Based on observation, resident and staff interview, and facility policy review, the facility failed to provide a resident with a clean, comfortable, and homelike environment when the facility failed to change the dirty, stained linen for (1) one of 53 residents' bed linens observed. Resident # 20 Findings include: A review of the facility policy titled, Making a bed, with no revision date revealed that all linens, including mattress pad, blanket, and bedspread should be replaced, if necessary . The pillowcase should also be checked for soiling and replaced as needed . Bed linens are regularly changed at least once a week. In an interview with Resident # 20 on 12/02/24 at 1:00 PM, she revealed she would like to have her bed linen changed, stating I can't remember the last time they were changed. An observation of the linen with Resident #20 revealed the bottom sheet to be dingy white, the top sheet had a baseball size brown stain which the resident stated was from a bowel movement. The pillowcase was covered in small dark dried stains which the resident stated were dried blood stains. An observation of Resident # 20's bed linen on 12/03/24 at 11:34 AM, revealed the bed linen remained dingy in appearance with a brown stain on the top sheet, and numerous small dark stains on the pillowcase. An observation and interview with Registered Nurse (RN) # 1 on 12/03/24 at 11:37 AM, she confirmed the sheets on Resident # 20's bed were dirty in appearance and dingy white, the top sheet had a brown stain on it, and the pillow had numerous dark stains that she identified as dried blood spots. RN # 1 then confirmed that the linens did not appear to have been changed recently, and stated the linen should have already been changed. It is a sanitization concern. In an interview with the Director of Nursing (DON) on 12/03/24 at 11:45 AM, she revealed the resident's beds should be made daily and linen changed weekly and each time the linen is soiled. She then confirmed that it was a sanitization problem. Review of the admission Record revealed Resident #20 was admitted by the facility on 2/27/24. Record review of Resident #20's Section C of the Minimum Data Set (MDS) revealed that on 9/17/24 the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact.

Based on staff interview, record review, and Resident Assessment Instrument (RAI) review, the facility failed to ensure that Minimum Data Set (MDS) was coded accurately for one (1) of 18 sampled residents. Resident #5. Findings included: Record review of the facility policy, titled MDS with a revision date of 9/25/17 revealed Policy .Each person completing a section or portion of the MDS signs the Attestation Statement indicating its accuracy . A record review of the admission Record revealed Resident # 5 was admitted by the facility on 12/24/20 with a diagnosis of Bipolar Disorder. Record review of Resident #5's Significant Change MDS with an Assessment Reference Date (ARD) of 7/30/24, revealed Section A 1500 coded as No, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident # 5's Summary of Findings Report, from the PASRR Office, dated 12/30/20 under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. During an interview with the MDS Nurse on 12/4/24 at 9:30 AM, she verified that the MDS was coded incorrectly and agreed that the importance of correctly coding MDS was to ensure residents received care they needed. An interview with the Director of Nursing (DON) on 12/4/24 at 12:00 PM, she agreed that it was her expectation that the MDS would be coded correctly.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit a resident's information for Preadmission Screening and Resident Review (PASRR) for a Level II evaluation for (1) one of (4) four residents reviewed for PASRR. Resident #54 Findings include: Review of the facility policy titled, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/8/21 revealed, Policy: The center will assure that all Serious Mentally Ill (SMI) . residents receive appropriate pre-admission screenings according to the Federal/State guidelines. The purpose is to ensure that the residents with SMI .receive the care and services they need in the most appropriate settings. Record review of the admission Record revealed Resident #54 was admitted by the facility on 5/24/24 with diagnoses of Brief Psychotic Disorder and Anxiety Disorder. A record review of Resident #54's May 2024 Order Summary Report, revealed that Divalproex sodium delayed release tablet 500 mg (milligrams): give two tablets by mouth twice daily for behaviors and hydroxyzine pamoate 100 mg capsule: give one capsule three times daily for anxiety with an order date of 5/24/24. Record review of Resident #54's intake information for PASRR dated 5/24/24 revealed, Section J: Disease Diagnoses: the admitting diagnoses of Anxiety and Brief Psychotic Disorder were not listed as an active diagnosis . Section L: Referral Questions: 31.) Does Resident # 54 have any history of mental illness? answered No .32.) Does Resident #54 take, or have a history of taking, psychotropic medications? answered No. In an interview with the Social Service staff #1 on 12/3/24 at 2:45 PM, she revealed after reviewing Resident #54's intake information for Level II PASRR evaluation she confirmed that Resident #54's active admission diagnoses for mental illness and use of psychotropic medications were not listed. She stated the inaccurate completion resulted in an inaccurate depiction of the resident's mental health status. This resulted in Resident #54 not being referred for a level II PASRR evaluation. She stated that the concern from not completing the initial PASRR correctly is that a resident with mental illness may not be appropriate for nursing home stay and may need specialized mental health services.

Based on observations, resident and staff interviews, record reviews, professional standards of practice, and facility policy review the facility failed to provide Peripherally Inserted Central Catheter (PICC) care for one (1) of four (4) residents with intravenous access. Resident #10. Findings include: Record review of the facility policy titled Central Vascular Access Device (CVAD) Dressing Change, effective date 6/1/24 revealed the guidance: Perform sterile dressing changes using Standard-Aseptic Non-Touch Technique (ANTT) at least weekly. Review of the professional standard of practice Checklist for Prevention of Central Line Associated Blood Stream Infections published by the Centers for Disease Control (CDC) revealed change semipermeable dressings at least every seven days. During an observation on 12/2/24 at 12:00 PM, Resident #10 was noted to have a PICC line inserted to the right arm with a transparent dressing dated 11/21/24. The resident stated that she had been on intravenous (IV) antibiotics, which were completed on 11/29/24, and was unsure why the PICC line had not been removed. She also stated that the dressing had not been changed. In an observation, interview and record review with Registered Nurse (RN) #2 on 12/2/24 at 12:20 PM, she verified that the PICC line dressing for Resident #10 was dated 11/21/24. She revealed after reviewing Resident #10's Order Summary Report that there were no orders for dressing changes to the PICC line, but there should have been. In an interview with the Director of Nursing (DON) on 12/2/24 at 1:00 PM, she confirmed that there should have been an order for Resident #10's PICC line dressing to be changed. The DON confirmed that Resident #10's PICC line dressing had not been changed and acknowledged that dressings should be changed every seven days. She stated that failure to do so could result in adverse effects, such as infection. Record review of the admission Record revealed that the facility admitted Resident #10 on 8/30/24 with a diagnosis of Diabetes Mellitus. Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 11/28/24 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure that medications were securely stored as evidenced by medications observed on the bedside table for two (2) of 53 residents reviewed. Resident #13 and #22. Findings Include: Review of the facility policy titled, Medication and Medication Supply Storage and Disposal, with no revision date revealed, Central storage of medications is required for prescription, prescribed over-the-counter medications .Will be kept in a locked area .Procedure :1.) Storage is required for the following situations and will be locked with limited access: If the facility administers or assists with self-administration of medication . Resident # 13 An observation on 12/2/24 at 2:30 PM revealed a bottle of Travoprost 0.004% eye drops sitting on Resident #13's overbed table. The resident stated that she puts the drops in her eyes herself at night and had been using the medication for 10 years. A record review of assessments revealed that Resident #13 did not have a Self-Administration of Medication assessment. A record review of the Order Review Report dated 12/3/24 for Resident #13 revealed that there was no physician's order for Travoprost 0.004%, nor an order to self-administer medications. An interview with Registered Nurse (RN) #3 on 12/3/24 at 1:25 PM, she stated that she was not aware of any medication that Resident #13 was self-administering. She verified that the resident did not have an order for Travoprost 0.004%. An observation and interview with RN #3 on 12/3/24 at 1:28 PM, she verified that there was a bottle of Travoprost 0.004% eye drops still sitting on residents over bed table. An interview with the Director of Nursing (DON) on 12/3/24 at 1:31 PM, she verified that Resident #13 did not have an assessment or a physician's order to self- administer any medications and did not have an order for the eye drops. She stated that the resident had been on the eye drops prior to her last hospitalization and felt they may not have been reordered upon her return. She agreed that the resident should be assessed for self-administration of mediation for safety. She agreed the resident could have adverse effects, such as drug interactions, from using a medication that was not ordered and agreed the medication should not be on the bedside table. Record review of the admission Record revealed that the facility admitted Resident #13 to the facility on [DATE] with a diagnosis of Unspecified Glaucoma. Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 10/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. Resident #22 An observation of Resident #22's room on 12/02/24 at 11:10 AM revealed a box sitting on the bedside table titled Hydrocortisone 1% cream. Resident #22 stated that he uses that cream for a rash on his arm. He stated that the treatment nurse gave him a full box of hydrocortisone and told him to apply it every day. In an observation of Resident #22's room with Registered Nurse (RN) #1 on 12/03/24 at 11:00 AM, she confirmed the box on Resident #22's bedside table was Hydrocortisone cream. A continued record review of Resident #22's Order Summary Report dated 12/3/24 revealed that the resident had no orders for the Hydrocortisone cream. RN #2 confirmed Resident #22 did not administer his medications and the cream should not have been in the room. In an interview with the Treatment Nurse on 12/03/24 at 11:10 AM, she revealed the box of Hydrocortisone in Resident # 22's room was facility stock medication. She stated she did not give the resident the box of hydrocortisone and confirmed he did not have an order for it. She then revealed the medication should not be in the resident's room because he could apply too much of the hydrocortisone and have a potential adverse reaction. In an interview with the Director of Nursing (DON) on 12/03/24 at 11:15 AM, she confirmed Resident #22 did not have an assessment to self-administer medications and confirmed the medication should not have been left in the room. The DON stated the cream should have been stored in a locked medication/treatment cart. Record review of the admission Record revealed Resident #22 was admitted by the facility on 3/21/24 with diagnosis of End-stage Renal Disease. Record review of Resident #22's Section C of the quarterly MDS with an ARD of 11/26/24 revealed a BIMS