**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and facility policy review, the facility failed to honor resident's rights to make health care decisions for three (3) of 24 residents reviewed for advanced directives. Resident #10, #36, and #48 Findings Include: Record review of the facility policy titled Do Not Resuscitate No Code Status Policy dated 2/2024 revealed, It is the policy of this facility to inform residents of the right to choose to have CPR (cardiopulmonary resuscitation) or no CPR to be performed at such time of imminent death. The code status form will be completed at the time of admission. Resident #10 Record review of Resident #10's Order Summary Report revealed, DNR (Do Not Resuscitate): Need for death with dignity related to choice of code status DNR per family/Resident Representative (RR) request. Record review of the Code Status form for Resident #10 revealed a family member signed the form dated [DATE], with no signature from the resident. An interview with Resident #10 on [DATE] at 10:35 AM revealed he can make his own decisions and sign his paperwork. He stated that when he was admitted to the facility, he did not recall anyone asking him whether he wanted to be a full code or DNR and admitted that he did not sign any paperwork on it. He stated that it should be his choice since I can make my own decisions. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] for Resident #10 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated the resident was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #10 on [DATE] with diagnoses that included Chronic Systolic (Congestive) Heart Failure, and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Resident #36 Record review of Resident #36's Order Summary Report revealed full code related to family/Resident Representative choice of code status. Resident is a full code. Record review of the Code Status form for Resident #36 revealed a family member signed the form dated [DATE], with no signature from the resident. An interview with Resident #36 on [DATE] at 11:45 AM, revealed when she was admitted to the facility, she did not sign her code status form, and no one spoke to her about it. She stated that she can still make her own decisions, and even though she has Parkinson's, and it may take her a little longer, she can still sign. Record review of Resident #36's MDS with an ARD of [DATE] revealed, under Section C, a BIMS summary score of 14, which indicated the resident was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #36 on [DATE] with diagnoses that included Hypoglycemia, Unspecified, and Parkinson's Disease without Dyskinesia. Resident #48 Record review of Resident #48's Order Summary Report revealed, full code related to family/Resident Representative choice of code status. Resident is a full code. Record review of the Code Status form for Resident #48 revealed a family member signed the form dated [DATE], with no signature from the resident. In an interview on [DATE] at 8:50 AM, Resident #48 revealed that she did not sign her Advance Directives when admitted to the facility. She stated that no one at the facility had spoken with her about her code status. Record review of the MDS with an ARD of [DATE] for Resident #48 revealed, under Section C, a BIMS summary score of 14, which indicated the resident was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #48 on [DATE] with diagnoses that included Multiple Fractures of Pelvis without Disruption of Pelvic Ring, and Chronic Kidney Disease, Stage 3. An interview with the Social Services Director on [DATE] at 1:15 PM, revealed that when a resident was admitted to the facility, she had been discussing their code status with the family representative or power of attorney (POA) and had not been going over it with the resident. She confirmed that Residents #10, #36, and #48 did not sign their code status form, and they should have because it was their right. During an interview on [DATE] at 1:40 PM, the Administrator confirmed that the residents who were competent and able to sign their Advance Directive should be allowed to do so, and we should ensure that their wishes were honored. In an interview on [DATE] at 10:38 AM, the Director of Nurses (DON) confirmed that Residents #10, #36, and #48 were cognitive and able to make their own decisions and should have had the opportunity to decide what their end-of-life wishes were.

Based on staff interview and record review, the facility failed to accurately code section A of the Minimum Data Set (MDS) for a resident with a serious mental illness for one (1) of 16 MDS reviewed. Resident #16 Findings Include: The facility provided a statement on letterhead dated 1/15/25 that read, It is the policy of Proper Name of the Facility to follow the RAI (Resident Assessment Instrument) manual for completion and accuracy of the MDS (Minimum Data Set) assessments. Record review of Resident #16's Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 6/14/2017, revealed under, Mental Health . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Schizophrenia was listed as the diagnosis. Record review of Resident #16's Annual MDS with an Assessment Reference Data (ARD) of 4/01/24 revealed, under section A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was answered. An interview with the MDS Nurse on 1/15/25 at 2:35 PM, confirmed Section A of Resident #16's MDS was coded inaccurately. She confirmed that the resident had a serious mental illness, and the assessment should be accurate to develop a complete plan of care. An interview with the Director of Nursing (DON) on 1/15/25 at 2:52 PM revealed, his expectations were for the MDS assessments to accurately reflect each resident's status and plan of care. Record review of the admission Record revealed the facility admitted Resident #16 on 5/03/17 with medical diagnoses that included Schizophrenia and Unspecified Psychosis.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene.(Resident #1, #2, #7) and adaptive equipment with meals (Resident #2) for three (3) of 16 care plans reviewed. Residents #1, # 2, #7 Findings Include: Review of the facility policy titled, Following the Care Plan Policy unrevised, revealed under, Policy: It is the Policy of this facility to follow a written and approved care plan for each resident. Resident #1 Record review of Resident #1's ADL (activities of daily living) Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia. Also revealed under, Intervention/Task: Personal hygiene/Oral care: The resident requires x (times) 1 (one) staff participation with personal hygiene . An observation on 1/14/25 at 9:20 AM revealed Resident #1 lying in bed with long facial hair on her chin, which was approximately three to four inches long. On 1/16/25 at 9:10 AM, an interview with the Director of Nursing (DON) confirmed the ADL care plan was not followed for Resident #1. Record review of the admission Record revealed the facility admitted Resident #1 on 4/03/2017 with medical diagnoses that included Major Depressive Disorder and Muscle Weakness. Resident #7 Record review of Resident #7's ADL Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t Rhabdomyolysis. Also revealed under, Intervention/Task: Check nail length and trim and clean on bath day and as necessary. An observation of Resident #7 on 1/14/25 at 9:00 AM, revealed she was lying in bed and had long fingernails approximately one-half (1/2) to three-fourths (3/4) inches in length on both hands. On 1/15/25 at 1:20 PM, an observation and interview with CNA #1 confirmed Resident #7's fingernails were too long. On 1/16/25 at 9:10 AM, an interview with the DON confirmed the ADL care plan was not followed for Resident #7. Record review of the admission Record revealed the facility admitted Resident #7 on 12/20/24 with a medical diagnosis of Rhabdomyolysis. Resident #2 Record review of Resident #2's ADL Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t weakness, osteoarthritis. Also revealed under, Interventions: Personal hygiene/Oral care: The resident requires x (times) 1 staff participation with personal hygiene and oral care. On 1/14/25 at 8:09 AM, an observation of Resident #2 revealed that she was sitting in her wheelchair in her room. As the resident was trying to communicate, a thick white substance was observed on her upper and lower teeth and on her gums. An observation and interview with the DON on 1/15/25 at 3:22 PM confirmed oral hygiene was not done and described Resident #2's teeth as plaque buildup and food particles. Resident #2 Record review of Resident #2's nutritional Care Plan revealed under, Focus: The resident at risk for potential nutritional problems related to diet restrictions . Also revealed under, Interventions/Task: Resident to have divided plate with meal, date initiated 9/15/22 and Resident to have sippy cup with meals, date initiated 9/22/23 . An observation of Resident #2's lunch meal on 1/14/25 at 11:55 AM revealed that she was served on a regular plate with a glass of tea and water in a goblet style. An observation of the resident's meal ticket at this time revealed, Divided plate, sippy cup. and the resident did not have these available. An interview with the DON on 1/14/25 at 12:01 PM, confirmed Resident #2 did not have the adaptive equipment that was listed on her meal ticket. An interview with the MDS Nurse on 1/16/25 at 8:16 AM revealed the purpose of the care plan was for the staff to know what care to provide for the residents. She confirmed Resident #2's care plan was not followed for oral hygiene and adaptive equipment. Record review of the admission Record revealed the facility admitted Resident #2 on 10/28/20 with medical diagnoses that included Dysphagia and Left Wrist Drop.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide nail care, oral care and facial hair removal for resident's requiring assistance with activities of daily living (ADLs) for three (3) of 16 sampled residents. Resident #1, #2, and #7 Findings Include: Record review of the facility policy, ADL Care Policy undated, revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis . Resident #1 An observation and interview on 1/14/25 at 9:20 AM revealed, Resident #1 with facial hair on her chin that was approximately three (3) to four (4) inches long. An interview with the resident revealed that she did not like facial hair and stated, I want them gone. An observation and interview on 1/15/25 at 1:27 PM, with Certified Nursing Assistant (CNA) #1 revealed facial hair and fingernails should be taken care of during bath time or anytime it was noticed. She confirmed that Resident #1 had long hair on her chin and admitted it should have already been taken care of. Record review of the admission Record revealed the facility admitted Resident #1 on 4/03/2017 with medical diagnoses that included Major Depressive Disorder and Muscle Weakness. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/24, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #7 On 1/14/25 at 9:00 AM, an observation and interview with Resident #7 revealed she had fingernails approximately one-half (1/2) to three-fourths (3/4) inches in length past the tips of the fingers. She admitted that she had never had fingernails this long before, and stated, I keep them very short; I feel like they are like claws now. The resident revealed she had been at the facility since December, and no one had offered to clip her nails. An observation and interview on 1/15/25 at 1:20 PM of Resident #7 with CNA #1 revealed that fingernails should be checked every day, cleaned and clipped when needed. She confirmed Resident #7's fingernails were long and Resident #7 stated to CNA #1, I have never had my nails this long before and I want them cut. CNA #1 stated that with the resident's fingernails that long she could scratch herself and cause skin tears or the spread of bacteria. On 1/16/25 at 8:30 AM, an interview with Registered Nurse (RN) Supervisor revealed that the nurses should be checking behind the aides to make sure the resident needs were taken care of. She revealed she was not aware Resident #7 had long fingernails and confirmed that nail care should be included in their personal hygiene task. On 1/16/25 at 9:10 AM, an interview with the Director of Nursing (DON) confirmed that the nurses and the aide supervisor should be overseeing the completion of ADL care. He revealed that anyone who noticed a need with a resident should take care of the problem or tell someone who could. Record review of the admission Record revealed the facility admitted Resident #7 on 12/20/24 with a medical diagnosis of Rhabdomyolysis. Record review of Resident #7's MDS with ARD of 11/26/24 revealed under Section C, a BIMS score of 10, which indicated the resident was moderately cognitively impaired. Resident #2 An observation of Resident #2 on 1/14/25 at 8:09 AM revealed the resident was trying to talk and a thick white substance was observed on her upper and lower teeth and gums. An observation of Resident #2 on 1/15/25 at 8:06 AM revealed no change in the resident's teeth and gums. An observation and interview on 1/15/25 at 3:10 PM, with CNA #2 revealed she was assigned to Resident #2 today on day shift. She confirmed the resident had excess buildup on her teeth and that she did not brush the residents' teeth today. She explained that the resident was on the get up list and that the night shift should have done it. She admitted that she should have checked behind them to ensure it was done. An observation and interview with the DON on 1/15/25 at 3:22 PM described Resident #2's teeth as plaque buildup and food particles. He revealed that the aides and nurses were responsible for oral care and brushing the resident's teeth. The DON stated that the resident could develop decay and cavities from not getting the appropriate oral care. Record review of the admission Record revealed the facility admitted Resident #2 on 10/28/20 with medical diagnoses that included Dysphagia and Left Wrist Drop.

