policy Policy 3.5 Biologicals and Vaccines dated 1/1/16 states . Facility staff should monitor the temperature of refrigerators and freezers where vaccines are stored two times a day per [Center for Disease Control] CDC guidelines On 4/17/24 at 10:37 a.m., during a medication room observation of long term care medication room, with LPN #1, vaccinations and biologicals were observed in the medication refrigerator. Review of facility refrigerator temperature logs revealed the following: -February 2024 temperature log lacked evidence that temperatures were documented twice daily on 2/18/24, 2/22/24, 2/23/24, 2/24/24, and 2/29/24. Documented once daily on 2/1/24, 2/2/24, 2/5/24, 2/6/24, 2/7/24, 2/8/24, 2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/17/24, 2/19/24, 2/20/24, 2/21/24, 2/25/24, 2/26/24, 2/27/24, and 2/28/24. -March 2024 temperature log lacked evidence that temperatures were documented twice daily on 3/1/24-3/22/24 (22 days), 3/24/24, 3/28/24, and 3/29/24. Documented once daily on 3/23/24, 3/26/24, 3/27/24, and 3/30/24. -April 2024 temperature log lacked evidence that temperatures were documented twice daily 4/13/24. Documented once daily on 4/8/24 and 4/14/24. On 4/18/24 at 8:20 a.m., interview with LPN #5 revealed that he was never told to take refrigerator temperatures and assumed this was a night shift task. On 4/18/24 at 8:27 a.m., interview with LPN # 2 indicated she believed that documenting refrigerator temperature is a night shift task. On 4/18/24 at 9:03 a.m. , interview with Registered Nurse Manager (RN) #1 indicated refrigerator temperatures should be checked twice a day and is unaware who is currently responsible for this task. At this time RN#1 confirmed above findings.

Based on observations, interviews and the facility's current Cleaning Dishes/Dish Machine policy, Dish Machine Temperature and Sanitizer Log Form policy, Food Storage Procedure, Sink/Bucket Sanitizer logs, Daily High-emp Ware Wash Checklist logs and Freezer and Refrigerator Temperatures Form logs, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a ceiling air handling unit, ceiling tiles, ceiling lights, ceiling vents, and wall mounted fans. In addition, the facility failed to ensure products in the reach-in refrigerator and the dry storage room (including a chest freezer) were labeled and/or dated for 1 of 1 kitchen tours. Further, the facility failed to ensure that the dish machine was maintaining proper temperature ranges for proper washing/cleaning and that the refrigerators and freezers were monitored and temperatures documentation consistently. This has the potential to affect all residents. Findings: The facility's Cleaning Dishes/Dish Machine policy noted: All flatware, serving dishes, and cookware will be clean, rinse, and sanitized after each use. The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Procedure: 1. Prior to use, verify proper temperatures and machine function. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. Note: staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures. The facility's Dish Machine Temperature and Sanitizer Log Form noted: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles after each meal. a. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. 3. Staff will be trained to report any problem with the dish machine to the director of food and nutrition services as soon as they occur. 4. The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. The facility's Food Storage policy noted: Procedure: 4. Plastic containers with tight fitting covers must be used for storing cereals, cereal product, flour, sugar, dried vegetables, and broken lots of bulk food. All containers must be legible and accurately labeled and dated. 7. c. Food should be dated as it is placed on the shelves if required by state regulation. 14. Refrigerated food storage: b. Thermometers should be checked at least two times a day. F. All foods should be covered, labeled and dated. All foods will be checked to assure that foods including leftovers will be consumed by their safe use by dates, or frozen where applicable, or discarded. 15. Frozen foods: c. All food should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. On 4/16/24 from 6:05 a.m. to 6:30 a.m., a surveyor conduced a tour of the kitchen in which the following findings were observed: 1. > The ceiling air handling unit and two ceiling tiles around that unit were moderately soiled with dust/dirt. > There were two ceiling lights that had dust/debris in the lenses. > There were two wall mounted fans, over food preparation areas, that were dusty/dirty. > The dish room had 4 ceiling tiles with dried food particles and liquid residue on them. The wall mounted fan was dusty/dirty. The ceiling vent was dusty/dirty. > The reach-in refrigerator had a package of whipped topping with no thaw date. Directions on the package stated that once thawed, the product was good for 14 days. > The dry storage room had 12 bags of crackers that was unlabeled. A large bag of noodles that was unlabeled and undated. The large chest freezer had a package of whipped topping with no date it was frozen. Directions on the package stated that the product was only good for 9 months when frozen. On 4/16/24 at 7:45 a.m., in an interview, the Food Service Director (FSD) confirmed the findings. 