Based on observation, record review, and interview with residents and staff it was determined that the facility failed to maintain and enhance the dignity of residents. This was evident for 1 (Resident #81) out of 3 residents reviewed for dignity during the annual survey. The findings include: A Hoyer lift is a mechanical lifting device that allows a person to be lifted and transferred to the bed or chair with a minimum of physical effort. On 5/14/2024 at 1:37 PM, during a tour of the first floor B Unit, the Surveyor noted Resident #81 in the doorway of his/her room, sitting in a wheelchair with a Hoyer pad underneath him, and his head down. The resident's call bell was alarming. The Surveyor conducted an interview with the resident and discovered that he/she had been sitting there for over 40 minutes waiting for someone to assist him/her back to bed. The resident stated that a Geriatric Nursing Assistant (GNA) left him/her there to locate a Hoyer lift to transfer him/her back to bed. Resident #81 mentioned that he/she had not been happy lately and was very upset because finding a Hoyer lift is always an issue here, so I just have to sit here and wait. According to Resident #81, the nursing staff fails to respond to call bells timely leaving the residents waiting for long periods of time before someone comes to check on them. The resident stated that one day he/she had to wait until 2 PM before someone could assist him/her with morning care and getting out of the bed to the chair for the day. The resident informed the Surveyor that he/she can't even go to activities if he/she wanted to because the nursing staff can never find a Hoyer lift to assist them out of bed. On 5/14/2024 at 1:45 PM, the Surveyor observed the Director of Nursing (DON) and Administrative Support assist the resident back to bed. The Surveyor informed the DON of the residents' concerns. On 5/30/2024 during an interview with the Director of Nursing (DON), the Surveyor made the DON aware of the concerns with the call bell system constantly alarming for long periods of time. The DON confirmed the issue. (Cross reference F558)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During interview with Resident #542 on 05/21/24 at 10:09 AM, Resident #542 was asked if he/she had been offered showers. Resident #542 stated no, he/she had not had a shower or bath, was not aware of specific days for showers and was only offered one shower since admission to the facility. On observation, Resident #542 pointed out that he/she had been using baby wipes that were brought in by a family member. Review of Resident #542's medical record on 5/23/24 revealed the resident was admitted to the facility on [DATE] and did not have any documented showers on 5/23/24. Interview with the Geriatric Nursing Assistant (GNA) #2 on 05/23/24 at 11:34 AM confirmed Resident #542 is mostly independent, and he/she expressed wanting a shower. GNA #2 stated they thought he/she ' s shower days were twice a week and there is a schedule posted. GNA #2 also confirmed Resident #542 had not showered during their shift since being at the facility. GNA #2 stated they offered Resident #542 a shower one time but Resident #542 refused and didn't know if anyone ever followed up on it. Based on observation, record review, and interview with staff it was determined that the facility failed to support resident choices. This was evident for 2 (Resident #85 and #542) out of 4 residents reviewed for choices during the annual survey. The findings include: Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. During an interview conducted on 5/14/2024 at 9:04 AM, Resident #60 informed the Surveyor that he/she would like to go to Mass services in the morning, but he/she must wait for the Geriatric Nursing Assistant (GNA) to finish up with the other residents before they can assist him/her with ADLs for the day. The resident stated he/she must wait until about 11:00 AM before the GNA can get to him/her. The resident also mentioned that, on the days of Mass, he/she would like to be assisted with ADLs first thing in the morning so he/she can attend services. While conducting the interview, the Surveyor observed an activity calendar from April 2024 posted on the back wall behind the resident's bed and a sign, which stated Mass services on Sundays at 10 AM, posted on the side wall by the window. During further interview with Resident #60, the resident informed the Surveyor that he/she would like to get out of the bed to the chair more often than twice a week. The resident also stated that he/she seldom goes out of the room and would like to go out for activities or fresh air, but it was never offered. Resident # 60 stated, I have been in the bed so long, I don't even know what my legs can do. On 5/23/2024 at 11:28 AM, the Surveyor conducted an interview with GNA #58. GNA #58 informed the Surveyor that the resident needed total assistance with ADL's and that she was headed to his/her room to provide morning care. On 5/16/2024, 5/20/2024, 5/23/2024, 5/24/2024, and 5/28/2024 the Surveyor observed that Resident #60 had received morning ADLs between 10:30 AM and 11:30 AM.

Based on record review, and interviews it was determined that the facility failed to accurately assess a resident. This was found evident of 1 (Resident #96) out of 62 residents reviewed during an annual and complaint survey. The findings include: On 5/15/24 at 10:47 AM, the surveyor reviewed Resident #96's medical record. The review revealed that Resident #96 was admitted to the facility in late February 2023 and had a past medical history of, but not limited to, difficulty walking, muscle weakness, seizures, and cerebral infarction (stroke). The surveyor further reviewed the hospital admission history and physical dated January 31st 2023. In the assessment and plan section seizures were listed. It further stated seizures resulted from an anterior cerebral artery (aca) stroke. The plan further stated, continue home lamotrigine 150 mg twice daily (a medication prescribed to prevent seizures) and sertraline 75 mg daily (a medication prescribed to treat depression). On 5/22/24 at 12:04 PM, the surveyor reviewed the Medication Administration Record (MAR) for Resident #96. The review revealed that Resident was prescribed and given lamotrigine 150 mg twice a day with a reason listed as seizures. The order was written on 2/18/23. On 5/22/24 at 12:50 PM, the surveyor reviewed Resident #96's admission Minimum Data Set (MDS) assessment completed on 2/22/23. In section I, active diagnoses, seizures are not listed among the other diagnoses. On 5/23/24 at 9:46 AM, the surveyor interviewed the MDS Coordinator Staff #20. During this interview Staff #20 stated conditions and diagnosis are coded by looking at the admitting diagnosis, reviewing the discharge summary, and reviewing the medications ordered. The surveyor asked if the resident had a history of seizures noted on the hospital discharge paperwork and a medication written for seizure on admission why seizures were not coded for this resident on her admission MDS assessment. Staff #20 confirmed it was not coded on the admission assessment however was on the discharge assessment. She further stated it could have been a date entry error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff, it was determined that the facility failed to protect a resident, who was dependent on staff for turning and repositioning, from falling out of bed during care. This was evident for 1(Resident #65) of 1 resident reviewed during the annual survey. The findings include: Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological, and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities. A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It also outlines what needs to be done to plan, assess, and manage care. This helps to evaluate the effectiveness of the resident's care. Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. On 5/29/2024 at approximately 10:45 AM, during an interview with Resident #65, while in bed, the Surveyor observed Geriatric Nursing Assistant (GNA) #35 enter the resident's room with a gown, mask, gloves on, and linens in hand in preparation to provide ADLs. The GNA informed the Surveyor that she can provide ADL care for the resident by herself. On 5/30/2024 at 11:42 AM, during review of Resident #65's electronic medical record, the Surveyor discovered a nursing note dated 5/18/2024 at 2:54 PM written by Registered Nurse (RN) #55 which stated that the resident fell off the bed when ADL care was being given by the assigned GNA, on assessment, no redness, bruises or new skin alteration noted, denied pain when asked, Resident helped back to bed by nursing staffs, and in no apparent acute distress as at this time, RP made aware. Additional review of Resident #65's electronic medical record revealed that GNA #35 was the assigned GNA for Resident #65 on 5/18/2024. During that shift, she documented that the resident was dependent, needed extensive assistance with bed mobility, and completed the task with 1 person. Further review revealed a quarterly MDS assessment dated [DATE], which indicated that the resident was dependent on staff for bed mobility, including turning and repositioning. The resident also had a care plan for requiring assistance with ADL's and an approach for 2 persons assistance with bed mobility to be utilized by all staff. On 5/31/2024 at 12:40 PM during an interview with the Director of Nursing (DON), the Surveyor expressed the concern about the fall that Resident #65 sustained on 5/18/2024 during the one person assisted ADL care. The DON stated that the GNA's should be aware of the functional status of the residents they provide care for. The DON stated she will conduct an in-service on bed mobility with the nursing staff.

Based on medical record review and interviews, it was determined that the facility staff failed to initiate appropriate bladder and bowel interventions to maintain dignity for (Resident #85). This was evident for 1 of 61 residents reviewed during an annual survey. The findings include: During an interview with Resident #85 on 05/13/24 at 11:13 AM, the resident stated that he/she could walk but had consistently worn a brief since admitted to the facility. He/she expressed the desire to use the bathroom. Resident #85 stated that he/she walks to therapy and other areas in the facility using a walker. During an interview with GNA #35 on 05/21/24 at 09:59 AM they were asked about the care she provided for Resident #85. GNA #35 stated she gave him/her a shower, oral care, and assisted with transfer to wheelchair. She also stated the resident stays in the room, he/she uses a walker to transfer to a wheelchair, and he/she would try to get to the bathroom. GNA #35 confirmed the resident wore briefs and occasionally used a urinal but she cleaned him/her up during her morning shift. GNA #35 stated the resident was able to use his/her call light when assistance was needed. During an interview with GNA #2 on 05/23/24 at 11:34 AM, she stated Resident #85 needed help with most things, mostly with his/her bottom half to change his/her brief. GNA #2 stated that the resident went to therapy by wheeling his/her self down, then he/she would walk back from therapy. GNA #2 confirmed the resident never used the bathroom since being here, and he/she wore a brief since being admitted .

Based on record review, and interviews it was determined that the facility failed to accurately dispense and record medications as per scheduled ordered time. This was found evident of 1 (Resident #103) of 5 Residents reviewed for pain management. The finding include: On 5/14/24 at 11:41 AM, the surveyor reviewed Resident #103's medical record. The review revealed that Resident #103 was admitted in early November 2022. Further review revealed that Resident #103 was prescribed a pain medication, oxycodone, on 11/3/22. The order was for oxycodone 5 mg every 6 hours as needed for pain. In review of the progress note dated, 11/7/22, Licensed Practical Nurse (LPN) Staff #30 wrote; Resident continues to complain of pain to his/her right knee. It further stated the Medical Director evaluated Resident #103 and wrote orders for routine oxycodone to be given at 7 AM along with the as needed oxycodone. On 5/15/24 at 7:56 AM, the surveyor reviewed Resident #103's Medication Administration Record (MAR). The review revealed that oxycodone 5 mg was scheduled to be given at 8 AM starting 11/8/22. From 11/8/22-11/30/22 the scheduled oxycodone was documented at given on the scheduled time twice, 12 times the scheduled oxycodone was documented as given with a comment; charted late, once charted as given late, once with a comment other and another medication not available. On 11/17/22 & 11/28/22 the sign off for the scheduled oxycodone was blank. On 5/15/24 at 11:49 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #19. During the interview Staff #19 stated that when she gives pain medications, she charts the administration shortly after giving the medications in the MAR. On 5/16/24 at 9:59 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated that it is the expectation that staff document administration of the medication in the MAR when the medication is given. The surveyor showed the DON the MAR documentation for Resident #103's scheduled oxycodone. The DON agreed that only 2 days the medication was documented as given on schedule and the delayed documentation was done by multiple staff. She further stated she was not the DON at the time and can't speak about the documentation practices at the time.

Based on observations, interviews and medical record review it was determined that the facility failed to label and store medications appropriately. This was evident in 1 (Resident #27) out of 1 Resident for medication labeling and storage. The findings include: During the initial tour of the second floor Nursing Unit A at 7:49 AM on 5/14/24 the surveyors observed Resident #27 in bed with medications at his/her bedside. The surveyors observed 2 medication cups, one sat inside the other on the overbed tray table. There were 2 small white tablets in one of the medication cups and an orange-colored tablet in the other medication cup. The surveyors interviewed Licensed Practical Nurse (LPN) #1 at 8:09 AM on 5/14/24 who observed the medications at the bedside, 2 small white tablets and an orange-colored tablet in the medication cups. LPN #1 stated to the surveyors that she was unsure of what the medications were and that she had not given the medications to Resident #27. LPN #1 further indicated that she did observe Resident #27 take the 8:00 AM medications that were scheduled to be administered that morning. When asked by the surveyors had she seen the medications on the overbed tray table, LPN #1 stated that she had not probably due to the clutter on the overbed tray table. The surveyors asked LPN #1 what the expectation was for medications at the bedside and LPN #1 informed the surveyors that medications should not be left at the resident's bedside. At 8:20 AM on 5/14/24 the surveyors conveyed to the Director of Nursing and the Interim Administrator that 3 medications were observed by the surveyors and LPN #1 at the bedside for Resident #27. There were 2 medication cups, one sat inside the other on Resident #27's overbed tray table. There were 2 small white tablets in one of the medication cups and an orange-colored tablet in the other medication cup. The Director of Nursing stated that she would investigate this. The Medication Administration Record (MAR) is the clinical record used by the nursing staff for documentation of medications administered to the resident. On 5/14/24 at 9:15 AM the surveyors reviewed Resident #27's medication administration records (MAR) for the month of April and May 2024. According to the documentation on the MAR for the month of May, Resident #27 received the following medications at 8:00 AM on 5/14/24: amlodipine tablet, metformin tablet, and metoprolol tablet and these medications were documented as given by LPN #1. No additional medications were administered to Resident #27 by LPN #1 according to the documentation on the MAR for 5/14/24. During an interview with the Director of Nursing (DON) on 5/14/24 at 9:20 am the DON confirmed with the surveyors that she observed an unknown medication in the medication cup on Resident #27's overbed tray table.