score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possible transmission of infections when staff failed to use enhanced barrier precautions (EBP) during catheter care for one (1) one of (4) four direct care areas observed. (Resident #12) Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, with a revision date of August 2022 revealed, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents . Policy Interpretation and Implementation: EBP's employ targeted gown and glove use during high contact resident care activities . Examples of high contact resident care activities g. device care .urinary catheter . An observation of catheter care for Resident #12 on 12/03/24 at 2:10 PM, revealed Certified Nurse Assistant (CNA) #1 and the Restorative CNA provided catheter care for Resident #12 and both CNAs failed to apply a gown before performing catheter care. In an interview with CNA #1 on 12/03/24 at 2:20 PM, she revealed she did not realize she had not used EBP. She then revealed that all residents with indwelling devices are on enhanced barrier precautions. In an interview with the Restorative CNA on 12/03/24 at 2:25 PM, she revealed that she had forgotten EBP and confirmed she knew she was supposed to. She then revealed the purpose of EBP is to reduce the risk of spread of infections for residents at increased risk of infection. Record review of the Order Summary Report for Resident #12 revealed an active order for Catheter care every shift and as needed, dated 11/18/24. In an interview with the Infection Control Nurse on 12/03/24 at 2:35 PM, she confirmed that the CNAs should have implemented EBP to provide a layer of protection to prevent the spread of infection for residents at increased risk. Review of the admission Record revealed Resident #12 was admitted by the facility on 8/20/20 with Encounter for Surgical Aftercare Following Surgery On The Genitourinary System. Record review of Resident #12's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/24 revealed in Section: H-Bladder and Bowel: H0100 was coded Indwelling catheter.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide an activities program seven (7) days a week as evidenced by a lack of structured activities on weekends for five (5) of six (6) residents at the Resident Council meeting, with the potential to affect all residents. Resident #8, #13, #36, #37 and #40. Findings Included: A record review of a facility policy, titled Group Activities with no revision date revealed Group activities are scheduled to enhance the resident's well-being and self-esteem . During a Resident Council meeting on 12/4/24 at 9:45 AM, Residents #8, #13, #36, #37, and #40 stated that church services are provided on Sundays, but no other activities occur on the weekends. The residents explained that the Activity Director leaves activity/coloring pages and puzzles for them, and occasionally Resident #40 plays the piano. Residents #36 and #37 noted that there are no scheduled weekend activities because no activity staff are present, and other staff do not assist with any activities. They expressed a desire for structured activities on weekends. A review of the September, October, and November 2024 activity schedules revealed that Saturday activities included providing coloring, puzzles, movies, arts, and dominoes for the residents to do on their own and Sunday activities were limited to a church service. During an interview with the Activity Director (AD) on 12/4/24 at 10:00 AM, she confirmed there are no scheduled activities on the weekends. She stated that she is scheduled to work Monday through Friday, with no activity staff assigned on weekends. She confirmed that she leaves puzzles and activity/coloring pages for residents to use during the weekend and encouraged staff to put on movies. She mentioned that some residents play the piano on weekends but verified that no structured activities occur beyond the Sunday church service. She acknowledged that residents have expressed interest in additional weekend activities and stated she reported this to the Administrator. The AD emphasized that having activities seven (7) days a week is important for preventing boredom, encouraging socialization, and promoting residents' well-being. In an interview with the Administrator on 12/4/24 at 10:25 AM, he stated that the Restorative Certified Nursing Assistant (RCNA) is responsible for facilitating activities on weekends if residents request them. He agreed that the lack of weekend activities could negatively impact residents' well-being and quality of life. An interview with the RCNA on 12/4/24 at 11:00 AM revealed that she works Saturdays conducting restorative exercises. She explained that if time permits, she may organize an activity such as singing while a resident plays the piano. However, she noted that her responsibilities also include transportation and covering staff shortages, leaving her unavailable to consistently provide activities. She confirmed that she does not work on Sundays. Record review of the admission Record revealed that the facility admitted Resident #8 on 12/25/17 with a diagnosis of Borderline Intellectual Functioning. Record review of Resident #8's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 9/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. Record review of the admission Record revealed that the facility admitted Resident #13 on 1/27/23 with a diagnosis of Major Depressive Disorder. Record review of the MDS with an ARD of 10/28/24 revealed Resident #13 had a BIMS score of 15 indicating that the resident is cognitively intact. Record review of the admission Record revealed that the facility admitted Resident #36 on 7/29/24 with a diagnosis of Major Depressive Disorder. Record review of Resident #36's MDS with an ARD of 8/29/24 revealed a BIMS score of 15 indicating that the resident is cognitively intact. Record review of the admission Record revealed that the facility admitted Resident #37 on 11/29/19 with a diagnosis of Major Depressive Disorder. Record review of Resident #37's MDS with an ARD of 9/25/24 revealed a BIMS score of 15 indicating that the resident is cognitively intact. Record review of the admission Record revealed that the facility admitted Resident #40 on 10/7/20 with a diagnosis of Blindness Right Eye. Record review of Resident #40's MDS with an ARD of 10/21/24 revealed a BIMS score of 15 indicating that the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and facility policy review the facility failed to honor the choice of a resident to get up early for one (1) of 23 residents in the sample. Resident #36 Findings Include: Record review of the facility policy titled, Policies and Procedures: Resident and Patient Rights with a revision date of 09/01/2017 revealed, Policy .It is the policy of the company that all employees will conduct themselves in a professional manner at all times, respecting the rights of each resident or patient to privacy, personal care, self-respect and confidentiality . An observation and interview on 07/31/23 at 12:43 PM, with Resident #36 revealed he was sitting up in his wheelchair in his room and the resident revealed that this facility needs staff bad. Resident #36 stated they do not have enough people to take care of us. He stated that he is supposed to get up every morning around 5:00 AM but he rarely does, and it is usually because they do not have enough staff. He revealed it was 10 AM before a staff member was able to get him up this morning. He stated, I cannot get myself out of bed and don't have use of my left arm. An interview and review of the bath schedule on 8/1/23 at 1:06 PM with Licensed Practical Nurse (LPN) #1 confirmed that Resident #36 likes to get up early and his bath is scheduled on the 11 PM-7 AM shift. A review of the bath schedule with LPN #1 confirmed the resident was scheduled for a bath on the 11 PM-7 AM shift. An interview, on 8/1/23 at 1:10 PM with Certified Nurse Assistant (CNA) #1 confirmed that Resident #36 likes to have his baths early in the morning and likes to stay up after that, so he is scheduled for his bath on the 11 PM-7 AM shift. She revealed about 2-3 times a week that does not happen, and they must do his bath and get him up on the 7 AM-3 PM shift because they don't have the staff to bath him at that time and get him up. An interview, on 8/3/23 at 8:20 AM with the Director of Nurses (DON) confirmed that Resident #36 has made the request to be gotten up and his bath to be given on the 11 PM-7 AM shift. She confirmed there are times that he is not able to be gotten up on the 11 PM-7 AM shift and it is usually due to staffing. She confirmed that a resident's choices should be honored though. Record review of Resident #36's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified. Record review of Resident #36's Documentation Survey Report v2 for July 2023 revealed under ADL (Activity of Daily Living) - for transferring there were five times in the last two weeks where the resident did not get out of bed on the 11PM-7AM shift for his bath. Record review of Resident #36's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact and under Section G that the resident needed extensive assistance for transferring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review and facility policy review, the facility failed to resolve a grievance in a timely manner for one (1) of six (6) residents reviewed for bathing, Resident #49, and foul odors inside the facility for five (5) of 12 residents reviewed during resident council. Resident #9, Resident #14, Resident #28, Resident #41, Resident #53. Findings Include: Record review of the facility policy titled Complaint/Grievance with a revision date of 10/24/22 revealed, under, Policy: The center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner .Procedure: 1. An employee receiving a complaint /grievance from a resident, family member and /or visitor will initiate a Complaint/Grievance Form. 2. Original grievance forms are then submitted to the Grievance Officer / designee for further action. 3. The Grievance Officer / designee shall act on the grievance and begin follow -up of the concern or submit it to the appropriate director for follow -up. 4. The grievance follow -up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint / Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/grievances in Monthly Grievance Log. 8. The individual voicing the grievance will receive follow -up communication with the resolution will be provided to the resident upon request . During an observation on 7/31/23 at 11:05 AM, the State Agency (SA) noticed a strong smell of urine as soon as you reach the nurses station that lingered between the North and South hallways and the smell extended all the way down the South hallway. During an observation on 7/31/23 at 3:00 PM walking from the front entrance the SA noted a strong smell of urine as soon as you get to the nurse's station and continued down the South hallway. During the Resident Council Meeting on 8/1/23 at 2:00 PM; Resident #9, Resident #14, Resident #28, Resident #41, and Resident #53 complained about the smell of urine and feces on the hallways. Resident #53 and Resident #41 stated they thought it was the dirty barrels on the hall where they put the dirty linens and it sits outside the room doors until they are done in that area. They revealed they have talked about this in the resident council meetings in the past, but it has not been resolved. An observation and interview on 08/01/23 at 03:02 PM with the Administrator confirmed that there was an odor of urine on the South hallway and some areas were worse than others. He confirmed that Resident #46 and Resident #52's rooms smelled of urine. He revealed they both use urinals and sometimes spill them. He confirmed that staff should be emptying the urinal and cleaning it out at least every 2 hours and frequently changing the urinals out as well. He revealed that each residents room gets mopped daily but admitted that those that usually have a strong odor of urine smell should be mopped more often. He stated that the facility is old and does not have good ventilation on the hallways and they have been working on possibly getting a split unit on each end of the halls to help with that and