**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide personal hygiene for 1 of 1 resident reviewed for Activities of Daily Living (ADL) (Resident #26). Findings: On 4/22/25 at 9:32 a.m., 4/23/25 at 12:09 p.m., and 4/23/25 at 2:20 p.m., Resident #26 was observed to have notable buildup on his/her bottom teeth. During an interview with Resident #26 representative stated [Resident #26] bottom teeth have build up on them, and resident can't brush them independently and further stated [Resident #26] used to insist on brushing their teeth when they were young, and it would bother resident to not have them clean. Review of Resident 26's care plan, updated 3/16/25 states: Personal Hygiene: partial/moderate assistance, helper provides less than half the effort. Oral Hygiene: set up/clean up assistance, helper provides set up/clean up assistance, . Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating he/she is not cognitively intact. Review of Resident #26's Activities of Daily Living (ADL) Oral Hygiene from 4/1/25 through 4/23/25 lacked evidence that he/she refused any oral hygiene care. During an interview on 4/24/25 at 2:00 p.m., Certified Nursing Assistance (CNA) stated residents should be offered oral hygiene when getting ready in the morning and before bed. CNA further stated that if a resident refuses it should be documented in the chart as a refusal. At this time a surveyor asked about Resident #26's teeth. CNA stated Resident #26 is not too big on brushing. This surveyor and CNA went into Resident # 26's room and Resident #26 was asked if he/she would like to have his/her teeth brushed and he/she stated that would be very nice. On 4/23/25 at 2:20 p.m., Registered Nurse (RN) observed Resident #26's mouth and confirmed obvious build up . On 4/23/25 at approximately 2:30 p.m., the above was discussed with Director of Nursing and Assistant Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to obtain provider orders for the maintenance and monitoring of a pacemaker. In addition, the facility failed to initiate goals and interventions necessary for the presence of a pacemaker for 1 of 13 care plans (Resident #34). Findings: Resident #34 was admitted in 2/25 and has a diagnoses to include chronic heart failure, ischemic cardiomyopathy, hypertensive heart disease, and type II diabetes mellitus. Review of Resident #35's clinical record revealed appointment CM Heart 4/10/25 at 1:00 p.m. Review of Resident #34's clinical record NSG Admission/readmission Evaluation originally dated 2/20/25 section: Devices and treatments (care profile) is blank in subsection: pacemaker . Review of clinical record [[Hospital] Consultation Note] dated 2/14/25 revealed Resident #35 had a past medical history of presence of combination internal cardiac defibrillator (ICD) and pacemaker. Review of Resident #34's signed provider orders for April 2025 lacked evidence that orders regarding maintenance/monitoring of Resident #34's pacemaker. Review of Resident #34's care plan initiated 2/21/25 lacked evidence of goals and interventions for the presence of a pacemaker. During an interview on 4/23/25 at 12:04 p.m., Registered Nurse (RN) stated Resident #34 did not go to his/her appointment scheduled for 4/11/25 at CM Heart as resident had a meeting with the care team, and they believed it was something Resident #34 could do once he/she was discharged . At this time RN stated the appointment was for a device check, but she was unsure if Resident #34 had a pacemaker or not and didn't know what kind of device resident has. Review of facility appointment calendar April 2025 revealed crossed out appointment on 4/11 states [Resident #35] CM Heart, 300 Main St, Lew [[NAME]] @ 13:00. Further review of residents clinical record lacked evidence Resident #35 went to this appointment. During an interview in presence of RN on 4/23/25 at 12:25 p.m., Resident #34 used his/her right hand and patted his/her upper left chest and confirmed he/she does have a pacemaker/defibrillator and hasn't gone to the cardiologist for a really long time and doesn't know why. States he/she does have a pacemaker monitor at home. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had a Brief Interview for Mental Status (BIMS) of 13 of 15 indicating he/she is cognitively intact. On 4/23/24 at approximately 3:15 p.m., the above was discussed with Director of Nursing and Assistant Director of Nursing.