Based on record review and interview with residents and staff, it was determined that the facility failed to ensure a resident requesting dental services received a timely appointment. This was evident for 1 (Resident #60) out of 2 residents investigated for dental services during the annual survey. The findings include: During an interview conducted on 5/14/2024 at 9:00 AM with Resident #60, the resident stated, I need to go to the dentist. The resident informed the Surveyor that he/she has not received any dental services while residing at the facility. On 5/24/2024 at 8:15 AM, review of Resident #60's electronic medical record revealed a nursing progress note written on 10/03/2023 at 12:08 PM written by Licensed Practical Nurse (LPN) #56 stating that the resident was requesting for [Company] dental. Additional record review revealed a nursing progress note dated 2/25/2024 at 8:33 AM written by LPN # 57 which stated Resident #60 was complaining of a toothache and another nursing progress note dated 2/25/2024 at 3:05 PM, stated that an order for pain relief medication and an order for a dental consult had been written. A social services progress note dated 3/05/2024 at 2:39 PM revealed that the resident had been referred to [company] for dental services as requested by the family. On 05/24/2024 at 08:39 AM during record review, the Surveyor noted a [company] request by the facility Medical Director on 3/06/2024 for Dental services for an Oral Health evaluation. During further review of Resident #60's electronic medical record, the Surveyor discovered that on 3/07/2024 an oral gel was ordered for pain and to be applied to the gums before meals. The resident experienced some pain relief. Additional review revealed a physician's progress note dated 3/11/2024 which stated that Resident #60 was still experiencing tooth and gum pain. An antibiotic was ordered for dental care from 3/11/2024-3/14/2024. On 5/24/2024 at 11:30 AM during continued record review, the Surveyor was unable to locate documentation stating that [Company] provided dental services for Resident #60 after the request on 10/03/2023. On 5/24/2024 at 12:06 PM, an interview conducted with Social Worker #28 revealed that he was unfamiliar with [Company's] process and he was unable to provide the Surveyor with documentation that the resident received dental services. Social Worker #28 was able to set up an appointment for the resident during the next in-house dental visit on 6/24/2024. As of 5/29/2024, the Surveyor did not receive documentation of dental services provided to Resident #60. The Director of Nursing (DON) had been made aware of the concern and reconfirmed the resident's appointment on 6/24/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to ensure medical records were complete by voiding old MOLST forms when new MOLST forms were completed. This was evident for 1 (Resident #60) of 62 residents reviewed during the annual survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. A full code provides full support, including CPR, and allows all interventions needed to restore breathing and/or heart functioning. During review of Resident #60's electronic medical record on [DATE] at 9:20 AM, the Surveyor discovered the 2 MOLST forms. The first completed MOLST form was signed and dated [DATE], certifying that the orders are entered as a result of a discussion with and the informed consent of the patient [resident], and allow for CPR to be provided. The second MOLST form was signed and dated on [DATE], certifying that the orders are entered as a result of a discussion with and the informed consent of the patient's [resident's] surrogate as per the authority granted by the Health Care Decision Act, and allow for CPR to be provided. During an interview conducted with the Director of Nursing (DON) on [DATE] at approximately 11:00 AM, the Surveyor was informed that when a new MOLST form is completed, the physician will notify the nursing staff, communicate any changes made, and place the form in the resident's physical chart. The physician will void the old MOLST form by drawing a diagonal line through the form, writing VOID across the page, sign and date it, and then place it in the resident's physical chart. Medical records will be informed and upload the current MOLST form into the resident's electronic medical record as well as the voided MOLST form to ensure nursing staff is aware of the changes made. On [DATE] at approximately 11:10 AM, the DON and Medical Records #45, confirmed that Resident #60 had two MOLST forms in their electronic medical record. Medical record #45 stated that she would make sure to have the physician void the old MOLST form dated [DATE], upload the voided document into the resident's electronic medical record, and then place the form in the resident's physical chart. On [DATE] at 12:05 PM, the Surveyor confirmed the current MOLST form date [DATE] and the voided MOLST form dated [DATE] updated in Resident #60's electronic medical record and the physical chart.

The facility failed to ensure that a staff member implemented appropriate processes related to handling and storing of a shared resident medical equipment. As a result, the potential existed for transmission of organisms between residents who received assessments of their blood pressure during medication observation. This was evident for 2 Residents (#2 and #68) of 5 observed during medication administration. The findings include: On 05/30/24 at 11:02 AM a Licensed Practical Nurse (LPN), Staff #19, was observed during medication administration to remove a blood pressure machine from the medication cart, apply the blood pressure cuff onto Resident #68's left arm, and place the attached digital screen on the resident's bedside table. After completing the assessment, Staff #19 placed the machine on the medication cart. On 5/30/24 at 11:18 AM surveyors conducted an interview with Staff # 19 promptly after the observation which revealed that Staff #19 confirmed that the blood pressure machine was for use with all residents for whom she was assigned. Staff #19 confirmed that she did not sanitize the machine before use with Resident #68. On 5/31/24 at 8:12 AM a Licensed Practical Nurse (LPN), Staff #7, was observed during medication administration to remove a digital blood pressure machine from the medication cart, apply the blood pressure cuff onto a Resident #2's arm and place the attached digital screen on the resident's bedside table. After completing the assessment, Staff #7 placed the machine on the medication cart without sanitizing/disinfecting the machine for use with another resident. An interview with the Director of Nursing (DON) on 5/31/24 at 10:50 AM, revealed that it was the expectation of the facility that shared equipment for resident care, such as a blood pressure machine, was to be disinfected before and after use with a resident. The surveyors shared the observations of Staff #19 and Staff #7 and the concern that they failed to follow standard precautions during the performance of blood pressure assessments.

Based on observation and interview, it was determined that the facility staff failed to maintain an adequate functioning call system in resident bathrooms. This was evident for 2 (Resident #85 and #542) of 62 residents reviewed during the annual survey. The findings include: During observation of Resident #85's room on 05/13/24 at 11:13 AM, surveyor observation determined an inadequate call system in Resident #85's bathroom. The call system was missing the string that is to be pulled for residents to access. During observation of Resident #542's room on 05/13/24 at 11:21 AM, surveyor observation determined an inadequate call system in Resident #542's bathroom. The call system was missing the pull cord used for emergencies. During interview with Maintenance Director (Staff # 17) on 05/21/24 at 01:07 PM, he was asked about what the resident bathroom call system configuration consisted of in the facility. Staff #17 confirmed he is new to the facility, some of them have strings, some have chains, and he was not familiar with call systems. He stated he would have to ask the nurses, he has never seen anything like this before and he has never worked in a healthcare facility. He also stated testing for call systems is done remotely and would have to rely on the nurses to identify dysfunctional call systems. During an interview with the Regional Clinical Consultant on 05/23/24 at 01:46 PM she stated essentially that if there is a hole in the call system appliance, there should be a string attached to it for the resident to pull. Staff #4 also stated whoever is in the room at the time should identify issues and put them in the maintenance logbook.

Based on observation and interview, it was determined that the facility failed to ensure that a handrail was secure. This was found to be evident for 1 out of 5 handrails tested during the annual survey. The findings include: During an observation on 05/16/2024 at 10:08 AM, the surveyor observed that the handrail to the left of the 1C Bath door was lose on the wall. The Maintenance Director was shown where the rail was loose from the wall on 05/16/2024 at 10:15 AM. The Maintenance Director stated he would fix it right away. The Administrator was shown the loose handrail on 05/16/2024 at 12:23 PM. She stated they would get it repaired as soon as possible. The surveyor and the Administrator observed that the handrail was tighter but still loose on 05/31/2024 at 8:57 AM. The Administrator called the Maintenance Director who stated he would fix it right away. The Administrator showed the surveyor at 05/31/2024 at 9:09 AM that the siderail was secure and stated the Maintenance Director was inspecting the remaining siderails in the building.

Based on observation, interview, and record review, it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of a pest in the hallway. This was found to be evident for the 1B hallway. The findings include: On 05/15/2024 at 7:46 AM, the surveyor and GNA #2 observed a cockroach crawl up the wall and behind a picture outside of room B130. The surveyor pointed to the wall and asked what's that? GNA #2 responded, That's a cockroach crawling up the wall. She further stated, we do see cockroaches here and there. More upstairs than down. The residents upstairs have more stuff in their rooms because they are long term. The surveyor asked if she had seen any other pests and GNA #2 stated, I have never seen any mice or other pests. On 05/15/2024 at 11:30 AM, the Administrator informed the surveyor that the pest management company would be coming to do an additional treatment that day. The surveyor observed the pest management company treating the facility on 05/15/2024 at 1:29 PM.

4) On the initial tour of nursing Unit A on the second floor of the facility, the surveyors observed on 5/14/24 at 10:15 AM, Resident #2 in bed. Resident #2's call light and cord were lying on the floor out of reach from the Resident to request his/her needs and preferences. The surveyors conveyed this observation on 5/14/24 at 10:45 AM to LPN (Licensed Practical Nurse) #1 that Resident #2's call light and cord was on the floor and not accessible for Resident #2 to request his/her needs and preferences. 3) A Hoyer lift is a mechanical lifting device that allows a person to be lifted and transferred to the bed or chair with a minimum of physical effort. On 5/14/2024 at 1:37 PM, during a tour of the first floor B Unit, the Surveyor noted Resident #81 in the doorway of his/her room, sitting in a wheelchair with a Hoyer pad underneath him/her, and his/her head down. The resident's call bell was alarming. The Surveyor conducted an interview with the resident and discovered that he/she had been sitting there for over 40 minutes waiting for someone to assist him/her back to bed. The resident stated that a Geriatric Nursing Assistant (GNA) left him/her there to locate a Hoyer lift to transfer him/her back to bed. Resident #81 mentioned that he/she had not been happy lately and was very upset because finding a Hoyer lift is always an issue here, so I just have to sit here and wait. According to Resident #81, the nursing staff fails to respond to call bells timely leaving the residents waiting for long periods of time before someone comes to check on them. The resident stated that one day he/she had to wait until 2 PM before someone could assist him/her with morning care and getting out of the bed to the chair for the day. The resident informed the Surveyor that he/she can't even go to activities if he/she wanted to because the nursing staff can never find a Hoyer lift to assist them out of bed. On 5/14/2024 at 1:45 PM, the Surveyor observed the Director of Nursing (DON) and Administrative Support assist the resident back to bed. The Surveyor informed the DON of the residents' concerns. On 5/16/2024 at 8:05 AM during review of Resident #81's electronic medical record, the Surveyor discovered the resident was unable to walk, dependent on a wheelchair for mobilization, and required the use of a mechanical lift (Hoyer lift) for transfers, with the assistance of 2 staff members. (Cross reference F550) Based on observations and interviews it was determined that the facility failed to provide residents with reasonable accommodations of needs. This was found evident of 5 (Resident #18, #11, #66, #81 & #2) out of 62 residents reviewed. The finding include: 1a) On 5/15/24 at 8:18 AM, the surveyor, along with Geriatric Nursing Assistant (GNA) Staff # 43, observed Resident #18 laying in bed. The surveyor asked Resident #18 where his/her call light was in case he/she needed to call for assistance. Resident #18 stated he/she did not know. At this time Staff #43 picks up the call light cord from behind Resident #18's bed and clips it to Resident 18's bed. Staff #43 confirmed that the call light was out of reach and should have been placed back in bed after it was removed. On 5/15/24 at 12:15 AM, the surveyor reviewed a progress note written on 2/24/24 by Licensed Practical Nurse (LPN) Staff #46. The note stated Resident #18 was a new admission adjusting well. It further stated Resident #18 demonstrates appropriate use of the call bell this day. On 5/16/24 at 9:59 AM, the surveyor informed the Director of Nursing (DON) of the observation and confirmed the Resident should have a call light in reach. 1b) On 5/29/24 at 9:09 AM, the surveyor observed GNA Staff #44 inside Resident #11's room. On further observation it was noted that Resident #11 was being lifted via a sling and a Hoyer lift. Resident #11 was observed being up in the air over his/her bed. Staff #44 was the only other person in the room with Resident #11. The surveyor was just outside the door and Staff #44 informed the surveyor that another staff member had just left to assist someone else and she was told he would return to help her. She further stated she was aware there must be two staff while moving someone in a Hoyer lift and confirmed that was why she was waiting to move Resident #11. On 5/29/24 at 9:14 AM, the surveyor observed Staff #44 lower Resident #11 back down to his/her bed and inform the resident that she would return when she found another staff member. On 5/29/24 at 9:19 AM, the surveyor interviews Resident #11. During this interview Resident #11 confirms two staff members were helping to get him/her up but one had to leave. On 5/29/24 at 9:19 AM, Staff #44 returned with another staff member to assist with the Hoyer lift. On 5/29/24 at 10:07 AM, the surveyor interviewed the Director of Nursing (DON). The surveyor described the observations of Resident #11 being left up in the sling while waiting for assistance from another GNA. Staff started to assist Resident #11 and was then asked to wait while in the middle of the assistance. The DON confirmed that Resident #11 should not have been left in the middle of assistance. She further stated she would be educating her staff and not have this happen again. 2a) During an observation conducted on 05/13/2024, 05/14/2024, and 05/15/2024 the surveyor observed three beds, cut cardboard boxes and trash located inside of the Chapel near the front entry of the Chapel. A review of the facility's activity calendar conducted on 05/14/2024 at 8:30 AM revealed that Chapel service was scheduled for every Tuesday and Thursday of each week at 2:00 PM. During an interview conducted on 05/14/2024 at 9:45 AM, the Activity's Assistant #31 stated that the beds were stored inside the Chapel on Thursday 05/09/2024. The Activity's Assistant further stated that the Chapel was not accessible to the residents because of the beds located in the Chapel. During an interview conducted on 05/14/2024 at 11:22 AM, the Director of Nursing (DON) confirmed the beds were stored inside of the Chapel and the plan was for all the beds to be removed by Friday 05/17/2024. On 05/20/2024 at 10:19 AM an interview was conducted with the Activity's Assistant #31. The Activity's Assistant confirmed that residents did not have access for Chapel Service on 05/14/2024 due to the storage of beds inside of the Chapel. 2b) During an observation conducted on 05/17/2024 at 11:47 AM the surveyor observed an audio call bell light blinking above Resident #66's entry door for 25 minutes. Resident #66 appeared frustrated and advised the surveyor that he/she had waited since breakfast to receive care and wanted to get up for lunch. The surveyor also observed Resident #81 in a wheelchair in front of his/ her entry door. Resident #81 advised the surveyor that a staff member moved him/her from the lobby and left him/her in the hallway to wait for a staff member to transfer him/her to the bed. The resident appeared frustrated and expressed he/she was tired of waiting and wanted to get back in bed. During an observation conducted on 05/17/2024 at 11:48 AM, the surveyor observed Licensed Practical Nurse (LPN) #19 at the medication cart two resident rooms down from Resident #66's room. During an interview conducted on 05/17/2024 at 11:48 AM, LPN #19 stated she was aware that Resident #66 required care since breakfast, but she could not locate GNA#50. On 05/17/2024 at 11:52 AM the surveyor advised the Director of Nursing (DON) during an interview that Resident #66 call bell light had been illuminated for an extended period. The surveyor also advised the DON that Resident #81 had been dropped off in his/her wheelchair in the hallway in front of his/her resident room and was waiting for staff to transfer him/her to bed. The DON stated that there was a callout, and she would have staff come to assist the residents. The DON further stated that the facility's expectation was for call bells to be answered in a timely manner and that if a GNA was not available the nurse would be expected to address the needs of the resident. The DON called Staff Scheduler /GNA #59 and Central Supplies /GNA #51 to come to the nursing unit to provide care to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation of Resident #85's room on 05/13/24 at 11:21 AM, surveyor observation revealed Resident #85's bathroom ceiling light fixture was filled with insects. During interview with the Housekeeping Director #10 on 05/23/24 at 01:46 PM she was asked about the cleaning schedule for the facility. They stated work is distributed for two wings per person, they clean rooms and bathrooms once per day. Staff #10 also stated housekeeping is responsible for cleaning bathroom counter sinks, windows, and mirrors. Staff #10 also confirmed they are aware of the bugs in light fixtures and that it is a maintenance responsibility and is usually put in the maintenance book. During interview with Resident #542 on 05/21/24 at 10:09 AM, he/she stated that the cleaning of bathrooms does not happen everyday. He/she also pointed out a broken light fixture behind bed, and lights not working over the sink. During observation of Resident #542's room on 05/13/24 at 11:21 AM, the surveyor observed Resident #542's bathroom with a brown stain on the ceiling. During observation of resident rooms on 5/21/24, the surveyor observed resident rooms [ROOM NUMBER] with sink lights not working. During observation of the facility on 05/13/24, the surveyor observed a mold-like, crusted, substance formed around the fire alarm in the ceiling of the hallway. During interview with Maintenance Director (Staff #17) on 05/21/24 at 01:07 PM he was asked about obtaining maintenance requests for the facility. Staff #17 confirmed that maintenance requests books are located at the front desk or nurses' station and on the second floor of the facility. Staff #17 stated he was not sure of any light bulbs out. He confirmed relying on the nurses to put requests in the maintenance log for light out. He stated there are only two of them working so they would have to prioritize what is important. Staff #17 was also asked about a mold-like substance formed around the fire alarm in the ceiling of the hallway. He stated there had been leaks in the facility the year prior, but no one had addressed the wall issues. On 05/16/2024 at 09:37 AM, the surveyor observed that the 1B Shower Room had an access panel in the shower room duct taped to the wall that was ajar 1 inch, caulk was stained and lose in the corner of the shower, and the window frame had two .5 inch holes. The screen behind the window was torn. The 1C Bath was observed on 05/16/2024 10:05 AM. The lock was broken, and maintenance had to be called to enter the room. Near the scale there was a soiled corner with missing caulk. This was shown to the Housekeeping Director who stated they would have it cleaned today. The Maintenance Director was shown the concerns regarding the 1B shower room access panel, the caulk, and the holes in the window and the 1C Bath missing caulk on 05/16/2024 at 10:50 AM. He stated they would be repaired as soon as possible. The Administrater was shown the 1B shower room access panel, the caulk, and the holes in the window on 05/16/2024 at 12:22 PM. She was also shown the concerns in the 1C Bath of the soiled corner and the missing caulk. She stated they would be repaired as soon as possible. The surveyor noted that the new lock had been installed on the 1C Bath door. 05/17/2024 at 12:12 PM the surveyor observed that the 1B shower stall caulk had been removed and new caulk applied. The 1C soiled corner had been cleaned but no caulk was replaced. 05/31/2024 at 8:28 AM the 1B Shower window holes had not been repaired or the 1C Bath caulk replaced. The Administrator and the Maintenance Director observed the 1B shower window holes and the 1C caulk on 05/31/2024 at 9:21 AM and stated both would be repaired shortly. Based on observations and facility staff interview it was determined the facility failed to maintain a safe, clean and comfortable home like environment free of possible hazards. This was evident for 5 residents ( # 40, #67, #24, #85, & #542) out of 62 residents observed for home like environment and 4 out of 6 shower and bathing environments observed in the facility. The findings include: During tour of the facility on 05/13/24 at 9:215 AM, surveyors observed: In Resident # 40's room: - Extensive paint damage on all walls (peeled/removed). - One green Geri- chair (a large padded chair with a wheeled base, designed to assist seniors with limited mobility) a the resident's -bedside with tattered arm rests, inner material visible. - A mattress air flow device attached to the foot of the resident's bed, with it's black power cord on the floor, plugged into an electrical wall socket located a the base of the wall opposite the resident's bed; the cord covered a distance of approximately 3 feet, cord approximately 10 feet in length. During tour of the facility on 05/14/24 at 8:15 AM, surveyors observed: In Resident # 67's room: - The door to the room was ajar, white bed linens on the mattress with a large dark stain on the middle section of the mattress, on plastic urinal container on the floor at the bedside; multiple sections of damaged paint on the wall behind the head of the resident's bed measuring approximately 2 to 3 feet in width. - Two meal trays: one rested on top of a flat surface near the entryway of the room which had a meal ticket dated 5/13/24 Dinner, with empty food containers, plate, plate warmers, and empty cups on the tray; the other meal tray located on top of the radiator under the window, had a meal ticket ticket dated 5/14/24 breakfast with an empty plate, plate warmers, empty juice container, crushed soiled papers and food debris. On 5/13/24 at 10:15 AM surveyors conducted a tour of the facility. The concerns identified during the tour were: The shower room on the 4th unit: - Several broken and loose white (2 inches by 2 inches each) wall tiles located on the partition wall between the shower area and the bath area. The shower rooms on the 2nd unit: - Rust-appearing substance on the upper door hinge; attaching the door top the upper door frame to the top side of the door. - Several broken tiles upon entrance to the shower room located on the left. - One rectangular, rusty metal container with sharp edges (device was approximately 10 inches by 6 inches) hanging on a wall opposite the shower area. - One window drape/shade propped up against the wall next to the window sill, appeared soiled with black and dark gray substance, no drape or shade in place on window. - Dark gray/Black- circular in shape substance, scattered along the entire door frame of the shower room. - A white sheet of paper posted to a wall with dark gray/black- circular in shape substance, on the entire surface of the paper. In Resident # 24's room: - A television mounted on the wall about 10 ft from the ground connected by its power cord (54 inches long) to a surge protector power strip suspended in mid-air (approximately 22 inches from the ground). On 5/21/24 at 10:38 AM surveyors conducted a tour of the facility with the Maintenance Director. The Maintenance Director acknowledged the electric cord in Resident #40's room as a potential hazard and confirmed all of the environmental concerns identified on 5/13/24. The Maintenance Director confirmed the identified concerns will be addressed and added to the department's work list. On 5/22/24 7:43 AM The Director of Nursing (DON) toured with the surveyors, observed the previously identified findings and confirmed that the Maintenance Department was to be consulted.