hopefully help with the smells. He confirmed that it didn't need to smell that way. An interview on 8/1/23 at 4:30 PM with the Activities Director confirmed that residents had complained about the smell of urine and feces in the halls during resident council meetings at times, but they do not want me to write it up as an actual complaint; they just want me to talk with the administrator about it for them and I have. She stated she is not sure what solution they came up with, but that the residents will say that the smell gets better at times and then will get bad again. An interview on 8/2/23 at 2:15 PM with Director of Nurses (DON) and the Assistant Director of Nurses (ADON) stated that they had been here so long they do not notice the smells of urine except occasionally. The ADON stated she just smells filth and thinks it is a ventilation problem, because there is no air circulation on the halls. She revealed that the Administrator has talked with corporate about getting some sort of units to put on both ends of the halls to increase air circulation and stated the air is just stale. An interview on 8/3/23 at 11:40 AM with the Administrator confirmed that he recalls the Activities Director mentioning that the resident's had complained of the smell at times in the past and he has discussed with her the need to write it up as an actual grievance. Resident #9 Record review of Resident #9's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that include Idiopathic Normal Pressure Hydrocephalus. Record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/4/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident is cognitively intact. Resident #14 Record review of Resident #14's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Rheumatoid Arthritis Unspecified. Record review of Resident #14' MDS with and ARD of 7/11/23 revealed under Section C a BIMS score of 14, which indicated that the resident is cognitively intact. Resident #28 Record review of Resident #28's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia. Record review of Resident #28's MDS with an ARD of 4/25/23 revealed under Section C a BIMS score of 13, which indicated the resident is cognitively intact, Resident #41 Record review of Resident #41's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dysphagia following Cerebral Infarction. Record review of Resident #41's MDS with an ARD of 5/22/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Resident #53 Record review of Resident #53's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Acute and Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #53's MDS with an ARD of 7/7/23 revealed under Section C a BIMS score of 11, which indicated the resident is moderately cognitively intact. Resident #49 An interview with Resident #49 on 07/31/23 11:15 AM, revealed she had not been getting her bath as scheduled on Monday, Wednesday, and Friday. She revealed her last bed bath was given last Monday. She stated that she was told last Wednesday and Thursday that there was not enough staff, and on Friday she was told the facility ran out of towels and wash cloths. The resident revealed, at one point, therapy was helping complete her baths due to the shortage of staff. She revealed she had filed a grievance regarding not getting her bath and things did get better for about 2 weeks. She revealed that staffing was the problem. The resident revealed that the aides worked with one aide on the hall at times and stated, It's impossible for them to do all those baths. An interview with the Social Worker (SW) on 08/01/23 at 11:03 AM, revealed that Resident #49 had filed two grievances regarding her not getting bathed and both were considered resolved. She revealed she did follow-up and spoke with the resident, and she voiced no issues. SW stated, She hasn't said anything else to me about it. An interview on 08/01/23 at 11:16 AM, with Resident #49 revealed that she requested her bathing schedule to be on Monday, Wednesday, and Friday. She stated, If I did refuse my bath, it was because I only wanted a bath on those days. An interview on 8/01/23 at 3:10 PM, with the DON revealed that Resident #49 had filed two grievances related to not receiving her baths that were dated 5/12/23 and 7/5/23. She revealed that on 5/12/23 the resident requested to get her baths on the 3-11 shift because she was not a morning person. The DON revealed that she updated the bath list and requested the nurses to follow up. The DON revealed that on 7/5/23 she had a meeting with the aides on the 3-11 shift. She revealed that she requested the nurses to follow up with the aides regarding the resident's bath. She stated that the aides would occasionally report that the resident refused because she didn't want to get a bath at that time. The DON revealed that she spoke with the resident concerning this, and the resident reported that the aides on 3-11 came at an odd time that was not convenient for her. An interview on 8/02/23 at 2:17 PM, with Licensed Practical Nurse (LPN) # 1 revealed the facility had a bath schedule at the nurse's desk that the aides were supposed to follow. An interview with the SW on 08/02/23 at 4:30 PM, revealed that she handled and kept all the grievances. She revealed that the residents that have resided in the facility awhile knew that she handled the grievances and would come by her office, or the staff would come get her. She revealed that as part of the admission process to the facility, she spoke with the residents and families and explained how to report issues or concerns. The SW revealed that once she completed her section of the grievance form, she took it to the morning meeting to discuss with the administrative staff. She revealed she then gave it to the needed department so that the issue/concern could be addressed. She revealed that after the issue/concern was addressed, the grievance form would be returned to her so that she could follow up on the outcome. The SW revealed that the Administrator does not sign off on the grievances. An interview with the Administrator (ADM) on 8/03/23 at 8:45 AM, revealed the grievances were reviewed in the morning meeting. He revealed that he used to sign off on the grievance form, but he currently does not because the form does not have an area for the ADM to sign. He stated he did sign off on Resident council, but not the grievances. The ADM revealed that they recently had an in-service with the corporate team, and they were making some upcoming changes. The ADM revealed that he had spoken with several aides that cared for Resident #49, and they reported that the resident would refuse to bathe at times. The ADM confirmed that the Activity of Daily Living (ADL) documentation did not support refusal and confirmed that here were several days with no documentation to prove bathing occurred. Record review of the grievance filed by Resident #49 dated 5/12/23 revealed, Resident not getting a shower. Under, Documentation of Investigation revealed Findings of Investigation: Resident only wants a bed bath on Mon, Wed, Fri. Under Plan to resolve complaint/grievance: Update bath list for bed bath on Mon, Wed, Fri, under Results of actions taken: On 24-hour report for nurses to follow up to make sure resident is getting bath Under, Complaint/Grievance resolved Yes is marked. Record review of the grievance filed by Resident #49 on 7/05/23 revealed, Resident states she hasn't taken a bath since last Wednesday Revealed under, Findings of investigation: Spoke with resident says she has to ask for a bath. Currently on 3-11 bath list Under, Plans to resolve complaint/grievance: Coach with 3-11 shift nurses and CNA's go over 3-11 bath list Under Results of actions taken: Met with 3-11 shift about bath schedule Under Complaint/Grievance resolved Yes is marked. Record review of the admission Record for Resident #49 revealed she was admitted to the facility on [DATE] with medical diagnoses that included Rheumatoid Arthritis, Repeated Falls, Chronic Pain Syndrome and Need for Assistance with Personal Care. Record review of the MDS with an ARD of 04/28/23 revealed under section G that Resident # 49 requires one-person physical assist with bathing. Record review of the MDS with an ARD of 04/28/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #49 is cognitively intact.

Based on staff interview, record review, and facility policy review the facility failed to correctly code a Minimum Data Set (MDS) related to weight loss for one (1) of 23 MDS records reviewed. Resident #11. Findings include: Review of the facility policy titled, MDS, with a revision date of 9/25/2017, revealed the center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required Resident Assessment Instrument (RAI). Record review of the quarterly MDS with an Assessment Reference Date of 4/14/23 revealed Section K 0300 #1 was checked: Yes, on physician prescribed weight loss regimen. An interview on 08/03/23 at 9:17 AM, with the MDS nurse stated she knew the resident had weight loss but was not physician prescribed. She stated the MDS was coded wrong, and it is part of the MDS process for her check the MDS for accuracy. An interview on 8/1/23 at 9:45 AM, with the Director of Nursing (DON) revealed Resident #11 had been doing fine, they were monitoring routine monthly weights. He got upper respiratory symptoms and next month his weight was significantly down. They monitored weekly weights, and the DON stated the weight loss occurred also because the resident is up and moving around the building constantly and smokes. An interview, with the Administrator on 8/3/23 at 2:00 PM, revealed he didn't know why Section K was marked incorrectly because the assessment was correct. He confirmed it must have just been an entry error. Record review of the Order Summary Report for Resident #11 revealed an order dated 7/24/23 for Regular diet, Regular texture. Regular/ thin liquids consistency. provide finger foods with all meals, Health shake at lunch and supper. Fortified foods with all meals for DIET. Review of the facility admission Record for Resident #11 revealed an admission date of 12/28/21 with diagnoses that included Heart Failure, Alzheimer's Disease, Nicotine dependence, Depressive disorder, and Muscle Wasting and Atrophy. Review of the MDS with an Assessment Reference Date (ARD) of 4/14/23 revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated Resident #11 had severe cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of Resident #29's care plans revealed under, Interventions/Task: Patient to wear left hand soft, comfy hand splint for 6-8 hours during the daytime shifts in order to prevent left digits contractures due to signs and symptoms of keeping fingers in flexed position. Make sure Velcro straps are not too tight and can place two fingers width underneath straps. Please notify OT (Occupational Therapy) of any skin integrity issues. please perform BUE (Bilateral Upper Extremity) PROM (Passive Range of Motion) daily. An observation of Resident # 29 on 8/01/23 9:45 AM, revealed she was lying in bed with her eyes closed and a hand splint was observed lying on the table beside the bed. An interview with the MDS Nurse on 8/02/23 at 4:19 PM, revealed the purpose of the care plan was to instruct the staff on what care should be provided for the resident. She confirmed that Resident #29 had a care plan for a left-hand splint and stated, If she's not wearing it, then we did not follow the care plan. An interview with the DON on 8/02/23 at 4:32 PM confirmed that Resident #29 had a care plan for a left-hand splint and stated, No, we weren't following the care plan. She revealed the purpose of the care plan was to have the information to meet the residents' needs. An interview with RN #1 on 8/03/23 at 8:15 AM, revealed the purpose of the care plan was to ensure that the resident was able to meet their goals and to ensure the resident gets the necessary care to ensure quality of care. She confirmed that the care plan for Resident # 29 was not followed. Record review of the admission Record revealed Resident #29 was admitted to the facility on [DATE] with medical diagnoses that included Sequelae of Cerebral Infarction, Pseudobulbar Affect, Major Depressive Disorder, Seizures, and