Based on observation, staff and resident interviews, and facility policy review, the facility failed to properly store medications, as evidenced by, medications left in a resident's room for one (1) of 16 sampled residents. Resident #41 Findings Include: Record review of the facility policy Medication Storage dated 01/2024, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication cart and/or medication rooms according to the manufacturer's recommendation An observation on 1/14/25 at 11:00 AM and 2:00 PM revealed a one-ounce bottle of lubricant eye drops and a two-ounce tube of pain relief cream on the overbed table in Resident #41's room. An interview on 1/14/25 at 2:50 PM, with Resident #41 revealed he brought his eye drops and pain cream from home, and he applied them himself. He revealed that he used the eye drops every day and that he hardly ever used the pain cream. The resident explained he kept these items in his room so he could use them as needed. An observation and interview with Licensed Practical Nurse (LPN) #1 on 1/15/25 at 9:58 AM, confirmed Resident #41 had a bottle of lubricant eye drops and a tube of pain cream on his bedside table. She revealed the resident had not been assessed for self-administration and explained medications were not supposed to be in his room. LPN #1 agreed that leaving medications in a resident's rooms was a risk, and another resident could enter his room and take something they were not supposed to have. An interview on 1/15/25 at 10:40 AM, with the Director of Nursing (DON) confirmed that leaving medications in a resident's room should not happen. He revealed that some residents were used to self-administering medications at home before coming into the facility, and it was often hard for them to adjust. The DON stated that if a resident requested to self-administer their medications, then an assessment should have been done to ensure they were competent and knew how to use it. He revealed this one must have slipped through the cracks and explained that someone should have seen the medications in Resident #41's room and removed them. Record review of Resident #41's admission Record revealed an admission date of 9/10/24, with medical diagnoses that included Unspecified Injury of Left Lower Leg, Muscle Weakness, and Need for Assistance with Personal Care. Record review of Resident #41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24, revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment during meals for one (1) of two (2) dining observations. Resident #2 Findings Include: Review of the facility policy titled Assistive Feeding Devices with a revision date of 6/14 revealed under, Policy: Residents shall be provided assistive devices to maintain or improve their ability to eat independently. Also revealed under, Procedure: . 4. The assistive devices are placed on the resident's tray at the time of meal service. An observation on 1/14/25 at 11:55 AM revealed Resident #2's lunch meal was served on a regular plate with a goblet glass of tea and water with a meal ticket that read, Divided plate, sippy cup. An interview with the Director of Nursing (DON) on 1/14/25 at 12:01 PM confirmed that Resident #2 did not have the adaptive equipment that the resident should have had. Record review of the Order Details for Resident #2 revealed an order dated 11/15/21, Patient to have sippy cup at breakfast, lunch, and dinner with meal. A record review of the Order Details for Resident #2 revealed an order dated 11/19/21, . Divided plate with meals. An interview with Dietary Staff #2, on 1/15/25 at 8:10 AM confirmed when adaptive equipment was on a meal ticket, the dietary server should provide it during the tray preparation. She revealed the purpose of ensuring the adaptive equipment was available with the meal was to help the residents be more independent with feeding themselves. An interview with the DON on 1/15/25 at 8:20 AM confirmed that the purpose of the adaptive equipment was to assist the resident with feeding herself and confirmed it should be available with each meal. Record review of the admission Record revealed the facility admitted Resident #2 on 10/28/20 with medical diagnoses that included Dysphagia and Left Wrist Drop.

Based on observation, staff interview, and facility policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) while providing resident care for two (2) of three (3) direct care observations. Resident #28 and Resident #49 Findings Include: Record review of the facility policy Enhanced Barrier Precautions with a revised date of 8/07/24, revealed under, Policy Explanation and Compliance Guidelines: . 2. Initiation of Enhanced Barrier Precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds . and/or indwelling medical devices ( .urinary catheters, feeding tubes .) even if the resident is not known to be infected . Resident #28 An observation on 1/15/25 at 8:55 AM revealed Licensed Practical Nurse (LPN) #2 administered Resident #28's medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube without wearing a gown for EBP. He revealed that EBP were supposed to be utilized when providing care to residents who had Covid-19 or open wounds. He stated that he did not think they had to follow the precautions for residents with PEG tubes. LPN #2 agreed that EBP were put in place to protect the residents and the staff to prevent the spread of germs. Record review of Resident #28's Order Summary Report with active orders as of 1/16/25 revealed an order for EBP related to PEG every shift and medication orders for administration through the PEG Tube. Record review of Resident #28's admission Record revealed an admission date of 4/29/24 with medical diagnoses that included Ventricular Fibrillation and Dysphagia. Resident #49 An observation on 1/15/25 at 10:50 AM revealed LPN #1 completed Resident #49's catheter care and changed the drainage bag without wearing a gown. LPN #1 revealed they (the staff) had to wear a gown if a resident had open wounds or something contagious like Covid-19. She stated that she was not aware that gowns had to be worn when providing catheter care. An interview on 1/15/25 at 11:25 AM, with the Director of Nursing (DON) revealed EBP were to be used with any residents who had indwelling medical devices to protect the residents from infection. He revealed the staff had been in-serviced and knew they were supposed to wear gloves and gowns when they provided care to these residents. Record review of Resident #49's admission Record revealed an admission date of 12/09/24 with medical diagnoses that included Malignant Neoplasm of the Prostate and Chronic Kidney Disease. Record review of Resident #49's Order Summary Report with active orders as of 1/16/25 revealed, Resident to be placed on EBP related to Foley and there was an order for catheter care every day related to Retention of Urine diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review the facility failed to ensure items in the walk-in kitchen refrigerator were labeled and dated, discarded by the expiration date, and arranged in a manner to prevent possible cross-contamination for one (1) of three (3) kitchen tours Findings include: Review of the facility policy titled, Labeling and Dating Inservice revised 2/2023, revealed All foods should be dated upon receipt before being stored. Food labels must include: The food item name, the date of preparation/receipt/removal from freezer, and the use by date.Leftovers must be labeled and dated with the date they are prepared and the use by date. Review of the facility policy titled, Food Storage: Cold Foods revealed, 5 .All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. An observation and interview on the initial tour of the kitchen with the Dietary Manager (DM) on 1/14/25 at 8:05 AM, revealed in the walk-in refrigerator two white opened containers with a manufacturer label of Yoplait Vanilla Yogurt. The containers were not dated and had a manufacturer best-by date of [DATE]. An observation of a five-pound opened Sysco Tropical Fruit Supreme with no open date nor use-by date. The DM revealed she was unsure when it was opened. An observation of a five-pound white container of Wholesome Farm sour cream dated 12/17/24 with no use-by date, and a large clear plastic container dated 1/11 with no label or use-by date. The DM identified the food item as chicken salad. An unlabeled clear plastic container dated 1/7 with no use-by date, which the DM identified as pimento cheese, a 2-inch-deep rectangular metal pan unlabeled with a date of 1/14, with no use-by date, the DM identified as liquid eggs, a square clear container unlabeled with a date of 1/14, with no use-by date, the DM revealed that is chopped ham, a transparent plastic square container unlabeled with a date of 1/8 on one side and a date of 1/13 on the other side, the DM revealed they had this last night for supper and confirmed the food item was cooked sausage and peppers. She confirmed the date for the meal was last night but wasn't sure why they didn't change the date on the container. Observation revealed a small square pan unlabeled and undated which the DM confirmed the food items were four boiled eggs in a clear liquid and revealed she wasn't sure how long they had been there. An observation of a rectangular metal tray on the bottom shelf of the refrigerator revealed a labeled gallon-sized bag of chicken in a liquid substance; the bag was undated, and in the same pan wrapped in cellophane was an unlabeled and undated food item the DM identified as pork loin . A liquid substance was noted on the bottom of the metal tray where both food items were placed. The DM revealed they were both undated and should not have been in the same container thawing because this could cause bacteria, and the residents could get sick. She confirmed that the food items in the refrigerator were not properly labeled and dated and that all foods should have dates for when they should be discarded. In an interview on 1/14/25 at 8:20 AM with the Dietary Aide revealed that when the food items come in, he puts the dates that they arrived, and then when they open them, they are supposed to put that date and then a use by date. He confirmed the items in the walk-in refrigerator were not correctly labeled. In an interview on 1/15/25 at 12:05 PM, the Administrator confirmed that it is the facility policy that all food items be properly labeled, dated when they arrive at the facility, when they are opened and discarded within the proper time to prevent any food-borne illnesses.