2. On 4/16/24 from 6:05 a.m. to 6:30 a.m., during a kitchen tour, a surveyor observed the facility had a high temperature dish machine. The dish machine was run 5 times in a row and could not reach the 150 degrees Fahrenheit required during the wash cycle. In an interview with the surveyor during this time, the morning dietary aide stated she knew that the wash temperature needed to be a least 150 degrees Fahrenheit and the rinse temperature needed to be at least 180 degrees Fahrenheit. She stated that the dish machine had been acting up and not working properly. She additionally stated that a company had been called and they said a part was needed. She stated the facility was still using the dish washer even though it did not work properly and consistently as far as wash temperatures were concerned. On 4/16/24 at 7:45 a.m., in an interview, the FSD confirmed the dish washer was not washing at the required temperature. On 4/16/24 at 11:30 a.m., in an interview, the surveyor reviewed the finding with the Administrator. The facility immediately stopped using the dish machine and started using paper and plastic for meal service. On 4/18/24 at 9:28 a.m., a surveyor reviewed kitchen documentation for refrigerators and freezers temperatures, dish washer temperatures and sanitation bucket/sink logs revealing monitoring and documentation was not consistently completed for January, February, March and April 2024. Daily High-Temp Dish Washing Log: Missing dates of monitoring and documenting and low wash temperature. January 2024: 4-supper, 5-lunch, 6-supper, 8-supper, 17-breakfast, and 25-supper. February 2024: No documentation provided. March 2024: 1-supper, 24-lunch and low wash temperature, 29- low wash temperature at supper, 30-breakfast and 31-lunch and low wash temperature at supper. April 2024: 3- low wash temperature for breakfast and lunch, 5- low wash temperature for supper, 7- low wash temperature for supper, 8- low wash temperature for lunch and supper, 9- low wash temperature for lunch and supper, 10- low wash temperature for breakfast and supper, 11- low wash temperature for breakfast/lunch and supper, 12- low wash temperature for breakfast and supper, 13- low wash temperature for supper, 14- low wash temperature for breakfast and supper, 15- low wash temperature for breakfast and supper and 16- low wash temperature for breakfast and supper. Sink/Bucket Sanitizer: Missing Monitoring and Documentation Dates January 2024: No Documentation February 2024: No Documentation March 2024: No Documentation April 2024: No Documentation from 1-14. Freezer and Refrigerator Temperature Log: Missing Monitoring and Documentation Dates January 2024: Milk Cooler: 4-evening, 6-morning and evening, 7-morning, 10-evening, 11-evening, 13-morning and evening, 14-morning, 15-evening, 16-evening, 17-evening, 20-morning, 21-morning, 22-evening, 23-evening, 24-evening, 27-morning, 28-morning, 30-evening and 31-evening. Vegetable Refrigerator: 4-evening, 6-morning and evening, 7-morning, 10-evening, 11-evening, 13-morning and evening, 14-morning, 15-evening, 16-evening, 17-evening, 20-morning, 21-morning, 22-evening, 23-evening, 24-evening, 27-morning, 28-morning, 30-evening and 31-evening. True Unit: 4-evening, 6-evening, 7-morning, 10-evening, 11-evening, 13-morning and evening, 14-morning, 15-evening, 16-evening, 17-evening, 20-morning, 21-morning, 22-evening, 23-evening, 24-evening, 27-morning, 28-morning, 30-evening and 31-evening. Kitchen Refrigerator: 3-evening, 4-evening, 5-evening, 7-evening, 11-morning and evening, 13-morning, 14-morning, 19-morning and 29-evening. [NAME] Refrigerator: 3-evening, 21-morning and 29-evening. Vegetable Freezer: 4-evening, 6-morning and evening, 7-morning, 10-evening, 11-evening, 13-morning and evening, 14-morning, 15-evening, 16-evening, 17-evening, 20-morning, 21-morning, 22-evening, 23-evening, 24-evening, 27-morning, 28-morning, 30-evening and 31-evening. Chest Freezer: 4-evening, 6-morning and evening, 7-morning, 10-evening, 11-evening, 13-morning and evening, 14-morning, 15-evening, 16-evening, 17-evening, 20-morning, 21-morning, 22-evening, 23-evening, 24-evening, 27-morning, 28-morning, 30-evening and 31-evening. Ice Cream Freezer: 4-evening, 6-evening, 7-morning, 10-evening, 11-evening, 13-morning and evening, 14-morning, 15-evening, 16-evening, 17-evening, 20-morning, 21-morning, 22-evening, 23-evening, 24-evening, 27-morning, 28-morning, 30-evening and 31-evening. Kitchen Freezer: 2-evening, 