Essential (Primary) Hypertension. Record review of the MDS with an ARD of 7/07/23 revealed under section C a BIMS score of 10, indicating Resident # 29 is moderately cognitively impaired. Resident #36 Record review of Resident #36's care plans revealed the resident did not have a care plan regarding his choice to get up around 5 AM and have his bath at that time. An observation and interview, on 07/31/23 at 12:43 PM with Resident #36 revealed he is supposed to get up every morning around 5:00 AM but he rarely does. He stated, I cannot get myself out of bed and don't have use of my left arm. An interview on 8/3/23 at 11:00 AM, the MDS/Registered Nurse (RN) revealed she had not been made aware that the resident requested to get up around AM and get his baths. She stated that if the resident had made that request, then it needed to be care planned to direct the staff on his choices. An interview on 8/3/23 at 11:45 AM, with the DON and the Assistant Director of Nurses (ADON) revealed everyone knew that the resident liked to get up early and he was on the bath schedule for 11pm -7am so they did not see the need for it to be in his care plans. Record review of Resident #36's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified. Record review of Resident #36's MDS with an ARD of 5/26/23 revealed under Section C a BIMS score of 15, which indicated that the resident was cognitively intact and under Section G that the resident needed extensive assistance for transferring. Resident #44 Record review of Resident #44's care plans revealed a care plan revised on 6/29/23, Focus (Proper Name of Resident #44) has an ADL deficit r/t (related to) dementia, weakness, and impaired balance, impaired vision .Interventions/Tasks . Bathing: extensive x (times) 1 assist .Personal hygiene: limited assist with one person assist, Staff will assist resident as needed with ADL's . An interview and observation on 07/31/23 at 11:35 AM, with Resident #44 revealed the resident had gray facial hair that was approximately 1 inch long with 1-inch-long gray hair coming out of his ears. The resident revealed he would like to be shaved. An interview on 8/2/23 at 1:30 PM with the DON and the ADON confirmed that shaving is a part of bathing and if the resident needs and wants to be shaved then the staff should take care of that during the resident's bath. An interview on 8/3/23 at 11:00 AM MDS/RN revealed the care plan is in order to direct the staff on care and should be implemented. Record review of Resident #44's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Gout, Unspecified Intellectual Disabilities, Unspecified Dementia and Blindness-right eye category 4 and left eye category 2. Record review of Resident #44's MDS with an ARD of 6/23/23 revealed under Section C a BIMS score of 12, which indicated the resident is cognitively intact and under Section G that the resident needed physical help with bathing. Based on staff interview, record review and facility policy review the facility failed to develop a person-centered care plan for a resident receiving oxygen for Resident #23 & Resident #106, and a resident's choice for Resident #36. The facility failed to implement a person-centered care plan for resident's dependent on staff for their Activities of Daily Living (ADL) for Resident #22, Resident #35, and Resident #44 and for a resident requiring a splint Resident #29 for seven (7) of 23 residents reviewed for care plans. Findings include: Review of the facility policy titled, Policies and Procedures: Plans of Care with a revision date of 09/25/17 under Procedure: Develop and implement an individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that include but is not limited to-the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, another appropriate staff or professionals in discipline as determined by the resident's needs or as requested by the resident, and to the extent practicable, the participation of the resident and the residents representative . Resident #22 Record review of Resident #22's care plan, last review 6/8/23, revealed, Focus .potential for skin problems r/t (related to) thin fragile skin .needs assist with ADL's .Interventions/Tasks .BATHING/SHOWERING: Check nail length and clean as necessary. Report any changes to the nurse .Provide sponge bath when a full bath or shower cannot be tolerated . An observation, on 07/31/23 at 12:29 PM and on 08/01/23 at 8:32 AM, revealed Resident #22's fingernails on both hands were long, past the end of the fingers. All the nails on left hand and middle finger on right hand had dark brown substance under each nail. An interview, on 8/1/23 at 3:05 PM with the Director of Nursing (DON) confirmed that long sharp fingernails could result in skin tears for the resident. She stated that if the resident had brown stuff caked between her toes she probably didn't get a good bath. Review of Resident #22's admission Record revealed an admission date of 5/29/21 with diagnoses that included Cerebral Infarction, Type 2 Diabetes Mellitus, and Alzheimer's Dementia. Review of Section C of the MDS with an ARD of 5/25/23 revealed Resident #22 did not require a Brief Interview for Mental Status (BIMS) to be conducted because the resident is rarely/never understood. Section G Functional Status revealed Resident #22 was totally dependent on two (2) staff members for personal hygiene and bathing. Resident #35 Record review of the care plan for Resident #35 revealed a care plan reviewed 6/29/23, Focus (Proper Name of Resident #35 has an ADL self-care performance deficit r/t (related to) muscle wasting and atrophy, weakness, need assist with ADLs, and dementia .Interventions .BATHING/SHOWERING: The resident requires extensive assist by one (1) staff with bathing/showering .DRESSING: The resident requires limited assist by (1) staff to dress . An observation, on 08/02/23 at 9:40 AM revealed Resident #35 wearing the same plaid pants and gray shirt that he had on the day before. An interview on 8/2/23 at 2:20 PM, with CNA #5 revealed that Resident #35 did not get a bath today. Resident #23 During an interview on 8/3/23 at 9:17 AM the MDS nurse confirmed the care plan directs staff on what needs to be done for the resident even if they cannot do it themselves, all information related to a resident's care should be in the care plan. An observation on 07/31/23 at 12:11 PM revealed Resident #23's oxygen cannula not bagged hanging on the front of the concentrator and there was no signage on the door indicating oxygen was in the room. An interview on 8/2/23 at 8:30 AM with the DON revealed that the cannula should have been stored in a bag and there should have been an oxygen in use sign on the door. Review of the admission Record for Resident #23 revealed an admission date of 3/17/23 with diagnoses that included Unspecified Dementia, Heart Failure, and Cerebral Infarction. Review of the MDS with an ARD of 4/20/23 revealed Resident #23 was severely impaired and never/rarely made decisions. Resident #106 An observation and interview on 07/31/23 at 12:04 PM revealed Resident #106's oxygen cannula hanging on the concentrator not in a bag and there was no signage on the door indicating oxygen was in use. An interview and record review on 08/03/23 at 9:17 AM with the Minimum Data Set (MDS) nurse confirmed Resident 106's care plan does not cover oxygen storage and signage. She stated that she did not think she needed to put it in the care plan because it is covered in the policy. Review of the admission Record for Resident #106 revealed and admission date of 11/25/2022 with diagnoses that included Chronic Obstructive Pulmonary Disease and Bronchitis. Review of the MDS with an ARD of 6/28/2023 revealed a BIMS score of 13 which indicated Resident #106 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review and facility policy review the facility failed to shave, clean and trim nails and bath residents that were dependent on staff for their Activities of Daily Living (ADL) for five (5) of 59 residents reviewed on the initial tour. Resident #22, Resident #35, Resident #38, Resident #44, and Resident 49. Findings include: Record review of the facility policy titled Grooming Activities with a revision date of 03/19/19 revealed, under, Policy: Grooming activities are provided to assist the residents in meeting their physical needs as well as self-esteem needs. Also revealed under, Procedure: 1. Grooming activities shall be offered daily. 2. Grooming Activities shall include, but are not limited to: Shaving, Applying Make-up, Combing Hair, Nail Care . Record review of the facility policy titled Bathing/Showering with a revision date of 04/20/22 revealed under Policy: The resident preferences on bathing/showering will be reviewed and identified upon admission, including frequency, and other preferences. Also revealed under, Procedure: . Document in the medical record. Record review of the facility policy titled Activities of Daily Living with an effective date of 02/01/2022 revealed under, Policy: . ADLs include bathing, dressing, grooming, hygiene, toileting, and eating. Also revealed under, Procedure: 1. CNA will review the resident [NAME] for information on individual care needs and preferences 2. CNA will provide needed oversight, cueing or assistance to resident 3. CNA will report any changes in ability or refusals to the nurse 4. CNA will document care provided in the medical record. Resident #22 Observations on 07/31/23 at 12:29 PM and on 8/1/23 at 8:32 AM revealed Resident #22's fingernails on both hands were long and grown out past the end of her fingers. All the nails on her left hand and middle finger on right hand had a dark brown substance under each nail. During an observation and interview, on 8/1/23 at 2:45 PM with Licensed Practical Nurse (LPN) #2 confirmed the brown substance under Resident #22's fingernails and that the nails were long and had sharp broken edges. She stated that the resident could scratch herself or someone else. Resident #22 also had a brown substance between all her toes on both feet. LPN #2 stated that it was horrible and obvious the resident had not been getting a good bath. During an interview on 8/1/23 at 3:05 PM, with the Director of Nursing (DON) confirmed that long sharp fingernails could result in skin tears for the resident. She stated if the resident is not diabetic, the Certified Nursing Assistants (CNA's) are responsible for nail care. The nurses are responsible for checking and cutting the nails of diabetic residents weekly. She stated that if the resident had brown stuff caked between her toes she probably didn't get a good bath. She stated that CNAs are responsible for baths and the wound care nurse is also responsible for doing skin checks. She stated that they were doing the best they can. Review of Resident #22's admission Record revealed an admission date of 5/29/21 with diagnoses that included Cerebral Infarction, Type 2 Diabetes Mellitus, and Alzheimer's Dementia. Review of Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/25/23 revealed Resident #22 did not require a Brief Interview for Mental Status (BIMS) to be conducted because the resident is rarely/never understood. Section G Functional Status revealed Resident #22 was totally dependent on two (2) staff members for personal hygiene and bathing. Resident #35 An interview, with Resident #35 on 8/1/23 at 8:30 AM revealed that he did not feel like the care was good here and stated that they are slow to come to the room. During an observation on 08/02/23 at 9:40 AM, revealed Resident #35 wearing the same plaid pants and gray shirt that he had on the day before. During an interview on 8/2/23 at 9:41 AM, with CNA #5 revealed she did not know if Resident #35 was supposed to get a bath today. She stated she did not know when he was supposed to get a shower and did not know how to find out that information. Later that day in an interview on 8/2/23 at 2:20 PM with CNA #5 stated that Resident #35 did not get a bath today and it was not charted that he did. During an interview on 8/2/23 at 2:30 PM, with the DON revealed that if something was not charted then it was not done. Record review of the ADL documentation for baths for Resident #35 revealed five (5) days in July 2023 