5.) On 5/30/24 at 9:57 AM the surveyor reviewed the Facility Reported Incident (FRI) dated 3/5/2024 (initial report) and 3/12/2024 (final report). The facility investigation alleged that Resident #19 had an injury of unknown origin. Further review of the Facility Reported Incident by the surveyors revealed that Resident #19 had a comminuted intratrochanteric fracture of the neck of the left femur as indicated on the TridentCare radiology report at 5:45 PM on 3/4/24 which was performed at the facility. Resident #19 was transferred to the hospital on 3/4/24 for the fracture of the left femur as per physician order and required surgical intervention for the fracture of the neck of the left femur. The surveyors reviewed the facility ' s Leadership Policies and Procedures - Organizational Ethics - Abuse, Neglect, Exploitation, or Mistreatment on 5/30/2024 at 12:47 PM. According to the facility policy and procedure dated 11/1/2017 for injury of unknown source this alleged violation is to be reported immediately. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where the state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 5/14/24 at 8:01 AM the surveyor attempted to interview Resident #19; Resident #19 responded to the surveyor by opening his/her eyes when his/her name was called and mumbled a word. The surveyor conducted a phone interview with Resident #19's daughter on 5/15/24 at 11:43 AM. Resident #19's daughter conveyed to the surveyor that the Resident went to the hospital for a broken hip and femur on 2 occasions, and the daughter did not know if the Resident had fallen. On 5/30/24 at 1:20 PM the surveyor interviewed the Director of Nursing (DON) and reviewed the facility investigation file of the reported injury of unknown origin. The surveyor confirmed with Director of Nursing (DON) that the facility received the radiology report at 5:45 PM on 3/4/24 and that Resident #19 was transferred to the hospital per physician order on 3/4/24 for the fracture of the neck of the left femur. Upon review of the hospital discharge summary it revealed that Resident #19 required a surgical intervention for intramedullary nailing (surgery to repair a broken bone and keep it stable) of the left femur. At 7:20 AM on 5/31/24 the surveyor conveyed to the Director of Nursing that further review of the investigation file for the Facility Reported Incident for Resident #19 revealed that the injury of unknown origin, serious bodily injury, fracture of left femur was not reported by the facility within 2 hours of the allegation to the State Survey Agency. The facility was notified of the fracture of the left femur at 5:45 PM on 3/4/24 by TridentCare radiology report. Resident #19's physician was notified at 6:25 PM on 3/4/24 of the fracture of the left femur and ordered to transfer Resident #19 to the emergency room (ER) for evaluation. The facility reported the injury of unknown origin, serious bodily injury, fracture of the left femur on 3/5/24 at 5:25 PM to the State Survey Agency. The Director of Nursing stated to the surveyor that she thought that she had 24 hours to report the initial report of an injury of unknown origin that resulted in serious bodily injury to the State survey Agency. Based on medical record review and interview, it was determined that the facility staff failed to timely report an allegation of abuse to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the abuse allegation was made. This was evident for 5 (Resident #57, #34, #93, #51, and #19) out of 30 residents reviewed for facility self-report incidents during an annual survey. The findings include: 1). Review, on 05/29/24 at 10:25 AM, of the facility's self-report investigation file revealed that the Assistant Director of Nursing (ADoN) documented on the Facility's Incident Investigation Form in reference to Resident #57 incident the time was on 06/28/23 at 3:00 PM. Based on the allegation of abuse/harm, the facility's self-report (MD00193871) had to be sent to the State agency no later than 2 hours after the incident had occurred or was reported. Further review revealed that staff had sent the facility self-report to the State agency, on 06/28/23 at 5:37 PM, 2 hours and 37 minutes later. During the interview, on 5/30/24 at 09:30 AM, the ADoN and the Regional Administrator Staff #4, confirmed that facility staff was made aware of the abuse allegation, however, the initial self-report was not sent to the State agency until 06/28/23 at 5:37 PM. 2). Record review, on 5/23/24 at 10:25 AM, of the facility's self-report investigation file revealed that the Director of Nursing (DoN) documented on the Facility's Incident Investigation Form that the facility was made aware of the incident in reference to Resident #57 on 12/11/23 at 3PM. The initial facility's self-report (MD00200712) was sent to the State agency on 12/12/23' at 10:50AM, more than 19 hours later. During the interview, on 5/26/24' at 9:56 AM, the DoN confirmed that the initial self-report for this abuse allegation had not been sent within 2 hours after the incident was reported. 3). Record review, on 5/29/24' at 09:05AM, of the facility's self-report file found that an initial self-report (MD00182503) in reference of Resident #34 was not sent to the State Agency. However, the local police report revealed that the Police was notified on 3-18-22' with a case# pp22031800001656. Further record review revealed that on the facility's self-report investigation form the alleged incident time dated on 03/23/22 at 8 AM which it was 5 days later. From the State Agency intake record indicated the received time was also 5 days late on 03/23/22' at 10:21 AM. During the interview, on 5/30/2024 at 1:00 PM, the DoN confirmed that the facility staff were made aware of this reasonable suspicion of abuse on 3-18-22. However, there was no record of the initial self-report investigation being conducted immediately. 4.) On 05/22/2024 at 1:02 PM a review of the Facility Reported Incident investigation revealed an allegation of abuse. According to the facility's investigation Resident #93 advised his/her Responsible Party (RP) that he/she was hit on the face with a pillow by a Geriatric Nursing Assistant (GNA). On 11/24/2022 Registered Nurse (RN) Supervisor #4 provided the RP a requested grievance form and was advised at that time of the allegation of abuse. However, the facility did not report the allegation of abuse to the OHCQ until 11/30/2022 following receipt of the resident's RP grievance form dated 11/29/2022. Further review of the investigation report revealed a written statement from the alleged perpetrator GNA #9. The GNA stated that following the care provided on 11/19/2022 Resident #93 accused the GNA of hitting him/her on the face with a pillow. The GNA also stated in the report that she mentioned it to the nurse but did not make a formal report. On an interview summary worksheet, Licensed Practical Nurse (LPN) #27 stated that Resident #93 told the LPN on 11/20/2022 that a GNA hit him/her on the face with a pillow the previous day. The LPN further stated that he/she reported the allegation to the RN Supervisor #26. On an interview summary worksheet, RN Supervisor # 26 stated that she was advised by LPN #27 on 11/20/2022 of the allegation of abuse for Resident #93. The RN Supervisor stated that she interviewed the resident who could not recall the incident. The RN Supervisor further stated that she did not report the incident to management because the resident could not recall the incident. During an interview conducted on 05/22/2024 at 11:09 AM, the Director of Nursing (DON) acknowledged the staff were made aware of the allegation of abuse but failed to report to management. The DON further stated that she would conduct an in service to educate her staff on following the facility policy in reporting abuse. During an interview conducted on 05/14/2024 at 8:30 AM, Resident #51 reported to the surveyors that a GNA provided rough care and pulled on his/her enteral feeding tube. On 05/14/2024 at 9:25 AM, the surveyors reported the allegation of abuse to the DON. The DON stated she would begin an investigation and notify OHCQ. A review of a Facility Reported Incident investigation on 05/30/2024 at 7:22 AM revealed an allegation of abuse for Resident #51. The investigation revealed that the Resident reported to the Assistant Director of Nursing (ADON) that GNA #48 provided rough care and pulled on his/her enteral feeding tube on 04/30/2024. The facility did not report the allegation of abuse until 05/14/2024 when the surveyors reported the allegation to the DON. During an interview conducted on 05/30/2024 at 10:49 AM, the ADON confirmed that Resident #51 reported that GNA #48 had an attitude and provided rough care on 04/30/2024. The ADON also stated that she did not report the allegation of abuse because the resident always complains about certain staff. During a follow-up interview conducted on 05/31/2024, The DON stated she would educate the ADON on the facility 's expectations and policy to report abuse.