3-evening and 29-evening. Freezer: 1 through 31-evening, 18-morning, 19- morning, 22 through 26-morning and 28 through 31-mrning. February 2024: Milk Cooler: 1-evening, 3-morning and evening, 4- morning, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11- morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-evening, 20-evening, 24- morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. Vegetable Refrigerator: 1-evening, 3-morning and evening, 4- morning, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11- morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-evening, 20-evening, 24- morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. True Unit: 1-evening, 3-morning and evening, 4-morning, 5-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11-morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-evening, 20-evening, 24-morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. Kitchen Refrigerator: 28-morning, 1 through 29 no documentation for evenings Chest Freezer: 1-evening, 3-morning and evening, 4- morning, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11- morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-evening, 20-evening, 24- morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. Ice Cream Freezer: 1-morning and evening, 3-morning and evening, 4- morning, 5-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11- morning, 14-evening, 15-evening, 16-evening, 17- morning and evening, 18-morning, 19-evening, 24- morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. Kitchen Freezer: 28-morning, 1 through 29 no documentation for evenings Veggie Freezer: 1-evening, 3-morning and evening, 4- morning, 5-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11- morning, 12-evening, 13-evening, 14-evening, 15- morning and evening, 16- morning and evening, 17- morning and evening, 18-morning, 20-evening, 21-evening, 24- morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. March 2024: Milk Cooler: 2-morning, 3-morning and evening, 12-morning, 17-evening, 18-evening- 19-evening and 28-morning. Vegetable Refrigerator: 2-morning, 3-morning and evening, 4-morning and evening, 15-evening, 17-evening, 18-evening, 19-evening, 23-morning and 29-morning. True Unit: 3-morning and evening, 4-morning and evening, 15-evening, 17-evening, 18-evening, 19-evening, 23-morning and 28-morning. Kitchen Refrigerator: 1-morning and evening, 2-evening, 3-evening, 4-evening, 5-evening, 6-evening, 7-evening, 8-evening, 9- morning and evening, 10-morning and evening, 11-evening, 12-evening, 13-evening, 14-evening, 15-evening, 16- morning and evening, 17- morning and evening, 18-evening, 19-evening, 21-evening, 24-evening, 28-evening, 28-evening and 30-morning and evening. Chest Freezer: 2-morning, 3-morning and evening, 9-morning and evening, 15-evening, 16-morning, 17-evening, 18-evening, 19-evening, 23-morning and 25-evening. Ice Cream Freezer: 3-morning and evening, 4-morning and evening, 15-evening, 17-evening, 18-evening, 19-evening, 23-morning and 28-morning. Kitchen Freezer: 1-morning and evening, 2-evening, 3-evening, 4-evening, 5-evening, 6-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11-evening, 12-evening, 13-evening, 14-evening, 15-evening, 16-morning and evening, 17- morning and evening, 18-evening, 19-evening, 21-evening, 24-evening, 28-evening, 28-evening and 30-morning and evening. Freezer: 2-morning, 3-morning and evening, 4-evening, 7-evening, 15-evening, 16-morning, 17-evening, 18-evening, 19-evening, 23-morning and 28-morning and evening. April 2024: Milk Cooler: 1-evening, 3-morning and evening, 4-morning, 5-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11-morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-evening, 20-evening, 24-morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. Vegetable Refrigerator: 1-evening, 3-morning and evening, 4-morning, 5-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11-morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-evening, 20-evening, 24-morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. True Unit: 1-evening, 3-morning and evening, 4-morning, 5-evening, 7-evening, 8-evening, 9-morning and evening, 10-morning and evening, 11-morning, 12-evening, 13-evening, 14-evening, 15-morning and evening, 16-morning and evening, 17-morning and evening, 18-morning, 19-morning and evening, 21-morning and evening, 24-morning and evening, 25-morning, 26-evening, 27-evening, 28-evening and 29-evening. Kitchen Refrigerator: 1 through 4-evening, 9-morning, 11- evening, 12-evening, 13- morning and evening. Chest Freezer: no documentation provided Ice Cream Freezer: no documentation provided Kitchen Freezer: 1 through 4-evening, 11- evening, 12-evening, 13- morning and evening. Freezer: no documentation provided On 4/18/24 at 9:33 a.m. in an interview, the FSD and the Nutritional Services Coordinator confirmed the finding.