that no bath/shower was documented for the resident. Record review of Section G of the MDS with an ARD of 6/7/2023 revealed Resident #35 required one-person physical assist for help in part of bathing activity. Section C revealed a BIMS score of five (5) which indicated Resident #35 was severely cognitively impaired. Review of the admission Record for Resident #35 revealed an admission date of 5/26/2023 with diagnoses that included Weakness and Overactive Bladder. Resident #44 During an interview and observation on 07/31/23 at 11:35 AM with Resident #44 revealed the resident had gray facial hair that was approximately 1 inch long with 1-inch-long gray hair coming out of his ears and the resident revealed he would like to be shaved. In an interview and observation on 8/1/23 at 1:13 PM, with CNA #1 confirmed that Resident #44 needed to be shaved, have a haircut and the hair in his ears needed to be trimmed. Resident #44 stated he wanted to be shaved, have a haircut, and trim his ear hairs. CNA #1 revealed shaving should be included in the resident's showers or baths and for some reason the other aides wait for her to do it, so he only gets it done when he is assigned to her. During an interview with the DON and the Assistant Director of Nurses (ADON) on 8/2/23 at 1:30 PM, confirmed that shaving is a part of bathing and if the resident needs and wants to be shaved then the staff should take care of that during the resident's bath. Record review of Resident #44's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Intellectual Disabilities, Unspecified Dementia and Blindness-right eye category 4 and left eye category 2. Record review of Resident #44's MDS with an ARD of 6/23/23 revealed under Section C a BIMS score of 12, which indicated the resident is cognitively intact and under Section G that the resident needed physical help with bathing. Resident #38 An observation on 07/31/23 at 12:02 PM, of Resident #38 revealed long nails, with a thick brown substance underneath. An observation on 8/01/23 at 12:53 PM, of Resident # 38 revealed she was sitting in a wheelchair in her room and nails were observed to be long with a dark brown substance underneath. An observation and interview on 8/01/23 at 1:00 PM, with CNA # 6 confirmed that Resident #38's nails were long and dirty. She revealed the CNA's do not cut or clean the residents' nails and revealed that it was the responsibility of the wound nurse. An observation and interview on 8/01/23 at 1:04 PM, with RN # 1 confirmed that Resident #38's nails were long and dirty. She revealed that it was the Wound Nurse's job to clean and cut the residents' nails and confirmed that Resident #38 could scratch herself and cause skin issues and stated, It's infection control. An observation and interview on 8/01/23 at 1:30 PM, with the DON confirmed that Resident #38's nails were dirty and needed trimming. She revealed that the aides were responsible for cleaning the nails as part of their routine daily care with the bathing. She revealed the aides can cut the nails of the residents if the resident was not a diabetic. She stated, They know that they should be doing that every day. Record review of the admission Record for Resident #38 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Dysphasia, Essential (Primary) Hypertension, and Pseudobulbar Affect. Record review of the MDS with an ARD of 6/19/23 revealed under section C a BIMS score of 10, indicating Resident #38 is moderately cognitively impaired. Resident #49 During an interview with Resident #49 on 7/31/23 at 11:15 AM, revealed she had not been getting her bath as scheduled on Monday, Wednesday, and Friday. She revealed that her last bed bath was given last Monday (7/24/23). An interview on 8/01/23 at 3:42 PM, with LPN # 2 revealed Resident # 49 did refuse some baths. She stated, She likes certain people to give her baths and if they're not here, she will refuse. In an interview on 08/01/23 at 11:16 AM, with Resident #49 revealed that she requested her bathing schedule to be on Monday, Wednesday, and Friday only. The resident stated, If I refuse, it is because I only want a bath on those days. During an interview on 8/02/23 at 2:17 PM, with LPN # 1 revealed the facility had a bath schedule at the nurse's desk that the aides were supposed to follow. Record review of the ADLs for the month of May 2023 revealed there was not any documentation for the bathing task for Monday 5/22/23. Documentation revealed under Monday, 5/29/23, 3 - Not Applicable for the bathing task. Record review of the ADLs for the month of June 2023 revealed there was not any documentation for the bathing task for Monday 6/5/23. Documentation revealed under, Friday, 6/02/23, Monday, 6/19/23, Wednesday, 6/21/23 and Monday 6/26/23, 3 - Not Applicable for the bathing task. Record Review of ADLs for the month of July 2023 revealed there was not any documentation for the bathing task for Friday 7/14/23, Monday 7/24/23 and Wednesday 7/26/23. Documentation revealed under, Monday 7/3/23, 3 - Not Applicable for the bathing task. An interview with the DON on 8/02/23 2:25 PM, confirmed that Resident # 49's bathing task revealed missing documentation supporting that resident was given a bath. She stated, I really couldn't say if she had taken a bath those days. She revealed that the aides sometimes leave after their shift without documenting. She confirmed that if the task was not documented, then it was not done. Record review of the admission Record for Resident #49 revealed she was admitted to the facility on [DATE] with medical diagnoses that included Rheumatoid Arthritis, Repeated Falls, Chronic Pain Syndrome and Need for Assistance with Personal Care. Record review of the MDS with an ARD of 04/28/23 revealed under section G that Resident #49 requires two-person physical assist with personal hygiene The MDS revealed under section C a BIMS score of 14, which indicated Resident #49 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review and facility policy review the facility failed to apply a splint to a resident as ordered for one (1) of 16 residents reviewed with contractures. Resident #29 Findings include: Review of the facility policy titled Contractures, Prevention with a revision date of 08/22/2017 revealed under, Policy: To prevent contracture of extremities for those residents who no longer have full use of their extremities. Procedure: . Some residents may have braces or splints to prevent or help release contractures - be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them . An observation of Resident #29 on 07/31/23 at 12:25 PM, revealed she was lying in bed, unable to arouse to verbal stimuli and a hand splint was located on a table beside the bed. During an observation of Resident # 29 on 8/01/23 at 9:45 AM, revealed she was lying in bed with her eyes closed and a hand splint located on the table beside the bed. An interview with the Occupation Therapist (OT) on 8/1/23 at 1:15 PM, revealed that Resident #29 was recently discontinued from therapy services and had a physician's order to wear a left-hand splint during the daytime hours. An interview and observation with Registered Nurse (RN) # 1 on 8/1/23 at 1:20 PM, revealed Resident #29 had a physician order to wear left hand splint for 6-8 (six-eight) hours during the daytime hours. She revealed the aides were responsible for applying the splint when they got her up and removed it when she went to bed. She confirmed that Resident # 29 did not have the left-hand splint on and stated, Maybe the aide didn't know. She revealed that Resident #29 could develop a worsening contracture by not wearing the splint. During an observation and interview with the Director of Nursing (DON) on 8/01/23 at 1:30 PM, confirmed that Resident #29 was not wearing the left-hand splint. She revealed that the Therapy Dept just discontinued the resident from therapy services and wrote the physician's order for the splint on 7/29/23. She revealed that the splint shows up on the Treatment Administration Record (TAR) for the Wound Nurse to apply. The DON revealed she was not sure why the Wound Nurse had not applied it and confirmed that Resident # 29 could develop a worsening contracture by not wearing it as ordered. An interview with the Wound Nurse on 8/03/23 at 9:40 AM, revealed she did not apply the splint to Resident #29's left hand on 7/31/23 and 8/01/23. She revealed it was brought to her attention by the Director of Nursing on 8/01/23, and it was applied later in the day. She confirmed that Resident #29 could develop worsening contractures by not wearing. Record review of Resident #29's Order Summary Report revealed an order dated 07/28/23, Patient to wear left hand soft, comfy hand splint for 6-8 hours during the daytime shifts in order to prevent left digits contractures due to signs and symptoms of keeping fingers in flexed position. Make sure Velcro straps are not too tight and can place two fingers width underneath straps. Please notify OT (Occupational Therapy) of any skin integrity issues . Record review of Resident #29's Treatment Administration Record (TAR) revealed there was not any documentation under 7/31/23 for applying the left-hand splint at 0900. Record review of the admission Record revealed Resident #29 was admitted to the facility on [DATE] with medical diagnoses that included Sequelae of Cerebral Infarction, Pseudobulbar Affect, Major Depressive Disorder, Seizures, and Essential (Primary) Hypertension. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/07/23 revealed under section G that Resident #29 has a functional limitation in range of motion impairment to the upper extremity on one side. Section C revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident # 29 is moderately cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to post oxygen in use signage on the door for two (2) of 11 residents receiving respiratory care. Resident #23 and Resident #106 Findings include: Record review of the facility policy titled, Oxygen Safety with a revision date of 1/25/2018 revealed, Policy: All personnel shall utilize oxygen in accordance with state and federal regulations. Procedure: .D .2 .Oxygen in Use signs shall be placed on the doors of rooms where oxygen is in use . Resident #23 During an observation on 07/31/23 at 12:11 PM, revealed Resident #23 had a an oxygen concentrator in the room and there was no signage on the door indicating oxygen was in the room. During an observation on 8/1/23 at 9:00 AM revealed the oxygen concentrator had been removed from the resident's room. On 8/2/23 at 8:30 AM, in an interview with the Director of Nursing (DON) revealed that someone must have taken the oxygen out of the room and there should have been a sign on the door. She stated that most of the time if oxygen is ordered as needed they do not keep it in the room. If the resident gets short of breath they bring a concentrator from the supply closet. Record review of the Order Summary Report revealed a physician order for Resident #23 dated 7/20/23 revealed Oxygen as needed (PRN) 2 liters (L) as needed for shortness of breath. Record review of the admission Record for Resident #23 revealed an admission date of 3/17/23 with diagnoses that included Unspecified Dementia, Heart Failure, and Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/20/23 revealed Resident #23 was severely cognitively impaired and never/rarely made decisions. Resident #106 During an observation on 07/31/23 at 12:04 PM, revealed Resident #106 had an oxygen concentrator in the room and there was no signage on the door indicating oxygen was in use. During an interview on 8/1/23 at 3:15 PM with the DON confirmed that there should be oxygen signs on every door for residents receiving oxygen. Record review of the Order Summary Report for Resident # 106 revealed a physician order dated 6/30/23 Oxygen a 2 l/min (liters/minute) via NC (nasal cannula) As Needed PRN . for sob (shortness of breath). Record review of the admission Record for Resident #106 revealed an admission date of 11/25/2022 with diagnoses that included Chronic Obstructive Pulmonary Disease and Bronchitis. Review of the MDS with an ARD of 6/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #106 was cognitively intact.