Based on observation, staff interview, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on four (4) of five (5) housekeeping carts observed during annual survey. Findings include: Review of the facility policy titled, Hazardous Chemical Storage, revealed Policy: Environmental services shall maintain all hazardous chemicals in a safe, clean, and locked location when not in use. All hazardous chemicals shall be in control of facility personnel while being used . An observation on 09/19/23 at 08:12 AM, of a housekeeping cart on the 100-hall revealed one (1) bottle of Lysol cleaner, one (1) bottle of Pledge glass cleaner, 1 bottle of Tilex cleaner, 1 bottle of 4 in 1 Clorox cleaner and 1 bottle of Clorox cleaning wipes sitting on top of the housekeeping cart on the 100-hall unattended. An interview, on 09/19/23 at 8:17 AM, with Housekeeper #1 confirmed that the chemicals should be locked up when she is not with the cart and that if a resident gets them it could harm them. An observation on 09/20/23 at 09:45 AM, of the housekeeping cart on the 200-hall revealed the housekeeping cart was unlocked and unattended. Inside the cabinet on the cart was 1 bottle of Air neutralizer,1 bottle of Clorox urine odor remover, and 1 bottle of Pledge glass cleaner. An observation and interview, on 09/20/23 at 09:50 AM, with the Administrator (ADM) confirmed that chemicals were sitting on top of the cart on the 200-hall and in the general sitting area unattended. The (ADM) confirmed that the chemicals should be locked inside the cart. The ADM confirmed that the key to lock the carts was unable to be located. The ADM confirmed that the chemicals could be harmful if residents got them. An observation, on 09/20/23 at 10:00 AM, with the Housekeeping Supervisor and Housekeeper #2 revealed two (2) housekeeping carts located in the general sitting area, unattended, with cleaning chemicals sitting on the top of the cart. The chemicals included: 1 bottle of Clorox urine odor remover, 1 bottle of Pledge glass cleaner, and 1 bottle of Tilex cleaner. The cabinet on the housekeeping carts were unlocked. Housekeeper #2 confirmed that chemicals should not be left on top of the cart unattended and that they should always be locked inside the cabinet of the housekeeping cart. Housekeeper #2 stated that a resident could get the chemicals and swallow them. Housekeeper #2 confirmed she did not have a key to lock her housekeeping cart. An interview on 09/20/23 at 10:10 AM with the Housekeeping Supervisor confirmed that there were cleaning chemicals on the top of the housekeeping cart on the 200 hall and the 2 housekeeping carts located in the general sitting area. The Housekeeping Supervisor confirmed that the cabinet was unlocked on the housekeeping carts on 200 hall and the 2 carts located in the sitting area. The Housekeeping Supervisor confirmed that he was unaware of where the keys were located to lock these carts. The Housekeeping Supervisor confirmed that he was never trained in storage of chemicals when he was given the position of Housekeeping Supervisor 2 years ago. The Housekeeping Supervisor confirmed that he has five (5) housekeeping carts and they are used in the facility daily. The Housekeeping Supervisor confirmed that leaving chemicals unattended and the cabinets unlocked could be harmful if residents were to get them. An interview on 09/21/23 at 08:30 AM, with the Director of Nursing (DON) confirmed that there are no wandering residents in the facility, and they have had no incidents in the last 12 months involving chemicals. An interview on 09/21/23 at 10:28 AM, with the ADM confirmed that the Housekeeping Supervisor was a floor technician at this facility prior to being moved into the Housekeeping Supervisor position. The ADM confirmed that the Housekeeping Supervisor received training on storage of chemicals and locking housekeeping carts. An interview, on 09/21/23 at 11:00 AM, with the Housekeeping Supervisor confirmed that he did attend the in-services on 05/09/23 and 7/31/23 conducted by the Administrator and was aware that the chemicals should not be left unattended, and the housekeeping carts should be always locked when unattended. Record review of the in-service training dated 05/09/23 and 07/31/23 revealed that the Housekeeping Supervisor, Housekeeper#1 and Housekeeper #2 were present and received training on the storage of chemicals. Record review of the Material Safety Data Sheets (MSDS) for the unattended chemicals revealed: Air Neutralizer - If on skin; take off immediately all contaminated clothing; Rinse skin with water/shower. Pledge Cleaner - Avoid contact with skin, eyes, and clothing. Use only as directed. Keep out of reach of children and pets. Tilex - Causes eye irritation, wash contaminated skin thoroughly after handling. Clorox Urine Remover - If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes (min). Wash off immediately with plenty of water, if skin irritation persists, call a physician. Remove to fresh air if breathing is difficult. Drink one or two glasses of water. Do not induce vomiting without medical advice. Clorox four in one disinfectant - Inhalation - remove to fresh air. Eye contact - Rinse thoroughly with plenty of water. Skin contact - Wash skin with soap and water. Ingestion - Clean mouth with water and drink afterwards plenty of water. Lysol Cleaner Eyes-If in eyes, hold eye open and rinse slowly and gently with water for 15-20 min Skin- Remove contaminated clothing. Rinse skin immediately with plenty of water 15-20 min Inhalation-Move exposed person to fresh air. Get medical attention immediately Ingestion-If swallowed, call poison control center. Do not induce vomiting. Have person sip a glass of water if able to swallow. Clorox Wipes Eyes- Open eyelids wide apart. Continue to rinse for at least 15 minutes. Get medical attention if symptoms persist. Skin-Rinse with water Inhalation-If throat irritation or cough, move person to fresh air. Ingestion-Rinse mouth. Get medical attention if any discomfort continues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 On 04/04/22 at 10:18 AM, an observation of Resident #19 from the hallway, revealed the door was open, and Resident #19 was lying in bed with only a brief on. No top sheet or blanket was covering him. On 04/05/22 at 08:51 AM, an observation of Resident #19 from the hallway, revealed him lying in bed exposed with only a brief on. Licensed Practical Nurse (LPN) #1 was in the room working on the resident's gastrostomy tube. The nurse exited the room leaving the door open with the resident remaining exposed with only a brief on. A Certified Nursing Assistant (CNA) entered the room closing the door behind her. An interview on 04/06/22 at 03:02 PM, with Licensed Practical Nurse (LPN) #1 revealed that Resident #19 should be covered when the door is open. LPN #1 stated that it could embarrassing to him, and it is a dignity issue. Record review of Resident #19's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Huntington's Disease, Dysphagia, Convulsions, and a Personal History of Traumatic Brain Injury. Record review of MDS with an ARD of 01/25/2022 revealed Resident #19 with a BIMS score of 03, which indicated the resident has severe cognitive impairment. Resident #42 Review of facility policy titled, Maintaining Privacy and Dignity For Residents with Foley Catheter Drainage Bags, with a revision date of 2/16 revealed, It is the policy of this facility to provide privacy and dignity to all residents that have a urinary drainage bag in use. The procedure revealed the drainage bag will be maintained in a storage pouch to hide the contents and prevent embarrassment to the resident. On 04/04/22 at 10:57 AM, 12:05 PM, and 03:05 PM, observations revealed Resident #42's urinary catheter bag was visible to the hallway. The catheter bag was on the right-hand side of the bed facing the entrance room door without a privacy bag. Urine was noted in urinary catheter bag. On 04/05/22 at 8:50 AM, and again at 3:50 PM, observations revealed Resident #42's urinary catheter bag on the right side of the bed facing the entrance room door without a privacy bag and visible to the hallway. During an observation on 04/06/22 at 09:33 AM , Resident #42's urinary catheter bag was on the right side of the bed without a privacy bag and facing the entrance room door. The catheter was visible from the hallway. During an observation and interview, on 04/06/22 at 1:00 PM, with the Director of Nurses (DON), she confirmed the resident had a privacy bag on the back of his wheelchair, but he should have a privacy bag for his bed, and his catheter bag should not be visible to the hallway. A record review of Resident #42's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Neuromuscular Dysfunction of the Bladder and Fracture of Left Femur. Record review of the MDS with an ARD of 02/22/2022, revealed Resident #42 had a BIMS score of 15, which indicated the resident was cognitively intact. Based on observation, staff interviews, resident interviews, record review, and facility policy review, the facility failed to ensure that each resident was treated with dignity as evidenced by failure to provide verbal communication to residents during care, knock on resident's door before entering, cover a resident and close door during care, and failure to provide a privacy bag for a catheter for 4 of 24 residents observed. Resident #19, #27, #42, #43. Findings Include Resident #27 Review of the facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 1-19, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under Compliance Guidelines. #1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .#5. When interacting with a resident, pay attention to the resident as an individual . #7. Explain care or procedures to the resident before initiating the activity. #8. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused, and resident centered .