3) On 5/15/24 at 10:00 AM, the surveyors reviewed the investigation file of the Facility Reported Incident (FRI) dated 5/19/2023. Review of this investigation file revealed that The Comprehensive & Extended Care Facilities Self-Report Form and the Resident Face Sheet were the only documentation included in this file. Further review of this form indicated that it was the initial report submitted by the facility. This initial report form revealed that Resident #2 reported that he/she was missing 25 dollars (two $10 bills and one $5 bill) and that the Administrator was notified and that the facility initiated an investigation. On 5/23/24 at 12:01 PM the surveyors interviewed the Interim Nursing Home Administrator (NHA) and she was not able to provide an investigation of the facility reported incident dated 5/19/23. At the request from the surveyor, the Office of Health Care Quality (OHCQ) provided a copy of the 5-day final report. The surveyor then provided a copy of the 5-day final report to the Interim NHA at her request. During an interview with the Director of Nursing (DON) at 11:00 AM on 5/24/24 she conveyed to the surveyors that Resident #2 was reimbursed with $25 from the Interim NHA on 5/23/24. The surveyor reviewed the facility ' s Leadership Policies and Procedures - Organizational Ethics - Abuse, Neglect, Exploitation, or Mistreatment policy on 5/28/24. The policy indicated that the facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property and/or funds and are reported immediately. On 5/30/24 at 9:57 AM the surveyor reviewed the Facility Reported Incident dated 3/5/2024 (initial report) and 3/12/2024 (final report). The facility investigation alleged that Resident #19 had an injury of unknown origin, fracture of the neck of the left femur. Further review of the facility investigation by the surveyors revealed that the facility only interviewed staff members and did not interview Resident #19 and/or Resident #19's daughter. Also, the investigation file did not include any documentation that other residents were interviewed during the investigation process. The surveyor interviewed the Director of Nursing on 5/30/24 at 10:28 AM and the DON confirmed that the investigation file that was reviewed by the surveyor was a complete investigation file. The surveyor conveyed to the Director of Nursing that other residents in the facility interviews were missing from the investigation file. The Director of Nursing provided no additional documentation for the investigation file as of exit on 5/31/24. 5) SBAR note stands for Situation, Background, Assessment, and Recommendation is a form of communication used to help the healthcare team share information about the condition of the patient/resident. On 5/30/2024 at 8:15 AM, the Surveyor reviewed Resident #21's electronic medical record and discovered an SBAR note written by Licensed Practical Nurse (LPN) #52 on 4/09/2023 at 8:50 PM. The note stated that the resident is noted with redness to the left forehead, denies pain, doesn't respond to pain when site is touched, Resident is alert and oriented x2, able to state [his/her] name and time. Resident #21 was unable to recall how and when the redness to the left forehead happened. There was no other documentation of this injury of unknown origin. A review of the Facility Reported Incident (FRI) investigative file on 5/30/2024 at 10:00 AM revealed that the facility began an investigation into an injury of unknown origin on 4/10/2023 and reported it to the Office of Healthcare Quality on 4/13/2023 at 10:38 AM. During continued review of Resident #21 investigative file, the Surveyor confirmed that the facility completed their investigation on 4/14/2023. Further review of the Facility Reported Incident (FRI) investigation revealed the facility failed to conduct a thorough investigation. The facility failed to interview all nursing staff who interacted with the resident on shifts prior to and after the identification of the injury of unknown origin, failed to obtain a statement from LPN #52, who documented the observation of the injury, failed to interview all residents on unit A on the second floor, and failed to obtain LPN #54's, the assigned nurse for Resident #21, signed statement. The Director of Nursing (DON) was unable to provide further information regarding the nature of the FRI investigation because the incident occurred prior to her start in the role of DON at the facility. Based on record review, and interviews, it was determined that the facility failed to: 1) thoroughly investigate alleged violations of abuse, and 2) prevent further potential of abuse while an investigation was in process. This was found evident of 6 (Resident #91, #108, #2, #19, #93, & #21) of 30 residents investigated for Facility Reported Incidents(FRI). The findings include: 1a) On 5/14/24 at 10:33 AM, the surveyor reviewed Resident #91's medical record. The review revealed that Resident #91 was admitted to the facility in late 2022 and had a past medical history that included, but not limited to, bilateral primary osteoarthritis of knee, adult failure to thrive, unspecified protein-calorie malnutrition, signs involving cognitive functions and awareness, difficulty in walking, and muscle weakness (generalized). Further review revealed Resident #91 was assessed with a Brief Interview for Mental Status (BIMS) assessment and received a score of 15, the highest score, indicating he/she was cognitively intact. On 5/14/24 at 11:12 AM, the surveyor reviewed the investigation report the facility conducted for an alleged allegation of abuse Resident #91's daughter reported to the facility. The review revealed that after the facility conducted interviews with staff and completed a head to toe assessment of Resident #91 the facility was not able to substantiate the allegation. Further the Geriatric Nursing Assistant (GNA) Staff #39, the alleged perpetrator, was placed on suspension pending the outcome of the investigation. However within the investigation file, there were no interviews taken from other residents that Staff #39 was assigned, to verify there were no other concerts from other residents about the GNA's care. On 5/21/24 at 11:14 AM, the surveyor conducted a phone interview with the previous Director of Nursing (DON), who took part in the investigation. During the interview, Staff #40 confirmed that no other residents were interviewed to validate there was no other concerns by other residents regarding the care Staff #39 provided. On 5/21/24 at 1:42 PM, the surveyor conducted an interview with the current DON. During the interview the surveyor informed the DON about the concern that the investigation into Resident #91 allegation was not a thoroughly investigation and lacked interviews from other residents to help confirm there were no other concerns about Staff #39. 1b) On 5/14/24 at 7:33 AM, the surveyor reviewed an investigation the facility conducted regarding an allegation of abuse of Geriatric Nursing Assistant (GNA) Staff # 38 to Resident #108. The review of the investigation was completed by the previous Director of Nursing (DON) Staff # 40 and the Nursing Home Administrator (NHA) (at the time of the survey out on leave). After the investigation, the facility was not able to substantiate the allegation of abuse. Summaries of all interviews were in the report. However, there were no interviews taken from other residents that Staff #38 was assigned, to verify there were no other residents that had concerns. Further there were no written statements from the staff, just summaries. On 5/21/24 at 8:32 AM, the surveyor conducted a phone interview with the previous Business Office Manager Staff #41. In the investigation a statement was summaries by Staff #41. During the interview Staff #41 stated her office was located in the hallway where residents resided. She stated if she heard any type of disturbance, she would evaluate the situation but also reported she would not have stepped outside her job's scope of practice. When asked if she recalled an incident in which she gave a statement about Resident #108 and an allegation of abuse, she reported she could not recall and further stated if she had signed a written statement, she would stand behind the statement, but she could not recall writing or giving a formal statement. On 5/21/24 at 9:46 AM, the surveyor conducted a phone interview with the Nursing Home Administrator (NHA) (currently on leave). During the interview the NHA stated he and the DON conducted the investigations together. The surveyor asked about interviews regarding the investigation into Resident #108's alleged abuse. He could not recall interviewing other residents who also were cared for by Staff #38 but stated the Director of Nursing (DON) at the time may have done them. He further stated he and the previous DON interviewed Staff #41 and took her statement. He confirmed he practice was to summarize the interview and no formal statements were obtained in the investigation. On 5/21/24 at 11:14 AM, the surveyor conducted a phone interview with the previous Director of Nursing (DON) Staff #40, who took part in the investigation. During the interview, Staff #40 confirmed that no other residents were interviewed to validate there was no other concerns by other residents who were cared for by Staff #38. She also stated she worked together on completing investigations with the NHA and human resource staff. She further stated she was responsible for interviewing clinical staff and the NHA or Human Resource staff would conduct interviews with non-clinical staff. She recalled taking a statement from Staff #41 and confirmed both the NHA and herself often wrote summaries of interviews instead of the questions asked and the response. On 5/21/24 at 1:42 PM, the surveyor conducted an interview with the current DON. During the interview the surveyor informed the DON about the concern that the investigation into Resident #108's allegation was not a thorough investigation and lacked interviews from other residents to help confirm there were no other concerns about Staff #38 and validated statements from other staff. 2) On 5/14/24 at 7:33 AM, the surveyor reviewed an investigation the facility conducted regarding an allegation of abuse of Geriatric Nursing Assistant (GNA) Staff # 38 to Resident #108. The review of the investigation was completed by the previous Director of Nursing (DON) Staff #40 and the Nursing Home Administrator (NHA) (at the time of the survey out on leave). After the investigation the facility was not able to substantiate the allegation of abuse. Further review of the investigation failed to show that Staff #38 was suspended pending the completion of the investigation. On 5/14/24 at 12:16 PM, the surveyor reviewed Geriatric Nursing Assistant (GNA) Staff #38's employee file. No suspension letter was noted in the file or termination letter. On review of Staff #38's payroll clock in and out record it revealed that Staff #38 worked on Tuesday, 1/24/24 until 3:11 PM. This was the day the allegation was reported to the facility and again the following day from 7:07 AM till 11PM. Further review revealed Staff #38 worked the next 4 consecutive shifts from 7AM- 3PM shift. No other shifts were documented after that. On 5/15/24 at 12:47 PM, the current DON confirmed that the Staff #38 no longer worked at the facility and her last day of work was on 1/29/24. The DON stated she was not the DON at the time and stated she found out Staff #38 was terminated related to attendance concerns, and she would ask Human Resources to obtain the termination letter. On 5/21/24 at 9:46 AM, the surveyor conducted a phone interview with the Nursing Home Administrator (NHA) (currently on leave). During the interview the NHA stated during the investigations of abuse the alleged perpetrator should be suspended pending the findings of the investigation. When asked why Staff #38 continued to clock in and work after the allegation was made the NHA stated he was not sure and believed it could have been that the investigation was already completed by the next day. On 5/21/24 at 11:14 AM, the surveyor conducted a phone interview with the previous Director of Nursing (DON) Staff #40, who took part in the investigation. During the interview Staff #40 confirmed that any employee suspected of abuse is suspended until the investigation is complete. When asked why Staff #38 was not suspended, Staff #40 stated, during the investigation the Resident denied the incident happened and we wrapped up our investigation. She further stated that she asked that Staff #38 not work with Resident #108 out of abundance of precaution. The surveyor confirmed that the Staff #38 was allowed to continue to work even after the facility did not obtain statements or interviews from other Residents whom Staff #38 worked with, thus validating there were no other concerns from other Residents. On 5/21/24 at 1:42 PM, the surveyor conducted an interview with the current DON. During the interview the surveyor expressed the concerns that Staff #38 continued to work after an allegation of abuse was made and no statements from other residents that she provided care to were interviewed to validate there were no other concerns. 4) On 05/22/2024 at 1:02 PM a review of the Facility Reported Incident investigation revealed an allegation of abuse. According to the facility's investigation Resident #93 advised his/her Responsible Party (RP) and facility staff that he/she was hit on the face with a pillow by a Geriatric Nursing Assistant (GNA) #9. The review of the facility's investigation file revealed that the facility failed to interview Resident #93 and the residents that GNA #9 provided care. A Minimum Data Set (MDS) assessment is a standardized, federally mandated process for evaluating the health status of residents in nursing homes that are certified by Medicare or Medicaid. The assessment is used to identify a resident's strengths, preferences, and potential problems, and to help nursing home staff identify health concerns. The Brief Interview for Mental Status (BIMS) is a 15-point cognitive screening tool used in long-term care facilities to evaluate memory and orientation in older adults. The BIMS assessment has three sections that test short-term word recall and orientation in time. The final score is calculated by combining the scores from all three sections. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact. A review of Resident #93's MDS; section C revealed that the resident BIMS was assessed at a 12 out of 15. During an interview conducted on 05/22/2024 at 1:33 PM, the DON confirmed that the investigation file was complete. The DON acknowledged that the investigation did not include an interview with Resident #93 and the residents that GNA #9 provided care. The DON further stated that she would provide education to the staff on how to investigate allegations of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 05/21/24 at 9:43AM a review of Resident #40' s medical records revealed that the resident was admitted to the facility on [DATE] with diagnoses including Multiple sclerosis, Muscle weakness (generalized), Mild cognitive impairment and Dysphagia oropharyngeal phase. On 11/18/23 Resident #40 was transferred to the hospital with symptoms relating to a respiratory infection and returned to the facility on [DATE]. On 09/10/24 Resident #40 was transferred to the hospital with symptoms of another respiratory infection and returned to the facility on [DATE]. Further review of Resident #40's medical records failed to reveal that the resident and or/Residents' Representative and Ombudsman were provided with written notification and rationale for residents' transfers to the hospital. During an interview on 05/23/24 at 6:55 AM the DON reported to the surveyor that she was having difficulty locating the written transfer notification record for Resident #40, as the staff member responsible for the record keeping was no longer working at the facility. No documentation was submitted during the interview. On 05/29/24 at 10:40 AM the Surveyor received documentation of a letter relating to Notice of discharge or transfer, dated 09/10/23 addressed to Resident #40, from the Regional Clinical Consultant. There was no indication that the document was received or given to the resident and or/the residents ' representative and the Ombudsman. No discharge or transfer notification document was provided to the surveyor regarding Resident #40's hospitalization on 11/18/23. Based on interviews and medical record review it was determined the facility failed to provide notification to the Ombudsman and the Responsible Party of the residents that transferred to the hospital. This was evident for 7 residents (#19, #44, #6, #41, #62, #71, and #40) out of 7 residents reviewed for hospitalizations. The findings include: 1) During a phone interview on 5/15/24 at 11:43 AM with Resident #19's daughter, the daughter stated that Resident #19 has had 2 hospitalizations recently. On 5/21/24 at 7:45 am the surveyor reviewed Resident #19's medical record. The review of the medical record revealed that Resident #19 was transferred to the hospital on March 4, 2024, and May 4, 2024. Further review of Resident #19's medical record revealed that there was no documentation that the facility Ombudsman was notified of Resident #19's transfer to the hospital on 3/4/24 or on 5/4/24. The Director of Nursing at 11:20 am on 5/23/24 conveyed to the surveyor that they are unable to locate documentation of notification to the Ombudsman of transfer to the hospital for Resident #19 for 3/4/24 or 5/4/24. In addition, the Director of Nursing conveyed that she is unsure of the system in place for this process by Social Services. During an interview with Resident #44 on 5/15/24 at 9:17 AM, Resident #44 stated that he/she had a recent hospitalization a few weeks ago. On 5/21/24 at 8:00 am the surveyor reviewed Resident #44's medical record. The review of the medical record revealed that Resident #44 was transferred to the hospital on 1/23/24 and 4/17/24. The Director of Nursing on 5/22/24 at 11:30 AM provided the surveyor with documentation that the facility Ombudsman was notified of Resident #44's transfer to the hospital on 1/23/24; however, the Director of Nursing stated that they were still looking for the documentation of Ombudsman notification for the 4/17/24 Resident transfer to the hospital. On 5/23/24 at 11:20 AM the Director of Nursing informed the surveyor that they were unable to locate the documentation of the Ombudsman being notified of the transfer of Resident #44 to the hospital on 4/17/24 and unsure of the process being done by Social Services. During an interview with Resident #6 on 5/14/24 at 11:30 AM Resident #6 stated that she recently went to the hospital for pneumonia. The surveyor reviewed Resident #6's medical record on 5/28/24 at 11:00 AM and the medical record review revealed that Resident #6 had 2 hospitalizations, one on 9/25/23 and the other one on 1/13/24. The surveyor requested on 5/28/24 at 1:13 PM from the Interim Nursing Home Administrator (NHA) documentation of notification to the facility Ombudsman of Resident #6's transfer to the hospital on 9/25/23 and 1/13/24. On 5/29/24 at 7:45 AM the Regional Nurse Consultant provided the surveyor with documentation of notification to the Ombudsman of Resident # 6's transfer to the hospital on 1/13/24; however, the Regional Nurse Consultant stated that they were still looking for the documentation of notification to the Ombudsman for the 9/25/23 transfer to the hospital. At time of exit on 5/31/24, the facility was unable to provide any documentation of notification to the Ombudsman for Resident #6's transfer to the hospital on 9/25/23. 2) On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written hospital transfer notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of transfer notices are kept. On 05/28/2024 at 09:15 AM, a review of Resident #41's electronic medical record revealed that Resident #41 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 06/02/2023, 03/26/2024 and 05/21/2024. Further review of Resident #41's electronic medical record revealed no documentation that the resident/resident representative was notified of the hospital transfers in writing. On 05/29/2024 at 08:55 AM, an interview conducted with Regulatory Specialist #29 revealed that she was not able to locate any evidence that a written notice of transfer was given to the resident/resident representative for hospital transfers on 06/02/2023, 03/26/2024 and 05/21/2024. At the time of exit conference, the facility did not provide any evidence that written notices of transfer were given to Resident #41 and the resident's representative for hospital transfers on 06/02/2023, 03/26/2024 and 05/21/2024. On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written hospital transfer notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of transfer notices are kept. On 05/28/2024 at 09:54 AM, a review of Resident #62's electronic medical record revealed that Resident #62 was transferred to the hospital for further evaluation of his/her medical needs on 05/10/2024. Further review of Resident #62's electronic medical record revealed no documentation that the resident/resident representative was notified of the hospital transfer in writing. On 05/29/2024 at 09:48 AM, an interview conducted with Regulatory Specialist #29 revealed that she was not able to locate any evidence that a written notice of transfer was given to the resident/resident representative for hospital transfer on 05/10/2024. At the time of exit conference, the facility did not provide any evidence that a written notice of transfer was given to Resident #62 and the resident's representative for hospital transfer on 05/10/2024. On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written hospital transfer notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of transfer notices are kept. On 05/28/2024 at 09:54 AM, a review of Resident #71's electronic medical record revealed that Resident #71 was transferred to the hospital for further evaluation of his/her medical needs on 04/15/2024. Further review of Resident #71's electronic medical record revealed no documentation that the resident/resident representative was notified of the hospital transfer in writing. On 05/29/2024 at 09:48 AM, an interview conducted with Regulatory Specialist #29 revealed that she was not able to locate any evidence that a written notice of transfer was given to the resident/resident representative for hospital transfer on 04/15/2024. At the time of exit conference, the facility did not provide any evidence that a written notice of transfer was given to Resident #71 and the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 05/21/24 at 9:43AM a review of Resident #40's medical records revealed that resident was admitted to the facility on [DATE] with diagnoses including Multiple sclerosis, Muscle weakness (generalized), Mild cognitive impairment and Dysphagia oropharyngeal phase. On 11/18/23 Resident #40 was transferred to the hospital with symptoms relating to a respiratory infection and returned to the facility on [DATE]. On 09/10/24 Resident #40 was transferred to the hospital with symptoms of another respiratory infection and returned to the facility on [DATE]. Further review of Resident #40's medical record failed to reveal that the resident or resident's representative was provided with the facility's policy on behold before the resident was transferred to the hospital on [DATE] and 09/10/24. During an interview on 05/23/24 at 6:55 AM the Director of Nursing (DON) reported to the surveyor that she was having difficulty locating the written bedhold notification for Resident #40, as the staff member responsible for the record keeping was no longer working at the facility. The DON did not produce the requested bed hold document. Based on medical record review and staff interviews, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 4 (#41, #62, #71, and #40) of 7 residents reviewed for hospitalizations during the annual survey. The findings include: 1. On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written bed hold notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of the bed hold notices are kept. On 05/28/2024 at 09:15 AM, a review of Resident #41's electronic medical record revealed that Resident #41 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 06/02/2023, 03/26/2024 and 05/21/2024. Further review of Resident #41's electronic medical record revealed no documentation that the resident/resident representative was notified of the bed hold policy in writing. On 05/29/2024 at 08:55 AM, an interview conducted with Regulatory Specialist #29 revealed that she was not able to locate any evidence that a written copy of the bed hold policy was given to the resident/resident representative for hospital transfers on 06/02/2023, 03/26/2024 and 05/21/2024. At the time of exit conference, the facility did not provide any evidence that a written copy of the bed hold policy was given to Resident #41 and the resident's representative for hospital transfers on 06/02/2023, 03/26/2024 and 05/21/2024. 2. On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written bed hold notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of bed hold notices are kept. On 05/28/2024 at 09:54 AM, a review of Resident 62's electronic medical record revealed that Resident #62 was transferred to the hospital for further evaluation of his/her medical needs on 05/10/2024. Further review of Resident #62's electronic medical record revealed no documentation that the resident/resident representative was notified of the bed hold policy in writing. On 05/29/2024 at 09:48 AM, an interview conducted with Regulatory Specialist #29 revealed that she was not able to locate any evidence that a written copy of the bed hold policy was given to the resident/resident representative for hospital transfer on 05/10/2024. At the time of exit conference, the facility did not provide any evidence that a written copy of the bed hold policy was given to Resident #62 and the resident's representative. 3. On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written bed hold notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of bed hold notices are kept. On 05/28/2024 at 09:54 AM, a review of Resident #71's electronic medical record revealed that Resident #71 was transferred to the hospital for further evaluation of his/her medical needs on 04/15/2024. Further review of Resident #71's electronic medical record revealed no documentation that the resident/resident representative was notified of the bed hold policy in writing. On 05/29/2024 at 09:48 AM, an interview conducted with Regulatory Specialist #29 revealed that she was not able to locate any evidence that a written copy of the bed hold policy was given to the resident/resident representative for hospital transfer on 04/15/2024. At the time of exit conference, the facility did not provide any evidence that a written copy of the bed hold policy was given to Resident #71 and the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 05/28/24 at 07:59 AM, a review of Resident #41's electronic medical record revealed that Resident #41 was admitted to the facility on [DATE]. Further review of the electronic medical record revealed no evidence that a baseline care plan was developed for Resident #41. On 05/28/24 08:23 AM, an interview conducted with MDS Coordinator #20 regarding baseline care plans revealed that the Medical Records staff may know how to access the older baseline care plans from 2019. On 05/28/24 at 12:37 PM, an interview was conducted with the Regional Clinical Consultant. The Regional Clinical Consultant stated, I haven't been able to find the baseline care plan for Resident #41, but I'm still looking. At the time of the exit conference, the facility did not provide any evidence that a baseline care plan was developed for Resident #41 when he/she was admitted on [DATE]. 3. On 05/21/24 12:45 PM, a review of Resident #58's electronic medical record revealed that Resident #58 was admitted to the facility on [DATE] and a baseline care plan was developed as required. Further review of Resident #58's electronic medical record revealed no documentation that a written summary of the baseline care plan was provided to the resident and resident representative. On 05/28/24 01:24 PM, an interview was conducted with the DON regarding baseline care plan. The DON stated, We are doing the baseline care plans within 48 hours, however providing the written summary to the resident and resident representative is a gray area for us. On 05/28/24 01:26 PM Review of the facility's Care Plan Process Policy and Procedure revealed that the facility is to provide the resident and their legal representative a copy of the baseline person-centered care plan summary for the completion date of the comprehensive assessment. Document receipt in the medical record. At the time of exit conference, the facility did not provide any evidence that a written summary of the baseline care plan was given to Resident #58 and the resident's representative. 4. 05/16/24 06:35 AM, a review of Resident #71's electronic medical record revealed that he/she was readmitted to the facility on [DATE] and a baseline care plan was developed as required. Further review of Resident #71's electronic medical record revealed no documentation that a written summary of the baseline care plan was provided to the resident and resident representative. On 05/28/24 01:24 PM, an interview was conducted with the DON regarding baseline care plan. The DON stated, We are doing the baseline care plans within 48 hours, however providing the written summary to the resident and resident representative is a gray area for us. On 05/28/24 01:26 PM Review of the facility's Care Plan Process Policy and Procedure revealed that the facility is to provide the resident and their legal representative a copy of the baseline person-centered care plan summary for the completion date of the comprehensive assessment. Document receipt in the medical record. At the time of exit conference, the facility did not provide any evidence that a written summary of the baseline care plan was given to Resident #71 and the resident's representative. Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a baseline care plan was created within the required 2 days and ensure a written summary of the baseline care was provided to the resident/resident representative. This was evident for 4 Residents (#542, #41, #58, and #71) out of 62 residents in the survey sample. The findings include: The baseline care plan must be completed within 48 hours of admission. It must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that are most likely to occur right after admission. 1. A review of Resident #542's clinical record on 5/31/24 revealed that the resident was admitted on [DATE]. Further review revealed the Interdisciplinary team developed a care plan on 5/3/24 that had the objective: The resident's Baseline Care Plan will be developed within 48 hours of admission and provided to the resident and legal representative by completion of the comprehensive assessment. A baseline care plan is required to be developed within two days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of medical records on 05/28/24 at 8:09AM revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Polyosteoarthritis, Depression, Dementia, Muscle weakness and Age-related physical debility. On 11/14/22 Resident#64 was seen by the Medical Director who documented in residents' History and Physical (H&P) assessment record, a pressure ulcer on the sacral region. Resident #64's pressure ulcer was treated from 11/12/22 until it was resolved. The wound consultant report dated 11/30/22 revealed that the resident's pressure ulcer was resolved on 11/30/22. A note written by Licensed Nurse #20 on 01/03/23 at 1:10PM stated that a fungal rash was observed on Resident #64's sacrum, abdominal fold and bilateral breast and he/she informed the Medical Director. On 01/03/23 Resident #64 was assessed by the Medical Director and a diagnosis of an Extensive Fungal Rash was documented. An antifungal powder was ordered along with an oral antifungal medication for 7 days to treat the rash. The antifungal powder was applied to Resident #64's affected areas from 01/03/23 to 02/06/23 and Resident #64 was medicated with an oral antifungal medication from 01/04/23 to 01/10/23. On 05/28/24 at 8:09 AM a review of Resident #64's comprehensive care plan revealed that the facility failed to develop /implement a care plan for Resident #64's pressure ulcer and fungal rash. During an interview on 05/29/24 at 11:49 AM the Director of Nursing (DON) informed the surveyors that she would look for the care plans. On 05/29/24 at 1:10 PM surveyors received a care plan from the DON which did not include Resident #64's plan of care for a pressure ulcer ulcer and fungal rash. Based on record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for: 1) residents with a history of seizure disorder currently taking medication for the condition, 2) a resident prescribed opioids for pain relief, and 3) a resident's pressure ulcer and a fungal skin infection. This was evident for 4 residents (Residents #60, #65, #96 and #64) out of 62 residents with care plans reviewed during the annual survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. 1a.On 5/23/2024 at 1:18 PM, during review of Resident #60's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, cognitive communication deficit, multiple sclerosis, hypertension, epilepsy (seizure disorder), cerebral vascular accident (CVA/stroke), and encephalopathy (brain disease). Resident #60 was taking an anticonvulsant medication to treat seizures associated with epilepsy. On 5/24/2024 at 10:35 AM, a review of Resident #60 's electronic medical record revealed an admission MDS assessment dated [DATE] which included epilepsy as an active diagnosis and a quarterly MDS assessment dated [DATE] included epilepsy as an active diagnosis. In addition, a review of Resident #60's care plan, from admission to current, failed to reveal a care plan to address his/her epilepsy disorder, precautions for epilepsy, nor the use and monitoring of an anticonvulsant medication. On 5/24/2024 at 10:45 AM, the Surveyor reviewed an interview conducted with MDS Coordinator #20 on 5/23/2024 at 9:50 AM which revealed that diagnoses are coded based off the discharge summary received from the hospital or another facility they are admitted from. The medications are reviewed and are coded based on the medication the resident is currently taking. According to Staff #20, Resident #60 should have been care planned for epilepsy because he/she was admitted while taking medication for it. 1b. On 5/29/2024 at 10:45 AM during a review of Resident #65's electronic medical record, the Surveyor discovered that the resident was admitted on [DATE] with diagnoses of, but not limited to, chronic pain syndrome, pressure ulcer of sacral region, stage 4 (Primary, Admission), pressure ulcers, cognitive communication deficit, atherosclerosis, rhabdomyolysis, and neuralgia and neuritis. During further review, the Surveyor discovered an order for a schedule IV opiate (narcotic) analgesic to be given twice a day for chronic pain syndrome from 11/10/2022 to 3/15/2023, an updated order from 3/16/2023 to current for a schedule II opiate (narcotic) analgesic PRN (as needed), and an updated order from 3/17/2023 to current for a schedule II opiate (narcotic) analgesic to be given once a day prior to wound care. On 5/30/2024 at 1:26 PM, additional review of Resident #65's electronic medical record revealed a care plan for pain. Care plan started on 10/08/2022 stated that Resident #65 had complaints of generalized chronic pain related to disease process, a short-term goal to develop effective coping strategies to help adapt to pain, and an approach for this goal was to administer medications as ordered with a start date of 10/12/2022. The last review was 11/22/2023, with no revisions. Continued review of Resident #65's care plan failed to reveal a care plan for the use and monitoring of an opiate (narcotic) analgesic for pain relief from admission through current. On 5/31/2024 at 12:00 PM, the Director of Nursing (DON) was made aware that the development and implementation of care plans for residents were a concern. 2) On 5/15/24 at 10:47 AM, the surveyor reviewed Resident #96's medical record. The review revealed that Resident #96 was admitted to the facility in late February 2023. The surveyor further reviewed the hospital admission history and physical dated January 31, 2023. In the assessment and plan section seizures were listed. It further stated seizures resulting from anterior cerebral artery (aca) stroke. The plan stated to continue home lamotrigine 150 mg twice daily (a medication prescribed to prevent seizures) and Sertraline 75 mg daily (a medication prescribed to treat depression). On 5/15/24 at 11:27 AM, the surveyor reviewed a progress note written by Registered Nurse (RN) Staff #42. The note stated Resident #96 was observed having a seizure while up in his/her wheelchair. It further stated after getting the Resident back to bed the resident had another seizure. The physician was notified, medications ordered and an order was given to transfer Resident #96 to the hospital On 5/22/24 at 12:04 PM, the surveyor reviewed the Medication Administration Record (MAR) for Resident #96. The review revealed that the resident was prescribed and given lamotrigine 150 mg twice a day with a reason given; seizures. On 5/22/24 at 11:50 AM, the surveyor reviewed Resident #96's care plans. No seizure care plan was initiated even though the resident had a diagnosis and was actively being treated for seizures. On 5/23/24 at 10:32 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON confirmed that there was no active care plan for seizure even though the resident was diagnosed with a seizure disorder and was taking seizure preventative medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #64 was admitted to the facility on [DATE] with diagnoses including Polyosteoarthritis, Depression, Dementia, Muscle weakness and Age-related physical debility. A review on 05/28/24 at 09:48AM of Resident #64's medical record revealed that the Medical Director ordered an antidepressant to be given to the resident at bedtime for depression from 11/22/22 to 1/10/24. Then the antidepressant was reduced to 7.5mg at bedtime from 1/10/24 to 04/16/24. On 4/16/24 the medication was discontinued due to the resident's weight gain. A review of Resident #64' care plan at the time of review on 05/28/24 revealed that the resident was receiving antidepressant medication for impaired cognition. The start date on the care plan was 11/13/22. The care plan was not updated to reflect that the antidepressant was discontinued on 4/16/24. On 05/29/24 at 11:49 AM the Director of Nursing (DON) and surveyors reviewed Resident#64's physician's orders and current care plan which revealed that the resident' care plan was not revised and updated. Based on record review and interviews with staff, it was determined that the facility failed to ensure care plans were reviewed and revised after 1) a resident's hospitalization and quarterly assessment and 2) a resident whose medication for depression was discontinued. This was found to be evident for 2 residents ( Res. #60 and Res. #64) out of 8 residents reviewed for care plans during the annual survey. The findings include: 1) A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. On 5/23/2024 at 1:18 PM, During review of Resident #60 electronic medical record, the Surveyor discovered that the resident has diagnoses of, but not limited to, cognitive communication deficit, influenza A with pneumonia, Urinary tract infection (UTI), multiple sclerosis, hypertension, seizure disorder, cerebral vascular accident (CVA/stroke), and encephalopathy (brain disease). On 5/24/2024 at 10:35 AM, a review of Resident #60's electronic medical record revealed that the resident was hospitalized on [DATE] for altered mental status and decreased response to stimuli. Review of the hospital notes stated that the resident had a history of recurrent urinary tract infections (UTI). The problem list included UTI due to extended-spectrum beta lactamase (ESBL) producing Escherichia coli on 2/01/2024, influenza A, pneumonia of both lower lobes, and severe sepsis and was treated with multiple antibiotics. The resident was discharged back to the facility 2/05/2024. In addition, further review of Resident #60' electronic medical record revealed a quarterly MDS assessment dated [DATE] in which UTIs and pneumonia were included in the active diagnoses. During continued review of the electronic medical record, the Surveyor examined the resident's care plan. Resident #60's care plan was not updated or revised to reflect the hospitalization from 1/26/2024 through 2/5/2024 nor to include history of recurrent UTIs, the new diagnoses of influenza A, pneumonia, and severe sepsis which were all reasons for the hospitalization. There were no revisions noted after the quarterly assessment completed on 2/06/2024 or care plan meeting on 2/22/2024. On 5/28/2024 at 12:49PM, the Surveyor conducted an interview with the Assistant Director of Nursing (ADON). The Surveyor discovered that the Director of Nursing (DON) and the ADON, along with specific department directors (ex: Social Work, Dietary, Activities), review and revise the resident's care plans as needed. The Surveyor reviewed the facility's Care Plan Policy and Procedures provided by ADON. According to the procedures section #6) The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments, and #9) Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need. The Director of Nursing (DON) and the ADON confirmed care plan revision concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) During an interview with Resident #542 on 05/13/24 at 11:13 AM, the resident was asked if they had attended activities. Resident #542 stated that he/she had not been offered activities and would have attended, if made aware. During an interview with Resident #542 on 05/15/24 at 11:45 AM, he/she still has not been offered to participate in activities and no one has told him/her about activities. Review of Resident #542's medical record on 5/29/24 revealed the resident was admitted to the facility on [DATE] and did not have any documented activities of attendance or refusal. During an interview with Activities Assistant (Staff #31) on 05/29/24 at 11:03 AM, they stated their responsibilities included conducting room visits for residents that consisted of asking residents about their day, and about family members for conversational purposes. Staff #31 also confirmed calendar visits and room visits were conducted from 8:00 AM-9:30 AM. They stated during that time they sometimes talk to residents about the day, time, and month and activity of the day. Staff #31 stated she recalled having an interaction with Resident #542 but he/she mostly stayed in his/her room. 2) On 5/14/2024 at 9 AM, the Surveyor conducted an interview with Resident #60 regarding activities at the facility. The resident stated, Do they have activities? They don't tell me about any. Resident #60 informed the Surveyor he/she is unaware of any activities except Mass services on Sunday mornings. The resident stated that he/she is interested in spirituality and church. The resident also stated that he/she would like to go to the Mass services at the facility on Sunday mornings, but it's too early. The resident stated that he/she would like to go to activities outside his/her room and with other residents however, no one has offered to take her. During the interview, the Surveyor observed the resident lying in bed with the TV turned on. There were no daily chronicles, newspapers, reading books, coloring books, or writing utensils observed in the room. There was an AI device in the window seal. The Surveyor observed an activity calendar from April 2024 posted on the back wall behind the resident's bed and a sign, which stated Mass services on Sundays at 10 AM, posted on the side wall by the window. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. Review of Resident #60's admission MDS on 5/17/2024 at 11:00 AM revealed that the resident participated in an assessment of activity preferences on 6/28/2023 and it indicated the residents interested in arts and crafts, community events, cooking, creative writing, spirituality and religious services, and current events. Additional review revealed activities care plan stating, Problem [Resident #60] is dependent on staff for meeting emotional, intellectual, physical, and social needs. Goal [Resident #60] will participate in activities of interest. Multiple approaches included but not limited to Staff will escort [Resident #60] to church services, Staff will provide daily chronicles for [him/her] to read, and Staff will be discussing the news during room visits. On 5/21/2024 at 9:41 AM, the Surveyor conducted a joined interview with the Human Resource (HR) Director #37 and Activity Assistant #31. HR #37 informed the Surveyors that she is interim personnel for the Activity Department until the facility hires an Activity Director. During the interview, Surveyor discovered Mass services are Tuesday and Thursday at 2 PM. The Activity Assistant # 31 informed the Surveyors that activity reports are updated daily and notate the resident's ability to participate in daily activities. On 5/24/2024 at 10:50 AM, the Director of Nursing (DON) provided the Surveyor with activity records for Resident #60. The activity log documentation revealed from September 2023 through November 2023, Resident #60 participated in TV, calendar, and talking. The resident's activity documentation failed to reflect the staff offered any activity to Resident #60 in December 2023 or January 2024. Activity documentation for February 2024 and March 2024 indicated that the resident was unable to participate in activities such as Mass, board games, socials, resident council, bingo, arts and crafts, and trivia. There was no documentation that the resident refused any activities. The DON confirmed documentation. On 5/24/24 at 11:22 AM the Surveyor conducted a follow up interview with HR #37 to update Resident #60's activity preferences and out of date activity signage in the resident's room. In addition, the Surveyor expressed the concerns that the activities department failed to provide documentation that the facility offered personalized resident specific activity services and failed to provide individualized preference-based activities for Resident #60. HR #37 explained that she is just covering this role for now and unfortunately this was not her area of expertise. HR #37 stated she would follow up with the resident. 3) On 5/16/2024 at 10:20 AM, 5/28/2024 at 10:47 AM, and 5/29/2024 at 11:00 AM Resident #65 was observed lying in his/her bed with the TV turned on. There were no daily chronicles, coloring books, or writing utensils observed in the room. The resident was not engaged in any individual activities nor were the facility staff engaging the resident in 1:1 activity. The resident expressed that he/she would like to go outside to catch a little fresh air. Review of Resident #65's electronic medical record on 5/28/2023 at 1:30 PM, revealed an annual MDS assessment dated [DATE], which indicated the resident liked to listen to gospel music, keep up with the news, participate in religious services, go outside when the weather permits, and likes 1:1 style activity. Additional review revealed activities care plan stating, Problem [Resident #65] is dependent on staff for meeting emotional, intellectual, physical, and social needs. Goal [Resident #65] will demonstrate acceptance or enjoyment of activities such as church services. Multiple approaches included but not limited to Invite and escort to and from activities, [Resident #85] will be receiving music therapy, and Staff will escort to church services. On 5/28/2024 at 1:45 PM, the Director of Nursing (DON) provided the Surveyor with activity records for Resident #65. The activity log documentation revealed from August 2023 through January 2024, Resident #65 participated in TV, calendar, reading, and talking. The resident's activity documentation failed to reflect the staff offered activities of interest or 1:1 activity with Resident #65. Activity documentation for February 2024 and March 2024 was incomplete and indicated that the resident was unable to participate in activities such as Mass, board games, bingo, calendar, and room visit. The facility was unable to provide activity documentation for April 2024 and May 2024. There is no documentation that the resident refused any activities. The DON confirmed documentation. Based on observation, medical record review and interview, it was determined that the facility failed to provide on-going personalized activities to meet the resident's needs and failed to inform or offer a resident the opportunity to attend facility activities. This was evident for 4 (Resident #34, #60, #65, & #542) out of 6 residents reviewed for the personalized activities during the annual survey. The findings include: 1) Observation, on 5/14/24 at 09:43 AM and 5/15/24 at 10:05AM for over an hour each time, found that Resident#4 was able to feed herself, change his/her position from side to side and clean her bedside table. However, the resident was confined to his/her room, dozing off after breakfast with the TV on. During another observation and interview, on 05/14/24 at 1:00 PM, Resident #34 stated I would like to go for group activity sometimes. There was no evidence that the activity staff provided any social group or one-to-one activity adequate provision of personalized activities. Record review, on 05/22/2024 at 12:31 PM, Resident #34's activity documentation from the month of February to May 2024 revealed that some one-to-one activity was documented. The facility has the month of May calendar posted including the following group social activities: sit and stretch, Mass, bingo, crepe makings, donut/ice cream social, happy hour, fruit kabob, board game, etc. During interview, on 05/28/24 at 11/10 AM, the Activity Aide (Staff #31) stated she had Resident #34 on the one-to-one visit list in following activities: listening to music, reading newspaper, storytelling, or TV watching. Requested activity log from the month of February to May 2024 for review. Record review, on 05/28/24 at 02:00 PM, Resident #34's activity logs in recent 5 months revealed that in following: February -Unable to attend any social group, no one-to-one visit. March- Unable to attend any social group, no one-to-one visit. April- Unable to attend any social group, six days had one-to-one visits for current events and family history. May- Unable to attend any social group and only two days had one-to-one visits. During Interview, 05/30/24 at 2:17 PM, Interim Administrator stated since the activity director resigned, the program was lacking direction. She was looking into having Resident #34 to be included in some suitable group social activity. It was a concern that the facility failed to provide an ongoing activity program to meet the resident's interests and support the physical, mental, and psychosocial well-being.