Based on observation, staff and resident interview and record review, the facility failed to store oxygen tubing in a bag to prevent the possibility of contamination and infection for two (2) of 12 resident receiving respiratory treatments. Resident #23 and Resident #106. Findings include: An observation, on 07/31/23 at 12:11 PM revealed Resident #23's oxygen cannula not bagged hanging on the front of the concentrator. An interview on 8/2/23 at 8:30 AM with the Director of Nursing (DON) revealed that someone must have taken the oxygen out of the room, but the cannula should have been stored in a bag. Record review of the Order Summary Report revealed a physician order for Resident #23 dated 7/20/23 revealed Oxygen as needed (PRN) 2 liters (L) as needed for shortness of breath. Record review of the admission Record for Resident #23 revealed an admission date of 3/17/23 with diagnoses that included Unspecified Dementia, Heart Failure, and Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/20/23 revealed Resident #23 was severely cognitively impaired and never/rarely made decisions. Resident #106 An observation and interview, on 07/31/23 at 12:04 PM revealed Resident #106's oxygen cannula hanging on the concentrator not in a bag. Resident #106 stated that she did not know it was supposed to be in bag. An observation and interview, on 8/1/23 at 2:30 PM with Licensed Practical Nurse (LPN) #2 confirmed Resident #106's oxygen cannula was laying on the bed not in a bag. She stated that using a dirty cannula could cause a respiratory infection. She stated that the Certified Nursing Assistants (CNA) and the nurses were responsible for making sure and educating the resident to place the cannula in a bag when not in use. Record review of the Order Summary Report for Resident # 106 revealed a physician order dated 6/30/23, Oxygen a 2 l/min (liters/minute) via NC (nasal cannula) As Needed . for sob (shortness of breath). Record review of the admission Record for Resident #106 revealed an admission date of 11/25/2022 with diagnoses that included Chronic Obstructive Pulmonary Disease and Bronchitis. Review of the MDS with an ARD of 6/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #106 was cognitively intact. An interview on 8/1/23 at 3:15 PM with the DON confirmed that oxygen tubing should be stored in a bag to prevent contamination and infection. She stated that all staff are responsible for noticing if the tubing is not in a bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation of Resident #50 on 07/31/23 at 11:20 AM, revealed him lying in bed eating lunch. The resident's left and right inner side rails noted with a brown substance adhering. The wall located beside the bed was noted with a brown substance smeared down the wall in the resident's view. The brown substance on the wall measured approximately 10 inches in length x 5 inches in width. An interview with the DON on 8/01/23 at 3:05 PM, confirmed that Resident # 50 had a brown substance smeared on the wall and on both inner side rails. She confirmed that this was not a sanitary environment for the resident to reside in. She revealed it was housekeeping's responsibility to ensure the residents' side rails and walls were cleaned. An interview with the Regional Housekeeping Director on 8/01/23 at 3:10 PM, confirmed the brown substance on the wall and on Resident #50's side rails. He revealed that if the brown substance was bodily fluids, the nursing department would be responsible for cleaning. He confirmed that this was not a sanitary environment for the resident. Record review of the admission Record for Resident # 50 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Nontraumatic Intracerebral Hemorrhage, Type 2 Diabetes Mellitus and Heart Failure. Based on observations, resident and staff interviews, record review and facility policy review the facility failed to maintain a clean environment that was free of odors as evidenced by dirty walls and siderails and provide a sufficient supply of clean linen for two (2) of four (4) survey days. Findings include: Record review of the facility policy titled Cleaning and Disinfection of Environmental Surfaces undated revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard. Policy Interpretation and Implementation: 1 . c. non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled . An observation on 7/31/23 at 11:05 AM, revealed a strong smell of urine as soon as you reach the nurses station that lingered between the North and South hallways and that smell extended all the way down the South hallway of the building. An observation on 7/31/23 at 3:00 PM, walking from the front door revealed a strong smell of urine as soon as you get to the nurse's station and continued down the South hallway. An interview on 8/1/23 at 8:51 AM, with Certified Nurse Assistant (CNA) #1 revealed that the facility only has one laundry staff member, and they are off on Tuesday's and Wednesday's, so they run out of towels and washcloths. She stated that when the staff came in this morning they were out of clean towels and wash cloths, so a CNA took it upon themselves to start a load of laundry. An observation and interview with Laundry & Housekeeping Supervisor on 8/1/23 at 9:25 AM in the laundry room revealed there were no clean towels or wash clothes available now. The Laundry & Housekeeping Supervisor stated that they have a laundry staff person that works 6AM-2PM every day except Tuesday and Wednesday, but on those days, he helps and does some washing. He revealed he was currently washing bath cloths and towels, but the staff come to the laundry room and stock their linen carts and take them to the halls. An observation on 8/1/23 at 9:40 AM, of the linen cart on the South Hall revealed there were only 3 wash cloths and no towels. CNA #1 confirmed this observation. An observation and interview with CNA #2 on 8/1/23 at 9:45 AM, confirmed the linen cart on the North Hall had no washcloths or towels and CNA #2 revealed that they still had about three baths to give and that they had given all the baths they could with the washcloths and towels that they had. During the resident council meeting on 8/1/23 at 2:00 PM, Residents #21, Resident #41 & Resident #28 complained that the facility runs out of towels and wash clothes often and all agreed that their baths had been postponed or delayed due to no clean washcloths or towels at that time. An interview on 8/1/23 at 3:30 PM, with the Activities Director and CNA #7 confirmed they run out of clean wash cloths and towels and revealed that when they run out of towels and wash clothes, they tell housekeeping. An interview on 8/1/23 at 4:30 PM, with the Activities Director stated that since the facility stopped letting the staff use wet wipes, they have started running low on wash cloths and towels and that has been going on for the last couple of weeks. An interview on 8/2/23 at 2:15 PM, with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) stated that they knew about the issue with the staff running out of washcloths and towels, and knew there were extra in storage, but staff have been washing some at night and during the day to try and have enough to give baths. When the State Agent (SA) ask if the staff would have known about the extra linens in storage the DON revealed the staff would have notified her or the ADON and they would have notified laundry. The DON admitted that the washcloth and towel situation had gotten worse since they decided to take the wet wipes away because a resident had been flushing the wipes down the toilet and it stopped up the town's sewer system. An observation on 7/31/23 at 11:20 AM, revealed that Resident #21's room had a strong smell of urine in the room. An observation and interview on 08/01/23 at 9:00 AM, revealed that Resident #21's room had a strong smell of urine. The resident stated that he gives himself a bath when they aren't out of towels and wash clothes, and they run out quick. Record review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Record review of Resident #28's MDS with an ARD of 4/25/23 revealed under Section C a BIMS score of 13, which indicated the resident is cognitively intact, Record review of Resident #41's MDS with an ARD of 5/22/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review the facility failed to provide sufficient staff to provide the care needed to the individual residents for two (2) of four (4) days of survey. Findings Include: Review of the typed statement on facility letterhead dated August 2, 2023, and signed by the Administrator revealed, . (Proper Name of Facility) does not have a policy on staffing. Facility Staffing is based off of the acuity of the residents as described in the Facility Assessment. Review of the typed statement on facility letterhead revealed the facility does not have a policy on answering of call lights and was signed by the Administrator. Resident #46 An observation and interview on 07/31/23 at 11:05 AM with Resident #46 revealed a strong urine odor in the room. The resident revealed he needs someone to come empty his urinal, but he cannot reach his call light. This observation revealed the resident's call light was laying in the floor behind his bed and his urinal was full of urine. He stated they never come when you need them. An observation and interview on 7/31/23 at 11:30 AM revealed Resident #46's urinal was still full of urine and his call light was within reach. The resident revealed the staff came in and turned his call light off but did not empty the urinal. Record review of Resident #46's admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction and Need for Assistance with Personal Care. Record review of Resident #46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact and in Section G that the resident needed extensive assistance with ADL's. An interview on 7/31/23 at 11:15 AM, with Certified Nurse Assistant (CNA) #1 revealed they are always short staffed, and three (3) CNAs called in today. She stated, she had been asking for help all morning and no one would come help, but as soon as the State Agency walked in everyone came out of their offices and started helping. She revealed that Resident #36 had been on his call light ever since she got here at AM, because he wanted to get up and 11 PM-7 AM shift is supposed to get him up, but they did not probably because they were shorthanded. She stated that she explained to the resident that she had to pass breakfast trays and had some resident's she needed to get up for therapy and he understood. She revealed that the Director of Nurses (DON) walked past Resident #36's room with the call light on and told me that resident needed me, and I told her I knew that but had not had a chance to get to him and she kept on walking. She stated they have 3 CNAs on duty with 58 residents in the building. She stated that she has 20 residents assigned to her, ten (10) must be gotten up for therapy and about 20-25 are supposed to get baths today. She stated she has several that must be turned and have incontinent care and it is hard to do those rounds every two (2) hours since she is alone. She revealed she is asked to work overtime a lot and usually volunteers to do so and works six (6) days a week normally. She stated that the facility just does not have enough help. An interview on 8/1/23 at 3:30 PM, with the Activities Director confirmed she is working the South Hall this afternoon because they only have one aid. She stated that staffing is an issue because there are a lot of call ins. She revealed that some things do not get done such as showers because we do not have enough staff. Resident #36 An observation and interview on 07/31/23 at 12:43 PM with Resident #36 revealed that this facility needs staff bad. Resident #36 stated they do not have enough people to take care of us. He revealed he is supposed to get up every morning around 5:00 AM but he rarely does and its usually because they do not have enough staff. He revealed it was 10 AM before a staff member was able to get him up this morning. He stated, I cannot get myself out of bed and don't have use of my left arm. An interview on 8/1/23 at 1:10 PM with CNA #1 confirmed that Resident #36 likes to have his baths early of the morning and likes to stay up after that, so he is scheduled for his bath on the 11 PM-7 AM shift. She revealed about 2-3 times a week that does not happen, and they must do his bath and get him up on the 7 AM-3 PM shift. An interview on 8/3/23 at 8:20 AM with the Director of Nurses (DON) confirmed that Resident #36 has made the request to be got up and bath given on the 11 PM-7 AM shift. She confirmed there are times that he is not able to be gotten up on the 11 PM-7 AM shift and it is usually due to staffing. Record review of Resident #36's MDS with an ARD of 5/26/23 revealed under Section C a BIMS score of 15, which indicated that the resident was cognitively intact and under Section G that the resident needed extensive assistance for transferring. Resident Council Meeting On 8/1/23 at 2:00 PM, during the Resident Council Meeting, Resident's #9, Resident #14, Resident #21, and Resident #41 revealed that the facility is short staffed a lot. Resident #41 stated that you hear the aides and nurses talking about being short staffed all the time. Resident #14 revealed it takes the staff a long time to answer the call light, that she has had to wait an hour before for them to answer the call lights. Resident #28 revealed he has had to wait 2 hours before for the staff to answer the call light. Record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/4/23 revealed under Section C a Brief Interview for Mental Status score of 13, which indicated the resident is cognitively intact. Record review of Resident #14' MDS with and ARD of 7/11/23 revealed under Section C a BIMS score of 14, which indicated that the resident is cognitively intact. Record review of Resident #21's MDS with an ARD of 6/14/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #28's MDS with an ARD of 4/25/23 revealed under Section C a BIMS score of 13, which indicated the resident is cognitively intact. Record review of Resident #41's MDS with an ARD of 5/22/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Resident #49 On 07/31/23 at 11:15 AM, in an interview with Resident # 49 , revealed she had not been getting her bath as scheduled on Monday, Wednesday, and Friday. She revealed her last bed bath was given last Monday. She revealed she was told last Wednesday and Thursday that there was not enough staff to do it, and on Friday she was told the facility ran out of towels and wash cloths. The resident revealed, at one point, therapy was helping complete her baths due to the shortage of staff. She revealed call ins were the main concern with staffing. On 8/01/23 at 2:25 PM, an interview with the DON , confirmed that Resident # 49's bathing task revealed missing documentation supporting that resident was not given a bath. She stated, I really couldn't say whether she had a bath those days or not. She revealed that the aides sometimes leave after their shift without documenting. She stated, It goes back to the staffing issue; When we have two or three aides on the floor, it's hard to find the time to document. She confirmed that if it's not documented, then it's no way to prove the bath was done. Record review of the MDS with an ARD of 04/28/23 revealed under section C a BIMS score of 14, which indicated Resident #49 was cognitively intact. Resident #52 An observation on 7/31/23 at 11:10 AM of Resident #52's room revealed his room smelled strong of urine. An interview and observation on 08/01/23 at 9:56 AM with Resident #52 revealed that he has prosthetic legs and when he is in bed without his legs on and uses his urinal, he calls for them to come empty it and the resident revealed that the staff sometimes takes 2-3 hours to come, or they will come and turn his light off and never empty the urinal. An interview on 8/1/23 at 1:53 PM, with Resident #52 revealed he must use his call light to have staff come clean him up when he uses the bathroom, and it usually takes them a long time to get to him especially on the night shift. He revealed if they don't show up in time then he tries to clean himself. He stated that the staff now know they would be better off to come clean me themselves because I make a mess. He stated, I just wish they would answer my call light quicker instead of going to take care of someone else while I've been waiting 30-45 minutes. Record review of Resident #52's MDS with an ARD of 5/23/23 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact and under Section G that the resident needed extensive assistance for toileting, personal hygiene, and bathing. An interview and review of the staffing grid for the last 14 days with the DON and the Assistant Director of Nurses (ADON) on 8/2/23 at 2:15 PM, revealed staffing is an issue. They both admitted that they have plenty of staff but have a lot of trouble with call ins. The ADON revealed they had 5 CNA's and 1 LPN call in on Monday 7/31/23, 5 CNAs called in on Tuesday, and 2 CNAs called in this morning. The DON stated they just do not know what to do to make people come to work. When reviewing the staffing grid for the past 14 days, it was documented that they had 4 CNAs on duty 7 AM-3 PM on 7/31/23. When the State Agent ask about the documented 4 CNA's because there were only 3 on duty when we entered the building at 11:00 AM on 7/31/23 the ADON admitted that 2 CNAs had called in for the 7 AM-3 PM shift Monday and CNA #7 went to work the floor after their morning meeting. When the SA asked what time the morning meeting was over, she revealed it ended around 10:30 AM, When the SA ask what time the majority of baths were completed, both the DON and ADON admitted they would be done between 7 AM-11 AM. The ADON stated that she thought 2 CNAs were coming in late and they usually are here by 9 AM, so she assumed they had already come in and no one told her any different Review of the facilities list of CNA'S revealed the facility had 24 CNAs with five (5) being full time and 19 being As Needed (PRN). The ADON stated that she admits there are things that don't get done due to not having enough staff such as baths. The DON agreed with the ADON and stated, we just try to do what's needed the most with the staff we have. An interview and review of the Facility Assessment with the Administrator on 8/2/23 at 11:15 AM, revealed on page 8 under Staffing Plan 3.2. Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time and in the staff, graph revealed that the facility needed 8 LPN's, 14-15 CNAs, and 3 other nursing personnel. During this interview the Administrator revealed that the graph information under Staffing Plan in the Facility Assessment that showed the facility needed eight (8) LPN's and 14-15 CNA's and 3 other nursing personnel was for a 24-hour period. Record review of the Staffing Grid for the past 14 days with the DON and the ADON revealed there were two days where the facility failed to provide sufficient staff to meet the needs of the residents. An interview on 8/2/23 at 1:45 PM, with the Administrator confirmed that the facility has issues with staffing especially CNA's. He revealed he is not sure how to make these people come to work but agreed it is not the resident's fault and they were needed for resident care. An interview with the DON on 8/01/23 at 2:50 PM, confirmed that the facility had been struggling with staffing issues for a while. She stated, Especially the CNA's. She revealed yesterday (7/31/23) they had 3 aides for the entire building with a census of 58, making each aide responsible for 19 or 20 residents. She revealed that they had 5 aides on the schedule and one aide called in and one aide called and said she would be late, but never showed. She revealed the nurses from the office usually come out to help when the aides are short but confirmed that the office staff failed to come out and help yesterday with only three aides. She stated, We should have been helping.