Based on Certified Nurse's Aide (CNA) employee education record reviews and interview, the facility failed to monitor and ensure that a CNA attended the required 12 hours of annual in-service education, for 3 of 3 randomly selected CNA's employed greater than 1 year. (#7, #8, and #9). Findings: 1.CNA #7 was hired on 1/7/22. Review of CNA #7's Employee In-service/attendance records revealed CNA #7 has only 3.5 documented in-service hours from 1/7/22 through 14/18/24. 2. CNA #8 was hired on 5/5/22. Review of CNA #8's Employee In-service/attendance records revealed CNA #8 has only 4 documented in-service hours between 5/22/22 through 4/18/24. 3. CNA #9 was hired on 7/15/19. Review of CNA #9's Employee In-service/attendance records revealed CNA #9 has only 3.5 documented in-service hours from 7/15/19 through 4/18/24. During an interview on 4/18/24 at 9:45 a.m., Director of Nursing confirmed the above CNA staff have not completed 12 hours of yearly in-service hours.

Based on observations and interview, the facility failed to have all residents sharing a table in the dining room eat at the same time. Meals were delivered between 12:24 p.m and 1:11 pm to residents sharing the same table. This has the potential to effect all the residents sitting in the dining room. Findings: On 10/18/22 from 12:24 p.m. to 1:11p.m., a surveyor observed the following during lunch meal pass. In the dining room there were 5 tables, clockwise: Table #1 had 4 residents, table #2 had 3 residents, table #3 had 1 resident (who wandered in and out of the dining room several times looking for his/her meal), table #4 had 4 residents and Table #5 had 2 residents (one of which also wandered in and out of the dining room looking for his/her meal). At 12:24 p.m., while waiting for lunch tray pass, a surveyor overheard one Certified Nursing Aide (CNA) state, it's almost 12:30, I'm about to make lunch myself. Then another CNA stated, where is lunch, this is frustrating. At 12:38 p.m., the first meal cart was delivered to the dining room. 1 CNA was present and began to pass out trays. The first tray to delivered to a resident at table #2. The next three trays were delivered to table #1. The fourth tray was delivered to table #2, leaving one resident at both table #1 and table #2 without food and watching tablemate's eating. No other trays were available to pass at this time to tables #3 - #5. At 12:54 p.m., a meal cart w/doors was brought to the Embden unit. A CNA retrieved an open metal utility rolling cart and removed 4 meal trays from the meal cart and place them on the utility rolling tray. She then rolled them to the other side of the building to the dining room. The CNA then delivered three of the trays to table #4, and the fourth tray was delivered to table #2 at an empty place setting, again leaving a resident at table #1, table #2 and now table #4 without food and watching tablemate's eating. At this time the Administrator entered the dining room an offered to take the utility cart back to Embden unit. At 1:07 p.m., a surveyor again observed a CNA remove 4 trays out of the meal cart w/doors on the Embden unit and place them on the utility cart which was then rolled to the other side of the building into the dining room. At this time there were 2 CNA's passing out the trays. At this time, the resident at table #2, who has not received lunch propelled away from the table heading to the dining room exit. A CNA asked the resident was he/she was going. Resident stated, did my meal get canceled? CNA stated, No, we don't have it yet. Resident then stated, why am I always the last to get food. CNA responded, it's coming. At 1:11 p.m., a meal cart entered the dining room. At this time, the last of the residents including the residents at table #1, table #2 and table #4 were served their lunch trays. At 1:16 p.m., in an interview with the Administrator, a surveyor explained the above concerns with late meals, trays delivered on open utility rolling cart and residents having to watch their table mates eat. Administrator stated, that's not supposed to happen, they should be served together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition on 2 of 4 Units (Lakewood and [NAME]) for 3 of 3 days of survey. Findings: 1. Lakewood Unit: On 10/17/22 at 10:08 a.m., and 10/18/22 at 9:05 a.m., the shared bathrooms for both rooms 101/103 and 105/107 had an unlabeled urinal hanging on the toilet handrails. The shared bathroom for rooms 106/108 had the heating register with the off exposing the heating coils and a unbagged plunger on the floor next to the toilet. 