Based on observations, record reviews, interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1of 1 resident reviewed for respiratory care (Resident #34). Findings: On 4/22/25 at 10:24 a.m., and 4/23/35 at 7:35 a.m., observations of Resident #34's nebulizer machine was observed on top of dresser with tubing and mask attached and resting on top of the nebulizer and not in a bag. Review of Resident #34's orders active for April 2025 revealed order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally every 4 hours as needed for Wheezing or dyspnea; flu Lung sounds pre and post nebulizer treatment: C=Clear, D=Diminished W=Wheeze, bCR=Crackles R=Rhonchib Report abnormal lung sounds to RN for assessment. Document total min spent for nebulizer TX. Document Respiratory Rate before and after TX. Review of Resident #34's TAR dated April 2025 revealed nebulizer was last used 4/9/25. On 4/23/25 at 12:25 p.m., during an observation of Resident #34, Registered Nurse (RN) confirmed the nebulizer tubing was unbagged and stated Resident #34 has not used the nebulizer in a few weeks and it should not still be in there. On 4/23/25 at approximately 4:15 p.m., the above was discussed with Director of Nursing and Assistant Director of Nursing.

Based on observation, interview, and review of the Culinary Services: Storage of Food & Supplies Policy and Procedure, revised 2/2022, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood, ceiling lights, a ceiling vent, and the walk-in refrigerator door; and failed to ensure foods were labeled and dated in a walk-in freezer for 1 of 1 kitchen tour for 1 of 1 day of survey (4/22/25). Findings: The facility's Culinary Services: Storage of Food & Supplies Policy and Procedure, revised 2/2022, noted: 2. Labeling and rotating food supply: a. Food products that are opened and not completely used or transferred from its original package to another storage container or prepared at the facility and stored should be labeled as to its contents and used by dates. 4. Food removed from its original container must be labeled with the common name of the food. On 4/22/25 from 9:00 a.m. to 9:30 a.m., an initial kitchen tour was conducted with the Food Service Director in which the following findings were observed: > The hood over the dish washing machine had rust build-up on the inside of it. > There were 3 ceiling lights, over a food preparation area, that had cracked/broken lenses. > There was a ceiling vent, over a food preparation area, that was heavily soiled with dust and had worn/missing paint. > The walk-in refrigerator door had rust build-up on the bottom inside of the door and up about halfway of the door. > The walk-in freezer had 8 bags of what appeared to be cauliflower that was not labeled and dated. On 4/22/25 at 9:30 a.m., in an interview, the Food Service Director confirmed the findings.

Based on interviews and record reviews, the facility failed to implement and maintain an effective training program for nursing staff contracted through the Clipboard Application (App), and NURSA App in the areas of dementia care, resident rights, neglect training by failing to ensure contracted Clipboard/NURSA Professionals (Users) completed training prior to independently providing services to residents for 3 of 3 contracted staff reviewed during a complaint investigation.( Staff #1,# 2, & # 4). Findings: Review of the Clipboard app Terms of Service Agreement last updated 10/9/23 states, Clipboard operates an online, marketplace, accessed through the Site, that allows third-party clients (each, a Client) to post open shifts at facilities (each, a Facility), and allows independent contractor professionals (each, a Professional) to view and sign up to work such shifts if they so choose. Under the subheading 2.1 CLIPBOARD'S ROLE AS A MARKETPLACE states, Clipboard merely makes the Site and Services available to enable Professionals and Clients to find and transact directly with each other . Users alone are responsible for evaluating and determining the suitability