Based on observations, resident and staff interviews, and facility policy review the facility failed to maintain an effective pest control program to prevent flying insects for four (4) of four (4) survey days. Findings Included: Record review of the facility policy titled Pest Control with an effective date of 11/30/2014 revealed under, Policy: The facility will maintain a pest control program, which includes inspection, reporting, and prevention. Also revealed under, Procedure: . 3. Treatment will be rendered as required to control insects and vermin. 4. Any unusual occurrence or sighting of insects should be reported immediately to the Supervisor (See policy- Maintenance Repair Request Form). Proper action will be taken . An observation on 7/31/23 at 11:15 AM, of the main dining room during the lunch meal revealed seven residents eating their meal with five to six flies flying over and landing on the tables and trays. Residents observed swatting at flies with their hands while trying to eat. An observation on 7/31/23 at 11:20 AM, revealed a fly over the uncovered cornbread on the steam table. Dietary staff was alerted, and they covered the cornbread. An observation on 07/31/23 at 12:16 PM, revealed Resident #47 lying in bed and was non-verbal. The Survey Agent (SA) observed two flies hovering over the resident and landing on the resident and the bedside table in the room. An observation on 8/01/23 11:01 AM, down the main entry corridor, revealed two to three flies swarming around the front door entry area. During an observation of medication pass on South Hall on 8/02/23 at 8:02 AM, Survey Agent (SA) observed several flies and gnats flying around the medication cart. An observation on 8/2/23 at 11:00 AM, revealed five (5) flies in the kitchen around the food prep table. An observation of Resident # 50 on 8/02/23 at 2:10 PM, revealed the resident lying in bed with eyes closed and two flies hovering and landing on the resident's side rail and bed linen. An interview with Resident # 14 on 8/02/23 3:45 PM, revealed they have issues in the dining room with numerous flies while they're trying to eat. She revealed she had noticed four to five flies flying around while the residents were trying to eat. An interview with the Administrator (ADM) on 8/3/23 at 8:40 AM, confirmed that the facility had an issue with flies. He revealed that the facility used Eco-Lab for pest control. He revealed that Eco Lab came out to the facility about 2 weeks ago but did not address the flies because at that time, flies were not an issue. He revealed he had one insect light in the kitchen to address the flies. An observation and interview, on 08/03/23 at 09:04 AM, with the Dietary Manager (DM) confirmed flies in the kitchen. She stated that they come in every time someone opens the back door. The DM confirmed six (6) flies on a pipe above the food prep table and others flies around the sink and window. She stated that flies are nasty and carry disease. An interview on 08/03/23 at 10:00 AM, with the ADM confirmed that he was aware of the fly problem. He stated the kitchen has one insect light and he had thought about a fan for the back door but had not gotten one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for dependent residents as evidenced by long facial and neck hair and long fingernails for two (2) of 24 residents reviewed. Resident #1 and Resident #1. Findings Include: Review of the facility policy titled, Care of Nails with a revision date of 9/1/2017, revealed under, Procedure: trim fingernails and clean nails. Resident #11 An observation on 01/04/22 at 01:12 PM, revealed Resident # 11's hair was disheveled with long hair on the face and neck. Fingernails were long with a brown substance under one nail. An interview on 01/04/22 at 1:15 PM with Resident #11 confirmed that he wants a shave and his nails trimmed. Another observation on 01/05/22 at 1:45 PM, of Resident #11 revealed long hair on the resident's face and neck, hair disheveled, nails were long with a brown substance under one nail. An interview on 01/05/22 at 1:50 PM, revealed that Resident # 11 wanted to be shaved and have his nails trimmed and that they have not done it yet. Record review of Resident # 11's admission Record revealed he was admitted to the facility 10/6/21, with diagnoses of the following: Cerebral infarction, Muscle Weakness, History of Falling, and Unsteadiness on Feet. Record review of Resident # 11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/21, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had full cognitive ability. Resident #1 An observation on 01/04/22 at 11:06 AM, revealed that Resident # 1 had long nails and hair on his face and neck. An observation again on 01/05/22 at 2:12 PM, revealed that Resident # 1 had long hair on his neck and face and long nails. Record review of the admission Record revealed Resident # 1 was admitted to the facility on [DATE] with a diagnosis of NEED FOR ASSISTANCE WITH PERSONAL CARE. Record review of Resident #1's MDS with an ARD dated 12/17/21, revealed a BIMS score of 3, indicating the resident had severe cognitive impairment. An interview on 01/05/22 at 1:55 PM, with Certified Nursing Assistant (CNA) # 3 revealed shaving and nail care is the responsibility of the CNAs. CNA # 3 revealed that the residents are shaved when we see it is needed or the resident asks to be shaved and nail care is given everyday if needed and nails are trimmed weekly; unless they are a diabetic then the nurse does it. An interview on 01/05/22 at 2: 05 PM, with Registered Nurse (RN) # 1 revealed that shaving and nail care are the responsibility of the CNA, and they have a schedule. RN # 1 revealed that nail care is done by the CNA unless they are diabetic. RN # 1 confirmed that Resident #1 and Resident #11 needed to be shaved and will be shaved today and stated, long hair on your neck is uncomfortable. An interview on 01/05/22 at 3:45 PM, with the Director of Nurses (DON) revealed the facility has an Activities of Daily Living (ADL) policy and that the CNAs are assigned the task of ADLs. She revealed that the CNAs know that a part of bathing is cleaning their nails and shaving. She revealed that they know to shave the residents if they need shaving and need their nails cleaned or trimmed then they know to do it unless they are a diabetic.