2. [NAME] Unit: On 10/17/22 at 9:57 a.m., 10/18/22 at 10:28 a.m., the end of [NAME] unit had a heater with the cover off exposing the heating coils, the shared bathroom for rooms 423/425 had broken tiles that were dirty around the toilet, room [ROOM NUMBER] comforter had unknown brown/debris stain, room [ROOM NUMBER] closet door (to the right) of the sink was gouged/scuffed, the shared bathroom for rooms 422/424 had the heater baseboard missing with coils exposed and had an unlabeled urinal on the toilet handle. 3. On 10/19/22 from 9:00 a.m. to 9:27 a.m., an Environmental Tour was conducted with the Administrator in which the above findings and the following additional concerns were observed: Clear Water Unit: room [ROOM NUMBER] Comforter an unknown brown debris/stain. At this time, the Administrator removed the comforter from the bed. The shared bathroom for rooms 423/425 broken tiles and dirt around toilet. The shared bathroom for rooms 422/424 heater baseboard missing cover with coils exposed, unlabeled urinal on the toilet handle and a broken tile around the toilet. Broken floor tiles at the entrance to Clear Water unit and in front of Employee Lounge. The entrance of [NAME] Unit had stained ceiling tiles. The floorboard split was from wall at double door (left door if exiting hall), across from oxygen storage room. Cracked tiles near the double door near the kitchen dishwashing room. 0n 10/19/2022 at 9:27 a.m. , in an interview, the Administrator confirmed the findings. On 10/19/2022 from 12:54 to 12:56 p.m., an additional Environmental Tour was conducted with the Administrator the following was observed: The floorboard/mop board in common area below Regulator clock dented/pushed in. The floor at the double door from common area (near where med cart stored), leading to kitchen dish room is raised and slightly splitting. 0n 10/19/2022 at 12:56 p.m., in an interview, the Administrator confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative to review and revise the care plan after each assessment for 5 of 13 sampled residents (#2, #3, #4, #28, #30). Findings: 1. On 10/19/22 at 11:47 a.m., during an interview with Resident #2's representative, when asked if he/she is invited and/or participates in his/her plan of care the representative stated, once [Resident #2] switched over to hospice, I didn't know if they were doing them anymore because I haven't been asked to come back. Review of Resident #2's medical record, the surveyor noted a Minimum Data Sets (MDS) Quarterly assessment dated [DATE], the clinical record lacked evidence of an IDT which included the resident, and resident's representative after the 7/19/22 assessment. 2. Review of Resident #3's medical record, the surveyor noted MDS Annual assessment dated [DATE] and Quarterly assessment dated [DATE]. The clinical record indicated the last IDT meeting was held on 1/13/22. On 10/19/22 at 12:03 p.m., in an interview with the surveyor, the Director of Nursing (DON) confirmed the last IDT held was 1/13/22. 3. Review of the Resident #4's medical record, the surveyor noted a MDS Quarterly assessment dated [DATE]. The clinical record lacked evidence of an IDT which included the resident, and resident's representative after the 7/19/22 assessment. On 10/19/22 at 10:13 a.m., the surveyor confirmed this finding during an interview with the DON. 4. Review of Resident #28's medical record, the surveyor noted a MDS Quarterly assessment, dated 9/5/22. The clinical record lacked evidence of an IDT which included the resident, and resident's representative for the 9/5/22 assessment. 5. On 10/17/22 at 12:11 p.m., during an interview with Resident #30, he/she stated, no when asked if he/she is invited and/or participates in his/her plan of care. Review of Resident #30's medical record, the surveyor noted a MDS Quarterly assessment, dated 9/5/22. The clinical record lacked evidence of an IDT which included the resident, and resident's representative for the 9/5/22 assessment. On 10/19/22 at 10:10 a.m., the surveyor confirmed this finding during an interview with the DON. On 10/19/22 at approximately 1:45 p.m., the above was confirmed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 1 medication rooms and 2 out of 3 medication carts observed. Findings: On 10/17/22 at 11:12 a.m., during observation of the facilities medication room and the Long Term Care and Skilled care medication carts with the Medication Technician (CNA-M) the following was observed: 1. Medication room contained an unopened bottle of Calcium 600 +D with best by date of 6/22. 2. In the [NAME] and Embden medication cart: a bingo card of 30 tabs of Fludrocortisone 0.1milligram (mg) tabs with expiration date of 8/31/22, 2 bingo cards with 30 tabs each of Glipizide 10mg with expiration date of 9/30/22, 2 bingo cards of Gabapentin 100mg (one with 30 tabs, another with 1 tab) with expiration date of 9/30/22 and a bingo card with 24 tabs of Quetiapine 200mg with expiration date of 6/30/22. 