Based on employee record reviews and interviews it was determined that the facility failed to ensure that the required Geriatric Nursing Assistant performance reviews were completed. This was evident in 4 out of 4 Geriatric Nursing Assistants (GNA) #6,12, 23 and 24 employee files reviewed for required performance reviews. The findings include: On 5/30/24 at 9:57 AM, the surveyor reviewed 4 Geriatric Nursing Assistant (GNA) employee files #6,12, 23 and 24. During the review of the 4 employee files the surveyor discovered that the facility did not have current performance reviews in the employee files for all 4 GNAs #6,12, 23 and 24 for 2023 and 2024. At 12:30 PM on 5/31/24 the surveyor interviewed the Director of Human Resources #37 and the Interim Nursing Home Administrator (NHA). During the interview the surveyor informed the Director of Human Resources and the Interim NHA that the 4 GNAs #6,12, 23 and 24 employee files did not contain any performance reviews for 2023 and 2024. The Director of Human Resources confirmed that the 4 GNA employee files #6,12, 23 and 24 did not have current performance reviews for 2023 and 2024 in the presence of the Interim NHA. At the time of the exit on 5/31/24 at 2:45 PM no further documentation was provided to the surveyor by the Interim Nursing Home Administrator for Geriatric Nursing Assistants (GNA) performance reviews.