#12. Maintain resident privacy. An observation on 04/04/22 at 11:59 AM, revealed Certified Nurse Assistant (CNA) #7 yelled from Resident #27's room to CNA #6 who was in the hall and asked her to come help pull the resident up in the bed. State Agency (SA) observed CNA #6 enter Resident #27's room without knocking and assisted CNA #7 to pull the resident up in the bed. Observed that neither CNA spoke to the resident while performing the task and before leaving the resident's room. An interview on 4/5/22 at 3:30 PM, with CNA #5 revealed that when staff enters a resident's room the staff member should knock on the door, speak to them, and let them know why they are entering their room. She revealed that not speaking to a resident while performing care would be rude and a dignity issue. She revealed that it is all about how you approach people when providing care. An interview on 4/5/22 at 4:30 PM, with CNA #8 revealed that the staff should always knock and tell the resident their name and what you are needing to do when entering their room. An interview on 4/6/22 at 1:00 PM, with CNA #6 revealed that it could be a dignity issue if staff did not speak to a resident when they entered their room and performed a task. She revealed that staff should knock, speak, and let them know what you are needing to do. She revealed that if staff does not speak to residents, then the residents may think we are upset with them or just having a bad day. She revealed that if people do not get spoken to then they sometimes will not speak. She revealed she did not remember not speaking to Resident #27 while helping pull her up in the bed. She revealed that she feels like sometimes the staff gets in a hurry and busy trying to complete the task and forget we need to socialize with them more. An interview on 4/7/22 at 10:00 AM, with the Director of Nursing (DON) revealed that staff should knock on the resident's door and introduce themselves if the resident does not know them, explain the care that needs to be performed and just socialize with them. She revealed that she is not sure if it would be a dignity issue or just non-sociable when a staff member does not speak to a resident while performing care An interview on 4/7/22 at 12:15 AM, with Resident #27 revealed that most of the time the staff does not speak to her when they come in to do something. She revealed that the staff will talk to each other in front of her, sometimes they have their blue-tooth headphones on and take personal phone calls on their cell phones. She revealed that she does not care if they want to ignore her, but it would be nice to be included. Record review of Resident #27's admission Record revealed an admission date of 10/09/15 with medical diagnoses that include Type 2 Diabetes Mellitus and Major Depressive Disorder. Record review of the residents Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/22 revealed a Brief Interview of Mental Status (BIMS) of 15, which indicates the resident is cognitively intact. Resident #43 An observation on 04/04/22 at 10:40 AM, revealed Resident #43 lying in bed, awake, alert and with speech that is hard to understand due to a Cerebrovascular Disease with an onset date of 10/15/13. An observation of CNA #7 enter the resident's room with a fresh glass of water and sit it on the resident's over-bed table. Observed CNA #7 point to the two glasses of water that were already on his over-bed table without speaking. Observed the resident speak to CNA #7, pull one of the glasses toward him and pushed the other glass toward the CNA #7. CNA #7 took the glass of water that the resident pushed toward her and left the room without speaking to the resident. An observation on 4/4/22 at 12:25 PM, revealed Resident #43 lying in bed, awake and alert. Observed CNA #6 enter Resident #43's room with his lunch tray, set it up on his over-bed table and leave the room without speaking to the resident. An interview on 4/6/22 at 1:00 PM, with CNA #6 revealed that it could be a dignity issue if staff did not speak to a resident when they entered their room and performed a task. She revealed that staff should knock, speak, and let them know what you are needing to do. She revealed that if staff does not speak to residents, then the residents may think we are upset with them or just having a bad day. She revealed that if people do not get spoken to then they sometimes will not speak. She revealed Resident #43 is hard to understand, but she did not remember, not speaking to him while setting his lunch tray up. She revealed that she feels like sometimes the staff get in a hurry and busy trying to complete the task and forget we need to socialize with them more. An interview on 4/7/22 at 11:58 AM, with Resident #43 revealed the staff usually does not talk to him when they come in his room. Record review of Resident #43's admission Record revealed an initial admission date of 10/15/13 and medical diagnoses that include Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Record review of Resident #43's MDS with an ARD of 2/26/22 revealed a BIMS of 15, which indicates the resident is cognitively intact.

Based on facility policy review, record reviews, and staff interviews, the facility failed to complete a Preadmission Screening (PAS) Level One (I) Assessment for a resident for one (1) of two (2) residents reviewed for Preadmission Screening and Resident Review (PASARR). Resident #34 Findings include: Review of the facility titled PASRR Policy, with no date on the policy, revealed POLICY - It is the policy of this facility to do the Pre-admission Screening process. Preadmission Screening (PAS) must be submitted within 30 days of the physician's certification. All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility. Record review revealed there was not a copy of a PAS Level I Assessment available from admission for Resident #34. An interview on 4/5/22 at 04:20 PM, with Social Services, confirmed the PAS Level I Assessment was not completed, upon admission to the nursing facility for Resident #34. Social Services revealed a PAS Level I Assessment needed to be completed for every resident that would be a long term stay in the nursing facility and confirmed a PAS Level I Assessment not being completed for Resident #34 prevents her from knowing if Resident #34 was appropriate for a nursing facility placement. Social Services also confirmed a completed PAS Level I Assessment could have possibly triggered a Preadmission Screening and Resident Review (PASRR) Level II Assessment that could have possibly provided additional information of whether Resident #34 was appropriate for nursing facility placement and/or possible recommendations of mental health services, to be provided to Resident #34, while living in the nursing facility. An interview on 4/6/22 at 09:50 AM, with the Administrator confirmed Resident #34 should have had a PAS Level I Assessment done upon admission, which could have possibly generated a PASRR Level II Assessment, and would have possibly provided the nursing facility with the information of whether Resident #34 was appropriate for nursing facility placement and if Resident #34 needed additional mental health services to be provided while in the nursing facility. Record review of the admission Record revealed Resident #34 was admitted to the nursing facility on 11/25/20, with diagnoses that included Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, Other Recurrent Depressive Disorders, and Schizophrenia Unspecified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and staff interviews, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one of two residents reviewed for PASRR. Resident #34. Findings include: Review of the facility titled. PASRR Policy, with no date on the policy, revealed POLICY - It is the policy of this facility to do the Pre-admission Screening process. PAS must be submitted within 30 days of the physician's certification. All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility. There was no information included in the policy regarding submissions for a change in a resident's mental health status. Record review revealed there was not a copy of a Change in Status Form available for a geriatric inpatient psychiatric facility admission on [DATE], for Resident #34. An interview on 4/5/22 at 04:20 PM, with Social Services, confirmed the Change in Status Form was not completed/submitted for Resident #34 to update the state mental health agency on the mental status change that resulted in a geriatric inpatient psychiatric facility admission on [DATE]. Social Services also confirmed that the Change in Status Form should have been submitted to the state mental health agency, to allow for possible update of the PASRR Level II process, to inquire about possible additional mental health services recommendations to be provided to Resident #34 in the nursing facility. An interview, on 4/6/22 at 09:50 AM, with the Administrator, confirmed that Resident #34 should have had a Change in Status Form completed/submitted to the state mental health agency to provide an update that Resident #34 had a mental status change that required a geriatric inpatient psychiatric facility admission on [DATE]. That would have provided a possible update to the PASRR Level II process, and the facility could have possibly obtained mental health services recommendations for care for Resident #34 in the nursing facility. Record review of the admission Record revealed Resident #34 admitted to the nursing facility on 11/25/20. Record review of the Diagnosis Information section of the admission Record revealed diagnoses of Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, dated 11/25/20, Other Recurrent Depressive Disorders, dated 11/25/20, and Schizophrenia Unspecified, dated 11/25/20. Record review of the Physician's Orders, dated 02/19/2021, for Resident #34, revealed, May transfer to (name of the facility removed here) Geri-Psych for evaluation and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and facility policy review, the facility failed to develop and implement comprehensive care plans for three (3) of 24 residents reviewed for care plans, Resident #19, Resident #20 and Resident #42. Findings include: Resident #19 A record review of the facility Policy, Titled, Care Plans-Comprehensive with a revision date of 10/2016, revealed, An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Under Policy interpretation and implementation. #3. Each resident's comprehensive care plan is designed to: (f) Identify the professional services that are responsible for each element of care. A record review of Resident #19's Comprehensive Care Plan initiated 10/26/2020 and reviewed on 02/04/2022 revealed, Focus The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Huntington disease .Interventions . BATHING: Check nail length