3. In the Lakewood and [NAME] Chase medication cart: 2 bingo cards of Baclofen 5mg (one with 30 tabs, another with 7 tabs) expiration of 10/9/22. On 10/17/22 at 11:31 a.m., the above was confirmed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, Resident Council Meeting Minutes, observations and lunch meal test tray, the facility failed to serve hot foods hot for 1 of 1 lunch meals tested for appetizing temperatures. (Residents #38, #9, #30) Findings: 1. On 10/17/22 at 9:43 a.m., during an interview with Resident #38, he/she stated, the food is always cold, almost every morning. I think I'm one of the few that ask to have it warmed up. 2. On 10/17/22 at 10:58 a.m., during an interview with Resident #9, he/she stated, the food is not hot and there is no steam table in dining room, not since COVID. It used to be good when the steam table was available. Food is not hot now. 3. On 10/18/22 at 1:34 p.m., during an interview with Resident #30. Surveyor asked about timeliness of meal trays. Resident stated Trays are late every day. I don't even bother to ask them to warm it up. That'll take an hour. 4. On 10/18/22 1:18 p.m. a lunch test tray was tested by two surveyors. The tray was tested after the last tray was served to a resident and he/she began eating. The tray consisted of spaghetti with sauce, meatballs, peas and carrots mixed, honeydew melon, a roll, and strawberry [NAME], along with two cold drinks (lemon soda and water). The meatballs, spaghetti, and sauce were cool to taste to both surveyors. The peas and carrots were warmer to the taste of both surveyors, however they were still not considered hot by either surveyor. The roll was served cold and was hard on the top. On 10/18/22 at 1:54 p.m. these findings were discussed with the Director of Nursing Services. 5. On 10/18/22, the surveyor reviewed the Resident Council meeting minutes from January 2022 through October 2022. Resident Council meeting minutes for 8/24/22 indicates that residents were requesting the steam table be used in the dining room and had complaints that there was a long wait for food to be served, food is cold, and meals are late. On 10/13/22 the Resident Council meeting minutes follow up response from the facility states, It was explained that the majority or greater number of residents have to be present to have the steam table present. On 10/18/22 at 2:00 p.m., a Resident Council interview conducted by the surveyor with 10 residents present. Residents voiced concerns about the steam table not being in the dining room during meals and complained that hot food is often cold when served. On 10/18/22 at approximately 2:30 p.m., during an interview with Director of Nursing , a surveyor discussed to above concerns.

Based on observations and interviews, the facility failed to assure the kitchen was maintained in a clean and sanity manner for an ice machine, ceiling tiles, and a fan, 1 of 1 kitchen tours. Findings: On 10/19/22 from approximately 10:55 a.m. to 11:10 a.m., a surveyor conducted a kitchen tour with the Food Service Director in which the following findings were observed: The ice machine had rust on the right hinge of the door (that opens upwards). The ceiling tile above/near the vector light had visible debris. The fan on the wall in the dish room (facing the dishwasher) had dust/debris on it. The dish room had 4 ceiling tiles with dirt/debris (near the ceiling fan/exhaust, near the exit). The dish room exhaust fan (on the ceiling) had dust/debris. On 10/19/22 at 11:10 a.m., the above findings were confirmed with the Food Service Director. In addition, on 10/19/22 at 12:27 p.m. the above findings were discussed with the Administrator.

Based on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property and dementia management by failing to ensure that 4 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training completed the required training (#1, #2, #3 and #5). Findings: On 10/18/22 during a review of facility staff education records the following were noted: CNA #1 was hired on 5/21/22. The last dementia training received by CNA #1 was completed on 10/29/20. The record lacks evidence of mandatory Dementia related training in 2021. CNA #2 was hired on 8/27/01. The last abuse and dementia training received by CNA #2 was completed on 10/29/20. The record lacks evidence of mandatory Abuse and Dementia related training in 2021. CNA #3 was hired on 5/21/22. The last dementia training received by CNA #3 was completed on 10/29/20. The record lacks evidence of mandatory Abuse and Dementia related training in 2021. CNA #5 was hired on 10/30/96. The last Abuse and Dementia related training received by CNA #5 was completed on 10/29/20. The record lacks evidence of mandatory Abuse and Dementia related training in 2021. On 10/18/22 at 8:30 a.m., in an interview, the Director of Nursing confirmed that not all of the mandatory training required was done in 2021 for the staff reviewed.