Based on observation and interviews, it was determined that the facility staff failed to ensure the safety of food products and food service areas. This was evident for food storage areas reviewed during an annual survey. The findings include: During observation of the facility kitchen on 05/13/24, the surveyor observed vanilla flavoring boxes with a handwritten date of 1/11/22. During an interview with Staff #49 on 5/13/24 at 9:30 AM, she was asked about the date written on the vanilla flavoring boxes and the shelf life. Staff #49 stated that's the date it came in, then confirmed it, she said she thought they lasted a couple of years but was unsure. During observation of the facility kitchen on 5/14/24 the surveyor observed two busted cans of ginger ale that were in the stand up freezers and were split almost in half. They were sitting in a container of frozen lemon ice cups. During observation of the facility kitchen on 5/14/24, the surveyor observed a jar of grape jelly opened to 3/4 full in a dry storage room. The label recommended refrigeration after opening. During an interview with Staff #49 on 5/14/24 at 11:15 AM, she was informed about the opened jar of grape jelly. During observation of the facility kitchen on 05/15/24 at 11:54 AM the surveyor observed a vanilla flavoring bottle with an open date of 11/30/22 on the spice shelf. During observation on 05/30/24 at 11:32 AM, the surveyor observed thickened apple juice from concentrate dated 5/28/24. The label recommendation indicated the product may be kept up to 7 days if refrigerated but was on a shelf in the dry storage room. During observation of the facility kitchen on 5/14/24 at 12:55 PM the surveyor observed the condition of walls to have water splashing from a sink pipe and leaking onto the floor near the dining room entrance to the kitchen. During observation on 05/15/24 at 12:02 PM the surveyor observed the area around the air conditioner to be dirty with small pieces of brown debris sitting on top and on the outer shelf housing the unit.