and trim and clean on bath day and as necessary Observations on 04/04/22 at 10:44 AM and at 12:11 PM, revealed Resident #19 lying in bed, hair matted with white fuzz in it. Fingernails are long and jagged approximately one-half (1/2) inch past the tip of the fingers on each hand. An observation on 04/05/22 at 09:14 AM, revealed Resident #19 lying in bed, hair matted with white fuzz in it. Nails are long and jagged approximately 1/2 inch past the tip of the fingers on each hand. An observation on 04/06/22 at 11:12 AM, Resident #19 was lying in bed. Hair matted with white fuzz. Fingernails were long and jagged approximately 1/2 inch long past the tips of fingers on both hands. An interview and observation on 04/06/22 at 01:05 PM, with the Director of Nurses (DON) confirmed the resident's nails are long and need to be trimmed. The DON removed a piece of white material from the resident's hair and stated that it looks like fuzz. The DON confirmed this should not be in his hair. During an interview on 04/07/22 at 05:05 PM, the Director of Nurses (DON) confirmed Resident #19's care plan was not followed for hair and nail care. Resident #20 A record review of Resident #20's comprehensive care plan initiated 10/29/2020 and last care plan review completed 02/04/2022 revealed, Focus The resident has a communication problem r/t (related to) being legally deaf and mute .Interventions . Ensure availability and functioning of adaptive communication equipment message board, telephone amplifier, computer, etc.Monitor effectiveness of communication strategies and assistive devices Provide translator as necessary to communicate with the resident .Use communication techniques which enhance interaction: Allow adequate time to respond. Repeat as necessary, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues,, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs,, and pictures An observation on 04/04/22 at 10:15 AM, Resident # 20 could be heard loudly down the hall. Upon entering Resident #20's room the resident had a splint in her left hand and continued to make verbal sounds and shake the splint. Resident #20 tried to communicate via sign language in a frustrated manner. Certified Nurse Assistant (CNA) #1 entered the room and said that she doesn't like the splint, and gets upset when she has to wear it. An observation on 04/04/22 at 03:00 PM, revealed Resident #20 sitting in a Geri-chair in her room. She was attempting to communicate via sign language and hand gestures. An interview on 04/06/22 at 02:55 PM, with Licensed Practical Nurse (LPN) #1 confirmed it's very difficult to understand what she wants, but I think the aides can understand her. The nurse confirmed there wasn't anything in the room to aide in communication with the resident. An interview on 04/06/22 at 03:00 PM , with the Social Worker (SW), revealed Resident #20 is deaf and mute. The social worker stated, the resident has a communication board, a whiteboard, and a phone in her room that is used for communication. An observation and interview on 04/06/22 at 03:10 PM, in Resident #20's room with the Social Worker (SW), and Director of Nurses (DON) confirmed there was no communication board or white board visible in the room. The DON began looking in the resident's chest of drawers for the communication board and found it in the second drawer under a brief. The SW found the whiteboard on the top shelf of the residents closet. The SW and DON confirmed that there was not a marker in the room to write on the communication board. The SW picked up a remote for the [NAME] device which was located on top of the chest of drawers. The SW revealed the resident a light on top of the machine will alert the resident when a call is coming through. The social worker (SW picked up the power cord to the [NAME] device and stated that it was disconnected. The SW revealed she had connected the device two (2) weeks ago but it is disconnected now. The DON and SW confirmed that the staff would not be able to communicate with her with the whiteboard in the top of the closet and the communication board in the drawer and the device not plugged in. The SW revealed that she had done an inservice at the old facility, but had not done one since being in the new facility. On 04/07/22 at 05:06 PM, in an interview with the Director of Nurses (DON) confirmed that Resident #20's communication careplan was not being followed. Resident #42 An observation on 04/04/22 at 10:20 AM and at 3:10 PM, revealed Resident #42's fingernails long and approximately 1/2 inch past the tips of fingers on both hands. An observation on 04/05/22 at 08:50 AM, revealed fingernails untrimmed. An observation and interview on 04/05/22 at 03:50 PM, revealed Resident #42's fingernails untrimmed. The resident stated that he doesn't know the last time his fingernails were trimmed. An observation on 04/06/22 at 09:15 AM and again at 12:50 PM, revealed resident's fingernails continued to be untrimmed and approximately 1/2 inch past the tips of fingers on both hands. An observation and interview on 04/06/22 at 01:00 PM, with the Director of Nurses (DON) confirmed his nails were long and need to be trimmed. The DON stated, I will make sure this gets done. An interview on 04/07/22 at 01:16 PM, with the Minimum Data Set (MDS) nurse, revealed that she was responsible for completing the care plan. She stated that there was a box to check for nail care and that she failed to check it. An interview on 04/07/22 at 05:21 PM, with the DON confirmed that Resident #42 did not have a nail care plan and that he should have had one. A record review of Resident #42 comprehensive care plan initiated 02/17/2022 revealed, Focus The resident has indwelling Catheter .Interventions/Tasks Position catheter bag and tubing below the level of the bladder and away from entrance room door. Observations on 04/04/22 at 10:57 AM, 12:05 PM, and 03:05 PM, revealed Resident #42's urinary catheter bag was visible to the hallway. The catheter bag was on the right-hand side of the bed facing the entrance room door without a privacy bag. Urine was noted in the urinary catheter bag. Observations on 04/05/22 at 8:50 AM, and again at 3:50 PM, revealed Resident #42's urinary catheter bag on the right side of the bed facing the entrance room door without a privacy bag and visible to the hallway. During an observation on 04/06/22 at 09:33 AM , Resident #42's urinary catheter bag was on the right side of the bed without a privacy bag and facing the entrance to the room, visible from the hallway. During an observation and interview on 04/06/22 at 1:00 PM with the Director of Nurses (DON), She confirmed the care plan was not followed. Resident had a privacy bag on the back of his wheelchair, but he should have a privacy bag for his bed, and his catheter bag should not be visible to the hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, facility policy review and record review, the facility failed to provide personal hygiene as evidenced by long and jagged nails and flecks of white material in resident's hair for 2 of 24 residents observed. Residents #42 and Resident #19. Findings include: A record review of the facility policy Fingernails/Toenails, Care of, undated, revealed, Policy The purposes of this policy is to clean the nail bed, to keep nails trimmed, and to prevent infections .Procedure .6. Nail care includes daily cleaning and regular trimming . 8. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . A record review of the facility policy titled Shampooing Hair Policy, undated, revealed, Policy . The purpose of this policy is to clean and maintain the resident's with healthy hair and scalp. Procedure 1. Use a comb to remove any tangles before washing the hair. Two observations on 04/04/22 at 10:44 AM and at 12:11 PM, of Resident #19 lying in his bed. His hair was matted with white fuzz in it. Nails are long and jagged approximately one -half (1/2) inch past the tip of the fingers on each hand. During an observation on 04/05/22 at 09:14 AM, Resident #19 was lying in bed, hair matted with white fuzz in it. Nails continue to be long and jagged approximately 1/2 inch past the tip of the fingers on each hand. An observation on 04/06/22 at 11:12 AM, revealed Resident #19 lying in bed. His hair was matted with white fuzz. Fingernails were long and jagged approximately 1/2 inch long past the tips of fingers on both hands. An interview and observation on 04/06/22 at 12:50 PM, with Certified Nurse Assistant (CNA) #1 confirmed the resident's nails are long and jagged and need to be trimmed and smoothed out. CNA #1 confirmed the jagged edges of the nails could cut us or the resident could cut himself. CNA #1 also confirmed that the resident has white fuzz in his hair. She stated she is not sure where it comes from but it is always like that. She stated, the resident's hair could be picked out. An interview and observation on 04/06/22 at 01:05 PM, the Director of Nurses (DON) removed a piece of white material from the resident's hair and stated that it looks like fuzz. The DON confirmed this should not be in his hair. She also confirmed the resident's nails are long and need to be trimmed. She stated that he could scratch and hurt himself with the jagged nails and she would make sure they get trimmed. A record review of the admission Record for Resident #19 revealed he was admitted to the facility on [DATE] with diagnoses of Huntington's Disease, Anxiety, Convulsions, and a Personal History of Traumatic Brain Injury. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/2022 revealed Resident #19 with a Brief Interview for Mental Status (BIMS) score of 03, which indicated resident has a severe cognitive impairment, requires extensive assistance of one person with personal hygiene. and total assistance of one person with bathing. Resident #42 An observation on 04/04/22 at 10:20 AM and at 3:10 PM, revealed Resident #42's fingernails long and approximately 1/2 inches past the tips of fingers on both hands. An observation on 04/05/22 at 08:50 AM, revealed Resident #42's fingernails untrimmed. An observation and interview on 04/05/22 at 03:50 PM, revealed Resident #42's fingernails untrimmed. The Resident stated that he doesn't know the last time his fingernails were trimmed. Observations on 04/06/22 at 09:15 AM and again at 12:50 PM, revealed the resident's fingernails continued to be untrimmed and approximately 1/2 inch past the tips of fingers on both hands. An observation and interview on 04/06/22 at 12:50 PM, with Certified Nurse Assistant (CNA) #1 confirmed the nails are long and needed to be trimmed and smoothed out. Resident #42 stated that he would like his fingernails cut. An observation and interview, on 04/06/22 at 01:00 PM, with the Director of Nurses (DON) confirmed his nails were long and need to be trimmed. The DON stated, I will make sure this gets done. A record review of Resident #42's admission Record revealed the resident was admitted to the facility on [DATE], with diagnoses of Neuromuscular Dysfunction of the Bladder, Chronic Gout, and Fracture of Left Femur. A record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/2022, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and requires extensive assistance of one person with personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, staff interviews, record review, and facility policy review, the facility failed to ensure a resident who was at risk for wandering was appropriately monitored and supervised to prevent wandering into other residents' rooms for one (1) of four (4) survey days. Resident #46. Findings include: A review of facility policy titled, Resident at Risk for Wandering Behavior, dated February 2017, revealed, This facility ensures that residents who exhibit wandering behavior receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy explanation and compliance guidelines: 'Wandering' is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or not-goal directed or aimless . Observation and interview on 4/4/22 at 3:05 PM, the State Agency (SA) tried to locate Resident #46. An interview with Certified Nurse Assistant (CNA) #6 revealed she had seen the resident a few minutes earlier in the hallway near his room. CNA #6 asked other staff about Resident #46's location and these staff members looked for the resident. An observation on 4/4/22 at 3:12 PM, revealed CNA #6 located Resident #46 in the bathroom of Resident #35's room, two doors down from his room. The resident living in that room was noted to be in bed and appeared to be asleep. An interview with CNA #6 on 4/4/22 at 3:15 PM, revealed Resident #46 rolled his wheelchair up and down the halls and in and out of residents' rooms to visit, but he is not a wanderer or exit seeking. An interview on 4/5/22 at 4:15 PM, with Resident #9, revealed the man living in the room next to hers came into her room last night, even though her door was closed. She stated she told him to get out and he did, but he came back. She stated several minutes ago, the same resident was trying to go into her room again and she did not let him in. She stated she does not want him in her room and wants someone to help her keep him out. An interview with CNA #8 on 4/5/22 at 4:20 PM, revealed she did not witness the interaction between Resident #46 and Resident #9. She stated that concerning Resident #46, a lot of residents have problems with him going in and out of their rooms. Stated she had not reported this since everyone was aware of Resident #46's wandering. An interview with Licensed Practical Nurse (LPN) #1 on 4/5/22 at 4:25 PM, revealed Resident #46 wandered around the facility but was not exit seeking. She stated he recently started approaching other residents' rooms and had wandered into other residents' rooms. She stated even though he went into other residents' rooms, he doesn't mean anything by it. An interview with LPN #6 on 4/5/22 at 4:30 PM, revealed in the previous facility building Resident #46 wandered and took items from people, but he had been more calm in the new building. She stated the resident is not exit seeking, but he does roll around the hallways and has gone into other residents' rooms. She stated she had not reported this since it was known to all the staff. An interview with CNA #4 on 4/5/22 at 4:55 PM, revealed Resident #46 had wandered into other residents' rooms and had to be redirected. She stated she had not reported to the charge nurses because everybody knew he wandered and they were seeing him wander, too. An interview with Registered Nurse (RN) #2 on 4/5/22 at 5:08 PM, revealed Resident #46 had recently started wandering the halls and for the past few days, he had been wandering into residents' rooms. She stated when the resident was in another resident's room, the staff asked them about Resident #46 being in their rooms and they said they were okay with it. She stated his condition had deteriorated over the past several weeks and currently requiring more assistance and redirection. She stated Resident #9 had told her Resident #46 came into her room. An interview with CNA #5 on 4/5/22 at 5:11 PM, revealed, Resident #46 goes up and down the halls and in and out of rooms. She stated he would go into a room, look around, and come back out. She stated he would occasionally try to take someone's food, but nothing else. An interview with the Director of Nurses on 4/5/22 at 5:00 PM, revealed Resident #46 had wandered up and down the halls and doorways recently, but she did not realize he went into other residents' rooms. She stated she should have known this was occurring to have helped decrease this behavior. An interview with Resident #42 on 4/5/22 at 5:18 PM, revealed Resident #46 had come into his room a few days ago. He stated he just rolled in and then rolled back out. He stated that was the only time that had happened. An interview with Resident #43 on 4/5/22 at 5:20 PM, revealed that several times a man resident in a wheelchair had come into his room and has looked around then turned around and went back out. An interview with Resident #27 on 4/5/22 at 5:25 PM, revealed a resident in a wheelchair had come into her room and told her that her room was his room, but she told him it was her room and he left. She stated she thought it had happened other times, but she was not sure when. An interview with RN #2 on 4/7/22 at 9:35 AM, revealed Resident #46 had been wandering up and down the hall and went into other residents' rooms to visit. She stated she only knew of one incident when he went into the bathroom of another resident on the day that SA entered the building. She stated she did not report his wandering since it was not noted to her that this was wanderings. An interview with CNA #5 on 4/7/22 at 9:45 AM, revealed Resident #46 goes in rooms and comes out. She stated no one had reported to her about him staying in a room and she had not reported to anyone since he just goes in and looks around then comes out. An interview with LPN #1 on 4/7/22 at 10:15 AM, revealed the resident would roll up and down the hallway and would go to other resident's doorway and would look in and she would hear the other resident fussing at him to leave. She stated the resident left and the staff redirected him. She stated she had never seen him actually in another resident's room, but he would be in the doorway. She stated it had never been reported to her that he was in another's resident's room and she had not reported since he was not all the way in another person's room. The SA asked her about her earlier statement about resident going into other resident's rooms and she said it was in the doorway and not into the room. An interview with the Minimum Data Set (MDS) Coordinator on 4/7/22 at 10:45 AM, revealed Resident #46 had a quarterly care plan meeting on 3/31/22 and his wandering was discussed in the meeting. She stated the resident's behavior of wandering goes way back and apparently it had improved over time and had recently become an issue again. She stated this was discussed and they discussed interventions for his wandering. She stated they discussed keeping an eye out on him to keep him out of other residents' rooms, redirecting him, and offering activities for him. An interview with the Social Worker on 4/7/22 at 11:00 AM, revealed Resident #46's care plan meeting was on 3/31/22. She stated that recently after his last hospitalization, his wandering seemed to increase. She stated he had always enjoyed rolling in the hallways, but recently he was going into other residents' rooms. She stated this was discussed in the last care plan meeting and interventions for staff to watch him and to redirect him were also discussed. An interview with the Activity Director on 4/7/22 at 11:45 AM, revealed she attended Resident #46's most recent care plan meeting. During the meeting, it was discussed about his increased wandering in the hallways and into some of the resident's rooms. She stated interventions discussed were to watch him closely, redirect him, talk to him, and give him activities. An interview with the DON on 4/7/22 at 1:00 PM, revealed she was unaware of Resident #46's recent increase in wandering. She stated she had not read the recent notes or care plan meeting notes on the resident's wandering and she was unaware of his history of wandering. She stated she was aware he was rolling up and down the hallway, but was not aware of him going into other residents' rooms. The DON confirmed the facility failed to ensure the resident was monitored closely to prevent his wandering into other residents' rooms. She confirmed his wandering could have led to other resident's items being taken and could have risked harm to the resident or to another resident. An interview with the Administrator on 4/7/22 at 4:55 PM, revealed the residents have the right to be able to enjoy the common areas of the facility, but residents should not go into other residents' rooms uninvited. She confirmed the facility has the responsibility to ensure a resident does not wander into another resident's room. She confirmed the need to keep residents safe and free of someone coming into their rooms and this resident should have been monitored closely. Record review of Social Services Plan of Care Note dated 3/31/2022 revealed, Care Plan Meeting: RR (Resident Representative) did not attend. Resident is receiving long term care. No plan of discharge. Resident has exhibited wandering. Staff redirects. Will continue to monitor. Record review of Resident #46's admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses include Metabolic Encephalopathy, Cognitive Communication Deficit, Dementia, and Conduct Disorder. Record review of Minimum Data Set, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment.