of any shift, Client or Professional. Review of the NURSA app Terms of Service Agreement dated 3/26/25 states, The NURSA Platform is a software platform whereby Facilities and Clinicians may connect for posting, viewing, requesting, and acceptance of Shifts. Subsection 7. ADDITIONAL TERMS APPLICABLE TO CLINITIANS: 7.2 Independent contractor status: .Clinicians utilizing the Nursa Platform do so only as independent contractors . Review of National Health Care Agency Orientation Packet undated lacked evidence of Neglect, Resident Rights, and dementia training for agency/contracted staff. Review of facility provided Contracted Staff List revealed the following: Staff#1 first shift on 12/12/24 through staffing app (Clipboard) and has worked a total of 2 shifts. Review of Staff #3's education file lacked evidence she received education in the areas of dementia care, resident rights, neglect training. Staff #2's first shift was on 10/28/24 through the staffing app (Clipboard) and has worked 11 shifts. Review of Staff#2's education file lacked evidence she received education in the areas of dementia care, resident rights, neglect training. Staff #3 first shift was on 11/14/24 through the staffing app (NURSA) and has worked 2 shifts. Review of Staff #3's education file lacked evidence she received education in the areas of dementia care, resident rights, neglect training. During an interview on 4/23/25 at 12:05 p.m., the Scheduler stated that if there is a call out or no show for a shift the Scheduler or the Director of Nursing (DON) will be notified. The shift will be posted on the Clipboard App with a fee rate. A Clipboard User will accept the shift and an email from Clipboard will be sent to the Scheduler and the DON notifying them the shift has been filled. If the User cancels the shift, the shift will automatically repost. Users who don't show up for their shift are automatically blocked. At this time scheduler stated that they currently do have access/use of the Clipboard app but have not used it since 12/25/24 because there were too many weekend no call, no shows. During a follow up interview on 4/23/25 at 12:14 p.m., the Scheduler stated the facility also uses the NURSA app for staffing needs but has not used them since 4/13/25. At this time the Scheduler and a surveyor reviewed Agency Report 01/01/2025-04/22/2025. The Scheduler confirmed NURSA staff normally only work in Residential Care, but they did use them in Long Term Care on 12/26/24 for an 8 hour shift. During an interview on 4/24/25 at 8:50 a.m., with 2 surveyors, the Director of Nursing stated agency and contracted staff from Clipboard and NURSA apps have to complete an online orientation packet prior to the first shift worked, which includes abuse, neglect and misappropriation, and the charge nurse does an agency walk around for emergency exits, and there is a sign off sheet that is completed. DON further stated the staff hired through Clipboard and NURSA apps receive dementia training through their app and the facility does not track it. At this time a surveyor asked for evidence of sign off sheets. For Clipboard and NURSA staff. These were not provided by the end of survey.

Based on record reviews, interviews, and the Payroll Based Journal Report (PPJ), the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents for 1 of 4 quarters reviewed for weekend staffing (9/1/24 through 12/31/24). Findings: Review of Center for Medicare & Medicaid (CMS) PPJ Report revealed the facility triggered for low weekend staffing during the first quarter (10/1/24 through 12/31/24). During a review of first quarter weekend staffing with scheduler on 4/24/25 at 12:05 p.m., the scheduler confirmed the facility was not adequately staffed for 7 of 39 days reviewed. During a review of the daily staffing sheets with the Director of Nursing (DON) on 4/24/25 at 1:05 p.m., the above was confirmed. At this time DON stated she would have daily punches obtained for the days in question. The daily punches were not obtained by the end of survey.