Based on employee record reviews and interviews it was determined that the facility failed to ensure that the required in-service training for Geriatric Nursing Assistants was completed. This was evident in 2 (Geriatric Nursing Assistants (GNA) #23 and #24) out of 4 employee files reviewed for required in-service training records. The findings include: On 5/30/24 at 9:57 am, the surveyor conducted a record review for 4 Geriatric Nursing Assistant (GNA) employee files #6, 12, 23 and 24. During the review of the 4 employee files the surveyor discovered that the facility had incomplete required in-service training for 2023 and 2024 for 2 GNAs #23 and #24. At 12:30 pm on 5/31/24 the surveyor interviewed the Interim Nursing Home Administrator (NHA). During the interview the surveyor informed the Interim NHA that GNA employee files had incomplete in-service training for 2023 and 2024 for 2 GNAs #23 and #24. The Interim NHA confirmed that there was incomplete in-service training for the 2 GNAs #23 and #24 for 2023 and 2024. The Interim Nursing Home Administrator stated that she would look for additional documentation for in-service training. At the time of the exit on 5/31/24 at 2:45 pm no further documentation was provided to the surveyor by the Interim NHA for in-service training for Geriatric Nursing Assistants (GNAs).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview of Resident #64 and medical record review it was determined the facility staff failed to accurately assess and manage the resident's pain. This was evident for 1 of 37 sampled residents selected for review. The findings include: Resident #64 was admitted to the facility on [DATE] for rehabilitation after being hospitalized and treated for injuries sustained in a motor vehicle accident. Medical record review revealed that the resident had an order for Oxycodone 10 mg. 1 tablet every 6 hours as needed for severe pain. The resident also had a routine order for Tylenol 500 mg. 3 times per day. Medical record review revealed that between 11/15/17 through 12/1/17 the resident received multiple doses of Oxycodone for pain rated 6 to 8 out of 10 on a pain scale of 1 to 10, with 10 being the worst pain. Interview of Resident #64 on 12/19/17 at 9:52 A.M. revealed that the resident has pain issues, is not satisfied with the physician's care for failure to address pain in a timely manner and failure to order cold compresses in a timely manner. The resident stated that he/she had received cold compresses 2 times. The first time the facility staff used a disposable glove filled with ice, and the second time the facility staff used a plastic bag filled with ice that leaked onto the resident's clothing and bed when the ice melted. Medical record review revealed that on 12/1/17 the resident was seen and examined by the physician. The physician assessed the resident with left thigh pain and documented that the resident could use a cold compress after therapy. However, the physician failed to write an order for cold compresses after therapy. On 12/4/17 the resident was seen and examined by the physician. The physician documented that the resident stated that he/she has pain routinely at midnight, pain in the left buttock with sitting and has to change position often. The physician assessed the resident with pelvic pain and documented to continue pain management. On 12/8/17 the resident was seen and examined by the physician. The physician documented that the resident stated that he/she had not received cold compresses to the left buttock and thigh. The physician assessed the resident with left thigh pain and documented that she spoke with the nurse and an order was given for cold compresses. Review of the treatment administration record (TAR) revealed that the resident received cold compresses two times only on 12/8/17 at 10:35 P.M. and 12/12/17 at 2:21 A.M. Interview of the Occupational Therapy Assistant, Staff #16, on 12/21/17 revealed that the Rehabilitation Department has gel cold packs that can be used as part of therapy. There is no documented evidence that facility staff consulted with the rehabilitation staff regarding the use of cold compresses as part of rehabilitation therapy. Review of the resident's care plan for actual pain that was initiated on 11/14/17 revealed that the facility staff failed to revise the resident's care plan with new interventions that included the use of cold compresses. Review of the TAR revealed that 12/9/17 through 12/12/17 the nurses documented every shift that the resident's pain was 0 out of 10. However, review of the Individual Resident's Controlled Substance Record revealed that Oxycodone 10 mg. 1 tablet had been signed out on 12/9/17 at 1:00 A.M., 12/10/17 at 1:00 A.M., 12/11/17 at 1:00 A.M. and 12/12/17 at 1:00 A.M. for Resident #64. However, review of the TAR revealed that there was no documented evidence that the resident was assessed and medicated for pain with Oxycodone 12/9/17 through 12/12/17. Medical record review revealed that the resident was seen and examined by the physician on 12/13/17. The physician documented that the resident had multiple complaints about the type of cold compresses received and that the cold compresses did not help anyway. The physician further documented that the resident's average pain is 5 to 6 out of 10 and that Tylenol is not relieving pain. The physician assessed the resident with left thigh pain and documented that she would add routine Oxycodone for persistent pain. The physician gave an order for Oxycodone 10 mg. 1 tablet every 6 hours for severe pain.

Based on medical record review it was determined that the facility staff failed to develop a care plan for Resident #29 related to the resident's inability to communicate and to make needs known. This was evident for 1 out of 37 residents observed during the survey process. The findings include: On 12/19/2017 during review of Resident # 29's MDS (minimum data set- a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) it was noted under the speech section that the resident had an inability to communicate. Under Speech Clarity, the resident was coded as Distinct intelligible words, and under the ability to understand others, it was coded as Rarely/never understands. Upon reviewing the Plan of Care, it was noted that there were no interventions on how the staff were going to assist the resident with making needs known. It is the facility's responsibility to create a Plan of Care that addresses special care requirements for each of its residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and medical record review, it was determined the facility staff failed to implement a care plan to address the toileting needs of the resident and to attempt to assist the resident in restoring continence of bowel and bladder. This was evident for 1 resident (#64) of the 37 sampled residents selected for review. The findings include: Resident #64 was admitted to the facility after being hospitalized and treated for injuries he/she sustained in a motor vehicle accident. Interview of Resident #64 on 12/19/17 revealed that the resident is able to let staff know when he/she needs to use the commode, but staff do not respond in a timely manner and therefore, he/she has to use a diaper. The resident further stated that he/she had complained to facility staff that staff do not respond in a timely manner. A bedside commode was observed by the resident's bed. Review of a complaint/grievance report revealed that on 11/17/17 the resident complained to facility staff that when he/she rings the call bell to be changed, staff take over an hour to come. The facility staff reviewed call light response times to the resident's room from 11/17/17 at 2:12 A.M. through 11/18/17 at 8:05 P.M. and determined that call light response times were not as long as the resident had stated in the complaint. Review of a complaint/grievance report revealed that on 11/20/17 the resident complained he/she sat in the wheelchair for 4 hours and repeatedly asked to be moved to change soiled diaper, and complained that on 11/18/17 she/he sat in a soiled diaper from 6:00 A.M. to 9:00 P.M. The facility staff reviewed the Point of Care Activities of Daily Living (ADL) Category Report 11/14/17 through 11/20/17 and determined all ADL care was provided on all shifts. Review of the admission Bowel assessment dated [DATE] revealed that the nurse documented that the resident's risk factor for bowel incontinence include the resident's need for extensive assistance to total dependence. The resident has signs and symptoms of bowel incontinence which are documented as presence of fecal staining. The nurse documented that the resident would not be included in a restorative program. The nurse failed to document the reason the resident is not a candidate for the bowel restorative program. Review of the admission Bladder assessment dated [DATE] revealed that the nurse documented that the resident's risk factor for urinary incontinence include impaired mobility and being dependent on 2 staff for assistance with transfer. Signs and symptoms of urinary incontinence include clothes or incontinence pad wet. The nurse failed to assess for potentially reversible (transient) causes of urinary incontinence. Contributing diagnosis/medical conditions include pain with movement. The nurse documented that the resident exhibits strong, uncontrolled urgency prior to incontinence. Review of the Minimum Data Set (MDS), an assessment tool, dated 11/21/17, revealed that the resident requires extensive assistance of 1 person for toileting; the resident is always incontinent of bowel and bladder; and a trial toileting program was not initiated to attempt to restore bowel and/or bladder continence. Review of the daily skilled observation notes 11/15/17 through 12/19/17 revealed that the nurses documented daily that the resident has no issues related to bowel or bladder incontinence. Review of the occupational therapy notes revealed that as of 12/1/17 the resident was able to perform toileting tasks using the bedside commode with contact guard assistance. Interview of the Geriatric Nursing Assistant (GNA), Staff #17, caring for the resident on the 3:00 P.M. - 11:00 P.M. shift 12/20/17 revealed that the resident is able to use the bedside commode with the assistance of 2 staff. The GNA stated that she asks the resident if he/she needs assistance with toileting needs when her shift starts, before meals, after meals and at bedtime. Interview of the resident on 12/20/17 revealed that the resident is satisfied with the GNAs approach for toileting needs. Review of the resident's care plan revealed that the facility staff failed to initiate interventions related to toileting needs and restoring bowel and bladder continence other than the assistance of 1 staff for toileting. The care plan fails to address how toileting tasks will be accomplished to promote bowel and bladder continence. After surveyor intervention, on 12/20/17 the Director of Nursing (DON) spoke with the resident regarding continence. The DON documented: Resident states that [he/she] would like to be continent. Informed resident that we will place a bedpan in [his/her] room. Discussed the possibility of placing resident on a toileting program and schedule. [He/She] stated that [he/she] would not like that and [he/she] will call when the need arises. CP [care plan] updated to reflect changes and tasked for GNAs to see. Will discuss weight bearing status and limits with therapy to full implement bedside commode if possible as consultation paper is not clear for resident's limits.

Based on interview and review of medical records, it was determined that facility staff failed to accurately assess the resident's oxygen saturation level. This occurred in 1 resident (#63) of the 37 residents selected for review. The findings include: The nursing standard of practice in assessing oxygen saturation levels on individuals while on oxygen therapy is to first turn off the oxygen supplied to the individual. This is done while monitoring the individual with a pulse oximetry meter (a device used on the finger to measure the amount of oxygen in the blood). The oxygen level of the blood is then recorded when the reading on the meter stabilizes. On 12/18/2017 at 10:00 AM, Resident #63's family member informed this surveyor that the physician's order for oxygen therapy was on an as needed basis (PRN). Review of medical records on 12/20/2017 revealed that the doctor's orders were for oxygen at 2 liters per minute via nasal cannula as needed and to maintain oxygen saturation levels above 93%. Facility staff were consistently documenting that Resident #63's oxygen saturation levels were above 93%, however, staff failed to remove the oxygen tubing from the patient's nose prior to checking the levels. This will cause an inaccurate oxygen saturation level reading. On 12/22/2017 at 1:00 PM, the Director of Nursing (DON) reviewed the facility staff documentation on oxygen saturation levels for Resident #63 with this surveyor and agreed that the staff were not properly assessing the resident's oxygen saturation levels. Failure to accurately perform oxygen saturation levels on residents has the potential to lead to unnecessary supplemental oxygen use. When oxygen is applied at all times, the resident may become dependent on the supplied oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and review of the medical record it was determine the facility failed to provide care and services to assist Resident #64 to restore bowel and bladder continence. This was evident for 1 of 37 sampled residents selected for review. The findings include: Resident #64 was admitted to the facility after being hospitalized and treated for injuries he/she sustained in a motor vehicle accident. Interview of Resident #64 on 12/19/17 revealed that the resident is able to let staff know when he/she needs to use the commode, but staff do not respond in a timely manner and therefore, he/she has to use a diaper. The resident further stated that he/she had complained to facility staff that staff do not respond in a timely manner. A bedside commode was observed by the resident's bed. Review of a complaint/grievance report revealed that on 11/17/17 the resident complained to facility staff that when he/she rings the call bell to be changed, staff take over an hour to come. The facility staff reviewed call light response times to the resident's room from 11/17/17 at 2:12 A.M. through 11/18/17 at 8:05 P.M. and determined that call light response times were not as long as the resident had stated in the complaint. Review of a complaint/grievance report revealed that on 11/20/17 the resident complained he/she sat in the wheelchair for 4 hours and repeatedly asked to be moved to change soiled diaper, and complained that on 11/18/17 she/he sat in a soiled diaper from 6:00 A.M. to 9:00 P.M. The facility staff reviewed the Point of Care Activities of Daily Living (ADL) Category Report 11/14/17 through 11/20/17 and determined all ADL care was provided on all shifts. Review of the admission Bowel assessment dated [DATE] revealed that the nurse documented that the resident's risk factor for bowel incontinence include the resident's need for extensive assistance to total dependence. The resident has signs and symptoms of bowel incontinence which are documented as presence of fecal staining. The nurse documented that the resident would not be included in a restorative program. The nurse failed to document the reason the resident is not a candidate for the bowel restorative program. Review of the admission Bladder assessment dated [DATE] revealed that the nurse documented that the resident's risk factor for urinary incontinence include impaired mobility and being dependent on 2 staff for assistance with transfer. Signs and symptoms of urinary incontinence include clothes or incontinence pad wet. The nurse failed to assess for potentially reversible (transient) causes of urinary incontinence. Contributing diagnosis/medical conditions include pain with movement. The nurse documented that the resident exhibits strong, uncontrolled urgency prior to incontinence. Review of the Minimum Data Set (MDS), an assessment tool, dated 11/21/17, revealed that the resident requires extensive assistance of 1 person for toileting; the resident is always incontinent of bowel and bladder; and a trial toileting program was not initiated to attempt to restore bowel and/or bladder continence. Review of the daily skilled observation notes 11/15/17 through 12/19/17 revealed that the nurses documented daily that the resident has no issues related to bowel or bladder incontinence. Review of the occupational therapy notes revealed that as of 12/1/17 the resident was able to perform toileting tasks using the bedside commode with contact guard assistance. Interview of the Geriatric Nursing Assistant (GNA), Staff #17, caring for the resident on the 3:00 P.M. - 11:00 P.M. shift 12/20/17 revealed that the resident is able to use the bedside commode with the assistance of 2 staff. The GNA stated that she asks the resident if he/she needs assistance with toileting needs when her shift starts, before meals, after meals and at bedtime. Interview of the resident on 12/20/17 revealed that the resident is satisfied with the GNAs approach for toileting needs. Review of the resident's care plan revealed that the facility staff failed to initiate interventions related to toileting needs and restoring bowel and bladder continence other than the assistance of 1 staff for toileting. The care plan fails to address how toileting tasks will be accomplished to promote bowel and bladder continence. After surveyor intervention, on 12/20/17 the Director of Nursing (DON) spoke with the resident regarding continence. The DON documented: Resident states that [he/she] would like to be continent. Informed resident that we will place a bedpan in [his/her] room. Discussed the possibility of placing resident on a toileting program and schedule. [He/She] stated that [he/she] would not like that and [he/she] will call when the need arises. CP [care plan] updated to reflect changes and tasked for GNAs to see. Will discuss weight bearing status and limits with therapy to full implement bedside commode if possible as consultation paper is not clear for resident's limits.

Based on observation it was determined that the facility staff failed to maintain appropriate hygienic care for 1 resident (#25) of the 37 residents selected for review in the final investigations. The findings include: On 12/18/2017 at 8:35 AM, Resident #25's finger nails were observed to be extremely long and soiled. This finding was immediately brought tto the attention of Staff #14. A follow-up observation on 12/21/2017 at 10:54 AM revealed that the resident's finger nails remained long and soiled. Staff # 15 was immediately made aware. It is the facilities responsibility to ensure that the resident receives services for maintenance of personal hygiene when the resident is unable to perform such services independently.