Based on observation, staff interview, record review and facility policy review the facility failed to label and date a tube feeding for one (1) of four (4) residents observed. Resident #5 Findings Include A review of the facility policy titled, Labeling of Enteral Feeding Supplies/Containers with a revision date of 4/20/19 revealed, It is the policy of this facility that all enteral feeding bottles/bags will be labeled with the rate of feeding, date bottle/bag began and initials of the nurse initiating as well as the feeding formula listed. An observation on 04/04/22 at 11:38 AM, revealed Resident #5 had a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube connected to a continuous feeding pump. This observation revealed a bottle of Osmolite formula connected to the resident's feeding pump running at 70 milliliter per hour (ml/hr.) with no date/time, resident name, room number(#) or flow rate of feeding labeled on the Osmolite bottle. An observation on 04/04/22 at 03:35 PM, revealed no date/time, resident name/room number or feeding flow rate on the Osmolite formula bottle connected to Resident #5's PEG tube that was running at 70 ml/hr. via pump. An interview on 4/5/22 at 5:00 PM with Licensed Practical Nurse (LPN) #1 revealed that when she hangs a new tube feeding that she is supposed to label it with the resident's name, room #, date and time it was started and the milliliters/hour (ml/hr). If she finds a tube feeding that is not labeled, then she is supposed to hang a new one. She revealed that all this information is written on the tube feeding to let the next nurse know when it was done. She revealed that she was not Resident #5's nurse, but she found another resident's feeding tube not labeled yesterday. An interview on 4/5/22 at 5:08 PM with Registered Nurse (RN) #2 confirmed that when a new feeding tube bottle is hung and attached to a resident's feeding pump then the date and time it is hung, flow rate, resident's name and room number should be written on the formula bottle. An interview on 4/7/22 at 9:22 AM, with LPN #2 revealed she worked 7 AM to 3 PM shift Monday 4/4/22 and she should have caught the fact that Resident #5's feeding tube bottle was not dated or labeled and corrected it. An interview on 4/7/22 at 10:45 AM, with the Director of Nurses (DON) confirmed that when a new feeding tube bottle is hung, it should be labeled with the resident's name, room number, date, and time. The DON revealed that the reason for labeling the feeding tube bottle is to ensure it is the correct resident, formula type and dose. The DON revealed that the date and time being labeled on the feeding bottle ensures that we know when it was hung, because if it was too old then the milk could spoil and make the resident sick. The DON revealed it is the facility policy to hang a brand-new bag if they discover one that is connected but not labeled. Record review of Resident #5's admission Record revealed an admission date of 9/29/20 with medical diagnoses of Parkinson's Disease and Dysphagia. Record review of Resident #5's Order Summary Report revealed an order dated 3/9/22, Enteral Feed Order every shift for feeding to be turned off at 11 PM and turned on at 12 am every day related to Dysphagia, Oropharyngeal Phase, Feeding tube-NPO (Nothing by mouth), Head of bed (HOB) up 30-45 degrees. Osmolite @ 70 ML (milliliters) per pump . Record review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/21, Section K revealed the resident is receiving tube feedings. Section C revealed a Brief Interview for Mental Status (BIMS) score of 02, which indicates the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to provide a proper barrier during medication administration and failed to ensure a catheter bag was properly positioned for three (3) of five (5) residents observed during medication pass and catheter observations. Unsampled Resident #1, Resident #33 and Resident #42 Findings include: Record review of the facility policy titled, Nasal Spray Administration, dated 2/18/20, revealed Nasal spray medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: 2. Procedure: . c. Place the equipment on the cleaned bedside stand or overbed table. Arrange the supplies so that they can be easily reached. Place paper towel, napkin or other barrier on table . The facility was unable to locate or produce a policy related to catheter bag storage and proper coverage for privacy issues. An observation on 04/06/22 at 8:55 AM, during medication pass revealed Registered Nurse (RN) #1 entered Unsampled Resident #1's room to administer eye drops. RN #1 removed the bottle of eye drops from the box and placed the box on the resident's chest of drawers without the use of a barrier. Following administration of the eye drops, RN #1 returned to the medication cart, wiped the eye drop bottle with a disinfectant wipe and put the bottle in the contaminated box and placed it in the medication cart. An observation on 04/06/22 at 9:00 AM, revealed RN #1 took nasal spray into Resident #33's room. RN #1 removed the nasal spray from the box and placed the box on the resident's bedside table without the use of a barrier. RN #1 returned to the medication cart with the bottle and the contaminated box in her hand. She wiped the nasal spray bottle with a disinfectant wipe and placed it in the contaminated box. RN #1 returned the contaminated box to the medication cart. An interview on 04/06/22 at 9:10 AM, with RN #1 revealed that she should not have set the eye drops on the chest of drawers and should not have placed the nasal spray on resident's bedside table without a barrier. She stated that this could cause cross contamination. An interview on 04/07/22 at 10:05 AM, with the Director of Nursing (DON) revealed that a barrier should be used when administering nasal sprays or eye drops when the box containing the medications is taken into the resident's room. The DON also stated that this is an infection control problem if a barrier is not used because the boxes are placed back into the medication cart after use. Record review of Unsampled Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Stage 3, Non-Type 2 Diabetes. Record review of Resident #33's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Pneumonia, Rheumatoid Arthritis and Shortness of Breath. Resident #42 On 04/04/22 at 10:57 AM, an observation revealed Resident #42's urinary catheter bag on the floor and without a cover. On 04/05/22 at 3:50 PM, an observation revealed Resident #42's urinary catheter bag on the floor and without a cover. An interview on 04/06/22 at 1:00 PM, with the Director of Nurses (DON), she confirmed the catheter bag should be in a privacy bag and off the floor. The DON stated that with the catheter bag being on the floor it could cut a hole in it and also cause infections. A record review, of Resident #42's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Neuromuscular Dysfunction of the Bladder, Chronic Gout, and Fracture of Left Femur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policy review, the facility failed to utilize assistive devices available to maintain resident's communication abilities for three of four survey days. Resident #20. Findings include: Review of the facilities policy, Communications Within and External to the Facility updated 2/21/21 reveals the facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility. An observation on 04/04/22 at 10:15 AM, Resident #20 could be heard loudly down the hall. Upon entering Resident #20's room the resident had a splint in her left hand and continued to make verbal sounds and shake the splint. Resident #20 tried to communicate via sign language in a frustrated manner. Certified Nurse Assistant (CNA) #1 entered the room and said that she doesn't like the splint, and gets upset when she has to wear it. An observation on 04/04/22 at 03:00 PM, revealed Resident #20 sitting in a Geri-chair in her room. She was attempting to communicate via sign language and hand gestures. An interview on 04/06/22 at 02:55 PM, with Licensed Practical Nurse (LPN) #1 confirmed it's very difficult to understand what she wants, but I think the aides can understand her. The nurse confirmed there wasn't anything in the room to aide in communication with the resident. An interview on 04/06/22 at 03:00 PM , with the Social Worker (SW), revealed Resident #20 is deaf and mute. The social worker stated, the resident has a communication board, a whiteboard, and a phone in her room that is used for communication. An observation and interview on 04/06/22 at 03:10 PM, in Resident #20's room with the SW and Director of Nurses (DON) confirmed there was no communication board or white board visible in the room. The DON began looking in the resident's chest of drawers for the communication board and found it in the second drawer under a brief. The SW found the whiteboard on the top shelf of the residents closet. The SW and DON confirmed that there was not a marker in the room to write on the communication board. The SW picked up a remote for the communication device for the deaf, which was located on top of the chest of drawers. The SW revealed to the resident there is a light on top of the machine that will alert the resident when a call is coming through. The social worker SW picked up the power cord to the communication device and stated that it was disconnected. The SW revealed she had connected the device two (2) weeks ago but it is disconnected now. The DON and SW confirmed that the staff would not be able to communicate with her with the whiteboard in the top of the closet and the communication board in the drawer and the device not plugged in. The SW revealed that she had done an inservice at the old facility, but had not done one since being in the new facility. An interview on 04/06/22 at 03:35 PM, with Certified Nurse Assistant (CNA) #2, revealed the Resident is very hard to understand, she gestures and nods. CNA #2 stated that Resident #20 used to write on a board, but she can't anymore. CNA #2 stated that she didn't even know if she had a board anymore. An interview on 04/06/22 03:36 PM, with Certified Nurse Assistant (CNA) #3 stated that Resident #20 is very hard to understand, but she can point some. When the SA questioned her about devices for communication, she stated she was not sure where it was. An interview on 04/06/22 at 03:37 PM, with Certified Nurse Assistant (CNA) #4 revealed that the resident is hard to understand. CNA #4 stated that she did not work with this resident much. A record review of in-service training, by Social Worker (SW) dated 11/10/2020, Title and detailed content of inservice: Information on how to use the communications device (with attached phone number), information on communicating with deaf and mute persons, Resident in 15B is deaf and mute. She has a communication book and board to make her needs known. Staff can use communication board to communicate with resident. [NAME] board is available to write on in order to communicate. A record review of Resident #20's admission Record revealed she was admitted to the facility on [DATE], with diagnoses including Deaf nonspeaking not elsewhere classified, Cognitive communication deficit, Anxiety disorder, Restlessness and Agitation. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/2022 revealed a Brief Interview for Mental Status (BIMS) score of 01 indicating Resident # 20 had severe cognitive impairment.

Based on observation, facility policy review, and staff interviews, the facility failed to prevent possible food contamination as evidenced by observations during the initial kitchen tour of improper thawing of raw chicken and three (3) and one-half (1/2) loaves of expired sliced sandwich bread, for 51 of 53 residents receiving dietary trays. Findings include: Record review of facility policy titled, Thawing Food revised 09/14 revealed, Policy: The facility shall ensure that foods served to residents are thawed in a manner to prevent contamination. PROCEDURE: Frozen food is thawed in one of these ways: 2. Running water .b. Completely submerge food under running potable (drinking) water at 70 degrees or below. Review of facility policy titled, FOOD STORAGE LABELING . with a revision date of 10/17 revealed POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures .5.i. Identify the food item's use by date or expiration date. ii. Store items with the earliest use-by or expiration date in front of items with later dates. iii. Use items stored in front first. iv. Foods stored in storage units will be surveyed routinely to identify and discard food that have passed it manufacturer use-by-date or expiration date. Suggested time frames: 1. Dry Storage - Weekly . An observation, during the initial kitchen tour, on 04/04/22 at 10:34 AM, revealed raw chicken thawing in one side of the deep two (2)-compartment sink, completely submerged with no running water. The raw chicken sat at the bottom of the opposite side of the sink that was away from the faucet. The initial kitchen tour observation also revealed three (3) full loaves of sliced sandwich bread and one-half (1/2) loaf of sliced sandwich bread with an expiration date of March 16, 2022. An interview on 04/04/22 at 10:35 AM, with the Dietary Department (DD) #2 (Manager), confirmed the raw chicken was being thawed in the 2-compartment sink full of water. The chicken sat at the bottom of and on the opposite side of the sink, away from the faucet, there was no water running over the chicken to thaw it, and that was not the proper process to be used to thaw raw chicken. DD #2 revealed that the incorrect thawing process could possibly cause Salmonella bacteria to grow, which could lead to sickness for the residents. DD #2 revealed she did not know the 3 ½ loaves of sliced sandwich bread was expired. There was no specific dietary employee assigned to ensure bread was disposed of after the expiration dates, and that it was the responsibility of all dietary staff to monitor the bread for expiration dates. DD #2 revealed the process for usage of the bread was to stack the oldest bread on the top of all the bread in storage to be used first, before the expiration date, and confirmed the expiration date of March 16, 2022, was on the 3 ½ loaves of sliced sandwich bread. DD #2 revealed the bread could have possibly molded from being kept and used past the expiration date, and could possibly cause the residents to be contaminated with whatever bacteria that could have possibly grown on the sliced sandwich bread. DD #2 revealed that sandwiches were made every evening and are sent to the nursing units to be used as part of the Diabetic residents' evening snack. DD #2 (Manager) revealed she had not conducted in-services with the dietary staff pertaining to proper thawing of foods or storage/disposal of expired foods since she started. An interview on 4/7/22 at 09:00 AM, with the DD #1, revealed she was thawing the raw chicken out and was not using the correct thawing process. DD#1 revealed she would normally put raw meat in a deep pan and then place the deep pan of raw meat under cool running water to thaw. DD #1 revealed not thawing the raw chicken correctly could possibly cause the residents to get Salmonella or food poisoning of some kind. An interview on 4/7/22 at 11:30 AM, with the Administrator confirmed the residents could possibly get Salmonella poisoning due to the dietary staff not using the correct thawing process to thaw out the raw chicken. The Administrator also confirmed there was a possibility of growth of bacteria on the sliced sandwich bread that expired on March 16, 2022, which could possibly cause some form of illness to the residents.