Based on record review and interview the facility failed to provide respiratory services as directed by physician orders related to nebulizer administration with monitoring for 1 of 3 residents reviewed who received nebulizer medications (Resident #27). Findings: On 2/13/22 at 12:57 p.m., observation of Resident #27 to have a nebulizer machine with tubing and face mask on the bed next to the pillow. Review of the medical record stated Resident #27 was admitted with acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, panlobular emphysema and dependence on supplemental oxygen. Physician orders dated, 2/2/23 for Ipratropium-Albuterol Solution 0.5-2.5 MG (milligram)/3ML (milliliter), 3 ml inhale orally four times a day for SOB (shortness of breath) or Wheezing with instructions for nursing to monitor Lung sounds pre and post nebulizer treatment: C=Clear, D=Diminished W=Wheeze, CR=Crackles R=Rhonchi. Report abnormal lung sounds to RN for assessment. Document total min spent for nebulizer TX (treatment). Document Respiratory Rate before and after. Review of the medication administration record from 2/2/23 through 2/12/23 indicated the medication Ipratropium-Albuterol Solution was administered a total of 41 doses where nursing did not monitor lung sounds pre and post nebulizer treatment, did not document the total minutes spent for the nebulizer TX and did not document Respiratory Rate before and after. On 2/14/23 at 9:55 a.m., during an interview, the Director of Nursing confirmed the lack of monitoring the pre and post lung sounds, minutes of treatment and respiratory rate pre and post treatment from 2/2/23 through 2/12/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 1 of 2 wings ( C wing), the laundry room, the handicap bathroom, and the employee/public bathroom for 1 of 1 Environmental tours (6/10/2021). Findings: On 6/10/2021 from 8:50 a.m. to 9:15 a.m., a surveyor and the Maintenance Director conducted an tour of the facility in which the following findings were observed: C Wing: > Six(6) hallway ceiling vents were visibly dusty/dirty. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet and along the edge of the walls. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. The privacy curtain, closest to the window, was in disrepair. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. Laundry Room: > There was a missing floor tile by the floor drain exposing untreated cement. > There were multiple missing and broken floor tiles between and behind the washing machines exposing untreated cement. > The floor had dirt/debris build-up throughout the room, around the edges and behind the washers/dryers. > The wall heater is broken and in disrepair. > The wall, beside the wall heater, is broken open exposing sheetrock. > Two(2) of three(3) dryers had duct tape on the top control door panels creating uncleanable surfaces. > The three(3) ceiling lights, above the dryers, had dust/debris in the lenses. Handicap Bathroom: > The floor was dirty around the base of the toilet. The floor had dirt/debris build-up in the corners of the room. The caulking was visibly soiled on the back of the sink. Employee Bathroom: > The floor was dirty around the base of the toilet. The caulking was visibly soiled on the back of the sink. The floor had dirt/debris build-up in the corners of the room. On 6/10/2021 at 9:15 a.m., a surveyor confirmed the above findings with the Maintenance Director.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the food disposal, the wall air conditioner, the wall exhaust fan, the floors, and failed to label and date foods in the walk-in freezer for 1 of 1 kitchen tours on 1 of 3 days of survey. (6/7/2021) Findings: On 06/07/2021 between 6:20 p.m. and 6:55 p.m., during the kitchen tour, a surveyor and the Food Service Director observed the following: > The food disposal unit had dried liquid splatter on it. > The wall air conditioning unit was dusty/dirty. > The wall exhaust fan was dirty/dusty. > The dry goods storage room floor had dirt/debris and trash on it and under the shelving. > The walk-in freezer had an open unlabeled and undated bag of chicken strips, an unlabeled and undated bag of meat patties, and the floor had dirt/debris and trash on it under the shelving. On 06/07/2021 at 6:55 p.m., the Food Service Director confirmed the findings.

Based on observations and interviews, the facility failed to maintain the garbage storage area in a condition to prevent the harborage and feeding of pests on 2 of 4 days of survey. (6/7/2021 and 6/10/2021) Findings: 1. On 6/7/2021 at 6:20 pm, a surveyor and the Food Service Director observed the trash dumpster to have the left side door and the right side door open, exposing garbage bags. Additionally, there were used nursing gloves, papers, cigarette butts, old packing tape, and plastic cup lids on the ground around the dumpster. On 6/7/2021 at 6:30 pm, the Food Service Director confirmed the findings. 2. On 6/10/2021 at 8:30 a.m., a surveyor and the Food Service Director observed the trash dumpster to have the left side door open, exposing garbage bags. On 6/10/2021 at 8:30 a.m., the Food Service Director confirmed the findings.