Based on interview of Resident #64 and medical record review, it was determined the facility staff failed to accurately assess and manage the resident's pain. This was evident for 1 of 37 sampled residents selected for review. The findings include: Resident #64 was admitted to the facility 11/14/17 for rehabilitation after being hospitalized and treated for injuries sustained in a motor vehicle accident. Medical record review revealed that the resident had an order for Oxycodone 10 mg. 1 tablet every 6 hours as needed for severe pain. The resident, also, had a routine order for Tylenol 500 mg. 3 times per day. Medical record review revealed that between 11/15/17 through 12/1/17 the resident received multiple doses of Oxycodone for pain rated 6 to 8 out of 10 on a pain scale of 1 to 10, with 10 being the worst pain. Interview of Resident #64 on 12/19/17 revealed that the resident has pain issues, is not satisfied with the physician's care for failure to address pain in a timely manner and failure to order cold compresses in a timely manner. The resident stated that he/she had received cold compresses 2 times. The first time the facility staff used a disposable glove filled with ice, and the second time the facility staff used a plastic bag filled with ice that leaked onto the resident's clothing and bed when the ice melted. Medical record review revealed that on 12/1/17 the resident was seen and examined by the physician. The physician assessed the resident with left thigh pain and documented that the resident could use a cold compress after therapy. However, the physician failed to write an order for cold compresses after therapy. On 12/4/17 the resident was seen and examined by the physician. The physician documented that the resident stated that he/she has pain routinely at midnight, pain in the left buttock with sitting and has to change position often. The physician assessed the resident with pelvic pain and documented to continue pain management. On 12/8/17 the resident was seen and examined by the physician. The physician documented that the resident stated that he/she had not received cold compresses to the left buttock and thigh. The physician assessed the resident with left thigh pain and documented that she spoke with the nurse and an order was given for cold compresses. Review of the treatment administration record (TAR) revealed that the resident received cold compresses two times only on 12/8/17 at 10:35 P.M. and 12/12/17 at 2:21 A.M. Interview of the Occupational Therapy Assistant, Staff #16, on 12/21/17 revealed that the Rehabilitation Department has gel cold packs that can be used as part of therapy. There is no documented evidence that facility staff consulted with the rehabilitation staff regarding the use of cold compresses as part of rehabilitation therapy. Review of the resident's pain care plan that was initiated on 11/14/17 revealed that the facility staff failed to revise the resident's care plan with new interventions that included the use of cold compresses. Review of the TAR revealed that on 12/9/17 through 12/12/17 the nurses documented every shift that the resident's pain was 0 out of 10. However, review of the Individual Resident's Controlled Substance Record revealed that Oxycodone 10 mg. 1 tablet had been signed out on 12/9/17 at 1:00 A.M., 12/10/17 at 1:00 A.M., 12/11/17 at 1:00 A.M. and 12/12/17 at 1:00 A.M. for Resident # 64. However, review of the TAR revealed that there is no documented evidence that the resident was assessed and medicated for pain with Oxycodone 12/9/17 through 12/12/17. Medical record review revealed that the resident was seen and examined by the physician on 12/13/17. The physician documented that the resident had multiple complaints about the type of cold compresses received and that the cold compresses did not help anyway. The physician further documented that the resident's average pain is 5 to 6 out of 10 and that Tylenol is not relieving pain. The physician assessed the resident with left thigh pain and documented that she would add routine Oxycodone for persistent pain. The physician gave an order for Oxycodone 10 mg. 1 tablet every 6 hours for severe pain.

Based on observations and verified by staff, it was determined the facility staff failed to ensure: 1) that medications were stored within the recommended temperatures of 36° F to 46°F and 2) that blood glucose (sugar) monitoring supplies were properly labeled after opening. This deficient practice was found on the 2nd floor in 1 of 1 medication storage refrigerators and in 1 of 2 medication carts examined. This practice has the potential to affect any resident receiving medications from the 2nd floor refrigerator and any resident receiving blood glucose monitoring on the 2nd floor. The findings include: 1) An observation conducted on 12/22/2017 at 11:15 AM revealed the thermometer on the inside door of the 2nd floor medication storage refrigerator recorded the inside temperature at 28°. Medications stored in the refrigerator included the IV antibiotic cefepime and various types of insulins. This finding was verified by staff #4. According to manufacturer instructions, neither IV cefepime and insulins should be allowed to freeze. 2) An observation conducted on 12/22/2017 at 11:25 AM revealed the C/D Wing medication cart on the 2nd floor contained 1 opened bottle of EvenCare® G2® control solution (a solution that mimics blood that is used to test the accuracy of both the blood glucose meter and the test strips) that was not labeled with the date opened. This finding was verified by staff #4. According to manufacturer of EvenCare® G2® blood glucose monitoring supplies, after opening the control solutions the date opened should be written on the bottles and discarded 3 months after the date opened. The facility staff have a responsibility to ensure that the medication storage refrigerator stays within the recommended temperature range and that blood glucose monitoring supplies are labeled with the date opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, it was determined that facility staff failed to: 1) assess proper placement and function of a safety device for 1 resident (#70) of 37 residents selected for review in the final sample. Staff had documented in the medical record that assessments had been completed, and 2) ensure that Medical Orders For Life-Sustaining Treatment (MOLST) forms were voided according to instructions. This practice affected 1 resident (#13) of the 37 residents selected for review in the final resident survey sample. The findings include: 1) On [DATE], at 12:19 PM, interview of Resident (#70) indicated that a Wanderguard, a safety device that protects vulnerable residents from leaving the facility, had been placed on the resident's ankle, but the resident had removed it two or three weeks ago. The surveyor observed the device in the resident's bedside drawer at that time. Review of the medical record on [DATE] at 10:23 AM revealed that the safety device had been ordered by the physician on [DATE]. Review of the TAR (treatment administration record) revealed that staff had documented that the Wanderguard was in place during each shift since it's initial placement. The surveyor returned to the resident's room on [DATE] at 10:40 AM and determined that the safety device was still in the resident's bedside table drawer. The Director of Nursing and Administrator were notified, and had staff check the drawer at 10:47 AM on [DATE], verifying that it was not on the resident's ankle. Facility staff failed to monitor the safety device and further documented that the device was in place on [DATE] and 21, 2017, when the device was removed and placed in the bedside table drawer. 2) MOLST is a form that makes treatment wishes known to health care professionals and is part of the resident's medical record. The MOLST form includes orders about cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. If there are any changes to a MOLST form, a new MOLST form must be completed and the old one voided. A medical record review conducted on [DATE] revealed that Resident #13's closed record contained 7 copies of a MOLST form dated [DATE] with the order to attempt CPR. 3 of the copies had been voided and 4 were not. There was 1 MOLST form dated [DATE] with the order to attempt CPR that had not been voided after a new MOLST with the order not to attempt CPR had been initiated [DATE]. The facility staff have a responsibility to ensure that MOLST forms are voided in order to protect the resident's wishes.

Based on observations, it was determined the facility staff failed to use proper hand washing techniques prior to administering medications to 2 Residents. This practice was observed for 2 out of 4 residents observed during the survey process. The findings include: On 12/21/17 during observation of the morning medication pass, writer witnessed staff #1 wash their hands with soap, under running water. The staff then was observed turning the faucet off with wet hands and not with a paper towel. Staff #1 then proceeded to dry their hands and proceed to administer medications to the next resident. This was witnessed on two occasions during the medication pass. Hand washing is one of the most effective ways to prevent the spread of germs from one person to another. Using a wet clean hand to turn off the faucet instead of a dry paper towel, transfer the germs from the faucet back to the hand. It is the facility's responsibility to protect its residents from any possible contaminations.

Based on observations, interviews, and medical records review, it was determined the facility staff failed to ensure: 1) that nursing staff assessed edema accurately in Resident #85, and 2) that nurses had the necessary competencies and skills to perform neurological assessments for 12 residents (#5, 17, 21, 22, 41, 49, 56, 61, 67, 93, 344, and 345). These practices were evident for 13 of the 37 selected for review in the final investigations. The findings include: 1) On 12/18/17 at 10:20 AM, an anonymous complainant stated that Resident #85 was having problems with foot and leg swelling and said that it had progressed since admission. Edema is the medical term for swelling. Generally, swelling in the feet, ankles and legs is called peripheral edema. Assessing edema includes determining if it is pitting or non-pitting. Pitting edema leaves an indentation when pressure is applied to an area and then released. It is described as 1+, 2+, 3+ and 4+ depending upon the size of the depression and how long it takes to rebound back into place. During review of the medical record for Resident #85 the following documentation was found in physician notes: 11/20/2017 .bilateral lower extremity edema 1-2+ nonpitting . An order was written for Furosemide 20 mg (milligrams) po (by mouth) to be administered once daily for 3 days. (Furosemide is a diuretic, commonly referred to by some as a water pill because it can help decrease excess fluid that can cause peripheral edema.) Nursing documented on 11/20/2017 at 16:34 (4:34 PM), .Edema present: no . 12/1/2017 .Bilateral lower extremity edema 1 nonpitting . Nursing observations on 12/1/17 at 23:38 (11:38 PM) state, .Edema present: no . 12/7/2017 .1 + edema bilateral (both) LE (lower extremities) . Nursing observations documented on 12/7/2017 at 21:57 (9:57 PM) state, . Edema present: no . No evidence of worsening edema after 12/7/2017 was found in the medical record. However, no record of peripheral edema was found in nursing observation notes on the dates the physician noted edema. The Director of Nursing (DON) confirmed the findings. The facility is responsible to ensure that nurses are competent to assess peripheral edema accurately. 2) A neurological assessment, or neuro assessment, is an evaluation of a person's nervous system (brain, spinal cord, and nerves). The assessment includes evaluating a nerve of the brain, the oculomotor nerve, which is responsible for pupil dilation and constriction and the ability to focus at different distances (accommodation). Normal pupil size in adults varies from 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Smaller or larger pupils could be an indication that there may be an underlying problem and should be reported. A medical record review of neurological assessments for 10 residents in December (Dec.) 2017 revealed that staff documented the pupil size as 1 millimeter (1 mm) on each of the following dates: A. Dec. 1, 2, 5 & 6 for Resident #5; B. Dec. 1, 2, 5, 6 & 15 for Resident #17; C. Dec.16 & 20 for Resident #21; D. Dec. 8 for Resident #22; E. Dec. 14 for Resident #49; F. Dec. 7 & 14 for Resident #56; G. Dec. 6 & for Resident #61; H. Dec. 10 & 14 for Resident #67; I. Dec. 3 & 6 for Resident #344; J. Dec. 9, 10, 13 & 14 for Resident #345. A review of nursing notes for the above residents did not indicate that the above findings, which if accurate would be considerd abnormal, had been reported to a Physician or Nurse Practitioner. An interview conducted 12/20/2017 at 11:00 AM with staff #8, a Nurse Practitioner, corroborated that there is the expectation that all abnormal findings, including abnormal pupil sizes, should be reported. On 12/21/2017 at 9:30 AM staff #2 was observed performing a neurological exam on Resident #41. Before entering the room, the staff member stated, I don't think I have a [penlight] with batteries and then proceeded to enter the room without one. Resident #41 was seated in a chair and the lights were turned off in the room. Staff #2 incorrectly assessed the pupils by opening the residents eye, looking in the eye, and then declared, the pupils are good, they are reactive. A penlight was never utilized to assess dilation and constriction and he/she did not assess for accommodation (ability to focus at different distances). When asked how he/she knew they were reactive he/she stated that they were dilated. Upon exiting the room staff #2 was asked what accommodation was and how he/she checked for accommodation during the assessment. Staff #2 could not provide an answer despite accommodation being part of the focused observation assessment. On 12/21/2017 at 9:40 AM, Staff #5 was asked how he/she checked for accommodation during the neurological assessment. Staff #5 did not know what accommodation was. On 12/21/2017 at 9:45 AM, Staff #3 was observed performing a neurological assessment on Resident #93. Staff #3 did not check for accommodation, and upon exiting the room could not provide a correct definition of accommodation. On 12/21/2017 at 12:10 P.M., these findings were brought to the attention of the Director of Nursing (DON). The DON stated that issues with nursing assessments had already been identified by the facility and were being addressed in the PIP (Performance Improvement Plan). The facility has a responsibility to ensure that nursing staff can correctly perform and accurately document neurological assessments.

Based on observation and verified by interview of staff, it was determined that facility staff failed to maintain refrigerated milk at acceptable temperatures and failed to ensure that food contact equipment was in good repair. The findings include: On December 18, 2017, at 7:36 AM, the surveyor observed food carts with cartons of milk in the dining room adjacent to the main kitchen. The surveyor requested that the temperature of the milk be checked. The [NAME] provided a thermometer and the milk was found to be at 66 degrees Fahrenheit (F). The surveyor checked the calibration of the thermometer and it was found to be inaccurate by four degrees F, reading 36 degrees in a 32 degree ice water slurry. Based on the thermometer inaccuracy, it was determined that the milk was at about 62 degrees F. The [NAME] told the surveyor that the milk was placed in the carts at about 6:50 AM, in anticipation of serving breakfast to the residents. The milk was voluntarily discarded by the Cook. Milk and other potentially hazardous foods must be kept at or below 41 degrees F. On December 19, 2017, at 3:00 PM, the surveyor conducted a tour of the facility main kitchen, accompanied by the Dietary Manager. The grinder, used for pureeing foods for residents who have difficulty eating whole foods, was found to have a broken plastic lid. The lid was taped together with plastic tape, creating a surface that cannot be cleaned and sanitized. Food contact equipment must be in good condition and easily cleanable.

Based on observation and interview, it was determined the facility staff failed to ensure that the units contained an adequate number of medical penlights. This deficient practice occurred on 1 of 2 floors and could affect any resident requiring staff to utilize the pen lights for assessments. The finding included: On 12/21/2017 at 9:30 AM, Staff #2 was asked to perform a neurological assessment on a resident. Staff #2 stated that his/her penlight (needed to check pupils as part of the neurological assessment) did not have batteries. At 9:35 AM, Staff #4 searched the unit for a penlight and was unable to locate one. He/she then proceeded to 1st floor to find one. Staff #4 returned to the unit at 9:45 AM. At 9:45 AM, Staff #3 was asked to perform a neurological assessment. He/she stated that he/she did not have a penlight because it was in the car. These findings were brought to the attention of the Director of Nursing and the Nursing Home Administrator. The facility has a responsibility to ensure that the units are stocked with the supplies needed to provide for resident needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview of facility staff, it was determined that that ventilation fans in the building were not maintained in operating condition. The findings include: On December 22, 2017, the surveyor, accompanied by the Administrator and Director of Maintenance, completed environmental rounds in the building to check for adequate ventilation. In the soiled utility room near room [ROOM NUMBER], the vent fan was inoperable. In the public toilet in room [ROOM NUMBER] A, the ventilation fan duct was damaged. In the shower room for unit 1 A, the ventilation fan was inoperable. At 11:19 AM on 12/22/2017, the Administrator told the surveyor that the rooftop motors for ventilation fans in the building were checked. Of nine fans, four were inoperable and one was in need of repair. Adequate ventilation is required to reduce odors in the building.