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possible spread of COVID-19 as evidenced by failure to fully implement their policy to ensure that all staff are fully vaccinated or received an exemption for two (2) of 97 employee records reviewed. Findings Include: Record review of the facility policy titled, Employee COVID-19 Vaccinations undated, revealed It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless religious or medical exemptions are granted. 2. Employees, who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated against COVID-19 . Record review of the facility form COVID-19 Staff Vaccination Status for Providers revealed that Certified Nurse Assistants (CNA) #12 and #13 were not fully vaccinated and did not have a granted exemption. Record review of CNA #12's vaccination record revealed she received her one dose of a multi-dose COVID-19 vaccination on 2-3-21 and has continued to work at the facility full time with her last day to work being 4-2-22. Record review of CNA #13's vaccination record revealed she received one dose of a multi-dose COVID-19 vaccination on 11-17-21 and has continued to work full time at the facility with her last day to work being 4-5-22. An interview on 4-5-22 at 9:30 AM, with the Infection Preventionist (IP) revealed she just started as the IP about a month ago and she is not aware of any deadline they have had in regards to the staff completing their COVID-19 vaccination or requesting an exemption. She revealed she is aware of the guidance that all staff is suppose to be fully vaccinated or have a granted exemption at this point. She confirmed there are three CNA's that are not fully vaccinated, but one of them is not due for her second vaccination yet. She confirmed that CNAs #12 and #13 should have had their second COVID-19 vaccine already and they have continued working here. She confirmed she understands the risk of those CNAs continuing to work in the facility without being fully vaccinated. An interview on 4-5-22 at 3:45 PM, with the Director of Nurses (DON) revealed the facility has had no positive COVID-19 residents or staff in the last 4 weeks and they test unvaccinated staff twice per week and those unvaccinated staff have to wear an N95 mask. An interview on 4-6-22 at 9:38 AM with the Administrator revealed that she is aware of the regulations and confirmed that she knew they were suppose to have all staff fully vaccinated or exemptions granted at this point. She revealed that the facilities last IP left on 1-12-22 and the current IP started about a month ago. The Administrator revealed she was not aware that they had two CNAs that had not had their 2nd COVID-19 vaccine and was continuing to work. The Administrator revealed that the IP that left on 1-12-22 was probably aware that those two CNAs needed their second COVID-19 vaccination. The Administrator revealed that they had told all staff that they had to have their 1st vaccination by the first deadline or an exemption. The Administrator confirmed she was unaware of who was keeping up with the staff vaccinations and the new guideline, but she wasn't. She confirmed the facility did develop a policy to ensure all staff were fully vaccinated or had an exemption, but had not fully implemented it. She confirmed that CNA #12 and #13 must have slipped through the cracks. An interview on 4-6-22 at 9:49 AM, with CNA #12 revealed that a facility staff member called her yesterday afternoon and told her she had to have her second COVID-19 vaccination before she could return to work. She revealed this was the first she had heard of it. She revealed she has been trying to get an appointment with the local pharmacy and she wishes she had known sooner so she did not have to miss work. She confirmed that she had been being tested twice per week and was wearing an N95 mask at work. She denied having COVID-19 or any signs or symptoms of COVID-19. She confirmed that her last day to work was 4-2-22. An interview on 4-6-22 at 4:20 PM, with the DON confirmed that having two CNAs working and not being fully vaccinated could increase the risk of spreading COVID-19 infection within the facility. An interview on 4-7-22 at 5:00 PM, with Human Resources (HR) staff revealed she completes the work schedule for the facility. She revealed that she was told on 4-5-22 that CNA #12 and #13 could not come back to work until they received their second COVID-19 vaccination. HR staff revealed CNA #13 was already at the end of her shift on 4-5-22 before she was made aware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy review the facility failed to provide a sufficient volume level on the resident call light system as evidenced by the inability to hear the call light system alarm on the nursing unit halls for four (4) of 4 days of survey. Findings include: Review of the facility policy titled, Call Light, Answering, undated, revealed, Purpose - The purpose of this procedure is to respond to the resident's requests and needs . An observation on 4/4/22 at 10:30 AM, revealed the call light globes, located above the resident room doors would light up when the call light system was activated, but no call light system alarm was heard on the nursing unit halls to alert the staff that the call light was activated. The call light system monitor was located at the 200 Hall nurse's desk and all the resident calls for assistance for the 100 Hall, 200 Hall, and 300 Hall, were to be answered through that one (1) call light system monitor. The State Agency (SA) was able to hear the call light system alarm while at the nurse's desk, which was at a low volume, but could not hear the call light system alarm at one of the closest resident rooms, #201, which was approximately 20-25 feet away from the 200 Hall nurse's station desk. The State Agency walked down to the end of the 100 Hall, which was approximately 40-50 feet away from the 200 Hall nurse's desk, walked down to the end of the 200 Hall, which was approximately 40 to 50 feet away from the 200 Hall nurse's station, and walked down to the nurse's station on the 300 Hall, which was approximately 30-40 feet away from the 200 Hall nurse's station, and was not able to hear the call light system alarm. An interview on 4/5/22 at 04:35 PM, with Registered Nurse (RN)#2 revealed that some nursing staff members had revealed to her as the RN Supervisor that they could not hear the call light system alarm if they were not directly at the nurse's station. RN #2 also revealed that there was not a staff member assigned to the desk to be able to monitor the call light system at all times. RN #2 revealed not being able to hear the call light system alarm was a problem the facility staff had been dealing with for a while but could not reveal how long the problem had existed. RN #2 revealed a verbal report had been made to the higher-level staff regarding the problem. An interview on 4/5/22 at 04:38 PM, with Certified Nurse Aide (CNA)#5, who was located behind the 300 Hall nurse's desk revealed that the CNA staff had expressed to her, as the Lead CNA, they are not able to hear the call light system alarm on the 100 Hall, 200 Hall, or the 300 Hall. CNA #5 revealed she could not hear the call light system alarm while she sat at the nurse's desk on the 300 Hall, and could only hear the call light system alarm when she stood at the 200 Hall nurse's station desk. CNA #5 revealed she had instructed the CNA staff to look up at the globes over the residents' rooms to see if a call light was on when they were out on the halls. An interview on 4/6/22 at 09:40 AM, with the Director of Nursing (DON), revealed the call light system alarm volume was too low to be heard down the nursing unit halls from the 200 Hall nurse's desk. The DON revealed the call light system alarm volume being down that low could possibly cause a call light not to be answered timely. An interview on 4/7/22 at 09:25 AM, with CNA #9 who was located on the 300 Hall, revealed she was not able to hear the call light system alarm when out on the nursing unit. CNA #9 revealed she could hear the alarm if she stood at the 200 Hall nurse's station desk. An interview on 4/7/22 at 09:29 AM, with CNA #10 who was located on the 300 Hall, revealed she was not able to hear the call light system alarm when she was away from the 200 Hall nurse's station desk. An interview on 4/7/22 at 09:34 AM, with RN #1 who was located on the 100 Hall, revealed she cannot hear the call light system alarm when away from the 200 Hall nurse's station desk. An interview on 4/7/22 at 12:30 PM, with Licensed Practical Nurse (LPN) #4, who was located on the 300 Hall, revealed she cannot hear the call light system alarm on the 300 Hall, because the call light system's volume was too low to hear from the 200 Hall nurse's station desk. An interview on 4/7/22 at 12: 35 PM, with CNA #11, who was located on the 300 Hall, revealed she could not hear the call light system alarm when she was on the 300 Hall. An observation and interview on 4/7/22 at 03:25 PM, with the Administrator revealed the Administrator increased the call light system monitor's volume, located at the 200 Hall nurse's station desk from medium to high. The SA went down the 200 Hall to listen for the call light system alarm's sound. The call light system alarm sound could be heard down to the end of the 200 hall, 40-50 feet away from the 200 Hall nurse's station desk, due to the increased volume. The Administrator also walked down the 200 Hall, past room [ROOM NUMBER], approximately 30 feet from the 200 Hall nurse's station desk, confirmed she was able to hear the call light system alarm. She revealed she had assigned the RN Charge Nurses to stay at the nurse's desk to monitor the call light system alarm and inform staff when a resident needed assistance but revealed there was not a written schedule for the assignment. The Administrator revealed that the call light system volume was low because she thought the high volume was too much noise. The Administrator revealed the call light system volume not being heard by the nursing staff could have possibly caused residents call lights not to be answered in a timely manner.