Based on observations, staff interview, record review and facility policy review the facility failed to properly label, date and store oxygen nebulizer mask and oxygen (O2) tubing to prevent contamination for two (2) of 12 residents receiving oxygen therapy. Resident #35 and Resident #99. Findings include: Review of the facility policy titled, Oxygen Therapy, with a revision date of 8/28/2017 revealed under procedure, to label tubing and humidifier with date and time. The procedure for nebulizer with a revision date of 3/20/2018, revealed place the entire unit in a bag to be maintained in the resident's room. Resident #35: An observation, on 01/04/22 at 01:06 PM, revealed Resident #35's O2 tubing was not dated or labeled. His nebulizer mask was laying on his bed not bagged. Record review of the Clinical Physicians Orders for Resident #35 revealed an order with a start date of 7/7/21 for O2 (oxygen) @ (at) 2L (liters) via (by) NC (nasal cannula) as needed for SOB (shortness of breath). Record review of the Clinical Physician's Orders printed 1/5/22 revealed an active order dated 8/24/21 for Albuterol Sulfate Nebulization Solution 0.83 MG(milligrams)/3ML(milliters), 1 vial inhale orally via neb . Record review of Resident #35's Face Sheet revealed diagnoses that included, Chronic Obstructive Pulmonary Disease, End Stage Heart Disease, Anemia, and Dependence on Supplemental Oxygen. Resident #99: An observation and interview on 01/04/22 at 03:57 PM revealed Resident #99's oxygen tubing/cannula laying on the floor. The tubing was not dated and there was no bag for storage of the oxygen tubing in the room. Registered Nurse (RN) #1 confirmed the resident's oxygen tubing was laying in the floor. RN #1 confirmed that the tubing should be in a bag when not in use. RN #1 stated that it was an infection control issue because the tubing was contaminated and was a risk for infections. An interview, on 1/5/22 at 3:30 PM, with the Director of Nursing (DON) revealed she had seen oxygen tubing not bagged and laying on the floor yesterday. She stated that was an infection control issue. The DON confirmed that all oxygen tubing and nebulizers should be bagged, and oxygen tubing should be dated. Record review of Resident #99's Clinical Physicians Orders revealed an order with a start date of 12/14/21 for Oxygen 2 L/min (minute) per NC as needed PRN. Record review of Resident #99's Face Sheet revealed diagnoses of Pneumonia and Dependence on Supplemental Oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interview and facility policy review, the facility failed to ensure that the call system was working for Resident # 8 for one (1) of 60 resident call lights in the facility. Findings include: Review of the facility policy titled, Call Bell System-Inoperable, dated 11/30/14, stated, Resident must have, at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regularly scheduled basis by Maintenance. If the call bell system is inoperable, in one room, one hall, or the entire unit, the following procedure must be followed: Maintenance, the Executive Director, and the Director of Clinical Services must be notified immediately if any call bell or the system is inoperable. Hand bells or tap type bells will be placed within reach of any resident affected by an inoperable call bell. On 01/04/22 at 12:30 PM an observation and interview was conducted with Resident # 8 in her room. She was laying in the bed and stated that she had moved into this private room last week and that she liked it but that her call light wasn't working. She stated that Maintenance had worked on it Friday and stated, I think he is having to order a part, I'm not sure. The State Agency (SA) pushed the resident's call light and did not hear it buzzing at the nurse's desk, nor was the call light over the door lighting up. The SA confirmed with Resident #8 through observation and interview that she did not have a device to utilize in order to call for assistance. The SA walked to the only nurse's desk in the building and did not see or hear the light blinking to identify that the call light had been pushed. An interview with Registered Nurse (RN) #2 on 01/04/22 at 12:35 PM stated if the call light is not buzzing or if it doesn't light up over the door then we would not know which room is needing assistance and we would have to check every resident in their rooms to see if anyone needs anything. RN#2 confirmed through interview and observation that she did not hear or see a call light buzzing or blinking at a resident's room. The SA told RN #2 that the call light for Resident #8 was pushed right now and RN#2 verified that she could not tell which room it was that needed assistance because the light was not working and the panel at the nurse's desk was not buzzing. An interview with the Maintenance Director on 01/04/22 at 12:45 PM stated that the resident had moved into that private room on Friday (12/31/21) and that her call light wasn't working and that he thought he had fixed it. The Maintenance Director went into the resident's room and confirmed that it was not currently working and that Resident #8 did not have a device to call for assistance if her call light was not working. The Maintenance Director immediately began to work on the call light to address the issue of why it was not working. He confirmed through interview that he did not follow back up to ensure that the call light was working after the repair on 12/31/21 and stated, I thought I had fixed it. An interview on 01/04/22 at 12:50 PM with the Resident #8 stated that she had pushed her call light the other night (01/03/22) around 8 o'clock or so and that no one ever came to her room so she got up and got in her wheelchair and went down to the nurse's desk to ask for some chap stick and that there was a girl that she told that her light wasn't working but she could not remember who she was. On 01/04/22 at 12:45 PM an observation of the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) making room to room rounds checking all the call lights in every resident's room and bathroom was observed. An interview at that time with the DON confirmed that all the call lights in the building were working properly except for Resident #8's room. The DON immediately placed a bell at the bedside of Resident #8's bed and instructed her how to utilize the bell while the Maintenance Director was working on the call light. The DON confirmed that she was not made aware that the resident's call light was not working last week. An interview with the Administrator on 01/04/22 at 1:00 PM confirmed that he was not aware that the resident's call light was not working last week and was not made aware that it was not working properly until now. Interview with the DON on 01/05/22 at 2:00 PM stated that she had investigated into who the resident had told that her call light wasn't working and it was Certified Nursing Assistant (CNA) #2 on the night of 01/03/22 around 9 PM. She said that CNA #2 confirmed to her on a phone interview on 01/04/22 that she failed to report to anyone that the call light for Resident #8 was not working, and she failed to provide an alternate way to call for assistance when the resident needed help. Record review of Resident # 8 medical record revealed that she was admitted to the facility on [DATE] with diagnosis of Cognitive Communication Deficit, Difficulty in Walking and Lack of Coordination. The most recent Brief Interview for Mental Status (BIMS) completed on 10/13/21 revealed a BIMS score of 15, indicating the resident had full cognitive ability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy review, the facility failed to maintain an environment that was clean and free of odors for two (2) of three (3) days of survey. Findings include: Review of the facility policy titled, Nursing Home Cleaning Routine, stated, Cleaning Responsibilities: .7:00-7:45 Morning walk through of your hall, sweep debris from the rooms, mop up spills in rooms, shower rooms. 1:20-1:50 Clean shower rooms, 1:50-2:00 Perform a final walk through of your area. Sweep up any debris, mop up any spills. Facility policy titled, Nursing Home Floor Care Routine For: Floor Tech, stated, The floortech is responsible for floor care throughout the building. Dust mop and mop all halls plus the lobby area. Follow buffing, clean the dining room, follow buffing and perform final walk through, sweep up any debris, mop up any spills. An observation was made on 01/04/22 upon entrance to the building at 10:00 AM the State Agency (SA) smelled a strong odor of urine upon entrance inside the building and also on the South hallway around rooms 101-103. The SA smelled odors of urine on 01/05/22 upon entrance to the building at 8:15 AM in the front lobby and around room [ROOM NUMBER] at 3:00 PM on the North Hallway and on the South Hallway around rooms 101-103 at 3:10 PM and again at 4:05 PM on the South Hallway on 01/05/22. An observation was made on 01/04/22 at 11:30 AM of the floors on the North and South hallways of dirt and debris, medicine cups, plastic wrapping from cracker packs, leaves and visible pieces of dirt and mud all throughout the facility on both hallways. An observation on 01/04/22 from 11:30 AM through 1:00 PM, on the North and South hallways of visible spills on the floors and dried liquid spills that have dirt dried on the top of the spills are observed in rooms 101, 112, 113, 117 and 133. An observation on 01/05/22 at 3:35 PM, revealed an area about the size of a small plate of a dark brown soiled area on the floor outside of room [ROOM NUMBER]. The Housekeeping Supervisor later confirmed at 4:20 PM on 01/05/22, that it was from the wall hand sanitizer leaking onto the floor and it had dried with accumulated dirt and debris on the area and that it had not been cleaned up. An interview on 01/05/22 at 4:00 PM, with the Housekeeping Supervisor and the District Housekeeping Manager stated that the floor cleaner had broken down about a year ago and the facility was responsible for replacing the equipment and they had not gotten a replacement until about two weeks ago. The District Housekeeping Manager stated that the floor cleaner will deodorize, clean, mop and buff the floors but that he has not had a chance to in-service the staff to use it yet so that is why the floors look so bad. The Housekeeping Supervisor stated that all they have to clean the floors with at this time is a mop and a broom and that they have not been able to buff the floors in over a year. An observation on 01/05/22 from 4:00 PM until 4:25 PM, with the District Housekeeping Manager and the Housekeeping Supervisor along with the SA made walking rounds of the building and they confirmed that the areas around rooms 101-103 had strong urine odors in the hallways and also outside of room [ROOM NUMBER]. The Housekeeping Supervisor confirmed that they had deodorizer sprayers mounted in the hallways but when she checked the wall mounted device, the deodorizer can was empty in the hallway outside of rooms 101-103. During this tour of the facility an observation of the two shower rooms on the South Hallway were observed to have dark black growth and an orange tan color build up on the shower floors and along the walls of the tile in the showers and on the rubber mat on the shower room floors in two (2) of two shower rooms on the South hallway. An interview with the Housekeeping Supervisor and the District Housekeeping Manager at the time of the observation confirmed that they have not cleaned or scrubbed the shower floors and walls for several weeks and she stated, We just need to throw those shower mats away. We come in the shower rooms and mop each day but we haven't had time to scrub the mold in the shower room floors and the walls for some time. An Interview with Certified Nursing Assistant (CNA) #3 on 01/05/22 at 4:30 PM, confirmed that both of the shower rooms on the South hall are used for resident care. each day and that is the only shower rooms in the building. An interview with the Housekeeping Supervisor on 01/05/22 at 4:45 PM, stated, We haven't had a chance to watch the video to operate the floor cleaner yet. The District Housekeeping Manager stated, I'm going to educate the staff on how to use it before I leave today. The District Housekeeping Manager and the Housekeeping Supervisor confirmed that they do not have a floor tech employed right now and stated, We are thinking about hiring someone to work about 3-4 hours in the evening to do that job. The Housekeeping Supervisor confirmed that it is herself and one other employee to clean the building daily and that they have one employee that is in the laundry department. An interview with the DON on 01/06/22 at 8:45 AM, stated that she had verbally talked with the District Housekeeping Manager several times over the last two weeks since the floor machine had been delivered to get them to train and in-service the housekeepers on how to use the new floor machine Because we needed our floors cleaned badly and he told me several times that he would do it and hasn't until you pointed it out to them yesterday about how bad the floors looked, so now they are running it today for the first time.

Based on observations, staff interviews, record review and facility policy review, the facility failed to provide a safe and clean environment for preparation and storage of food and ice for two (2) of three (3) kitchen tours. Findings include: Review of the facility policy titled, Equipment, revised 9/2017, revealed all food service equipment will be clean, sanitary, and in proper working order. All food contact equipment will be cleaned and sanitized after each use. All non-food contact equipment will be clean and free of debris. An observation of the kitchen on 01/4/22 at 10:05 AM, during the initial tour, revealed two (2) pitchers of tea and eight (8) glasses of milk in the refrigerator not dated. There were three (3) baking sheets, (2) muffin pans and (2) 9x13 pans covered with thick, rough black build up and (2) 10 inch skillets and one (1) 12 inch skillet with the outside coated with brownish black build up. The outside of the walk-in refrigerator door and handle was covered with brown and white splashes of debris and build up. The inside of the door was covered with a thin brownish film and the walls were splattered with dry brownish and white colored areas that had run down the walls. The ice machine had black buildup around the seal of the lid. On 01/05/22 at 11:05 AM, an observation and interview with the Dietary Manager (DM) and the District Dietary Manager (DDM) confirmed that the ice machine had buildup around the seal of the lid and noted an approximately 0.5 centimeter (cm) black flake in the center of the ice. The DDM confirmed the black flake in the ice and stated that it probably fell off the ice machine seal and stated that the ice was contaminated. An interview on 01/5/22 at 10:50 AM, with the DM stated that she saw a lot of dirtiness in the kitchen. An interview on 01/5/22 at 10:55 AM, with the DDM revealed he stated that the kitchen needed a good cleaning. An interview on 01/6/22 at 9:05 AM, with the Administrator (ADM) revealed that unlabeled food could cause food borne illness and the ice machine needed cleaning. He stated that he did not like that, it was nasty. The ADM stated that pans with carbon build up can harbor germs that the dishwasher might not handle, and it could be a fire hazard. He stated that they have new pans in storage, and they should have replaced them. An interview on 01/6/22 at 12:30 PM, with the DM confirmed there was not a cleaning schedule for the kitchen staff to follow. An interview on 01/6/22 at 12:35 PM, with Dietary Staff #1 confirmed there was no cleaning schedule posted for cleaning the kitchen and stated that they just did what they could. An interview with the Maintenance Director revealed that the ice machine is cleaned every month and that he thinks it was cleaned in December. Record review of the Work History report revealed the due date for cleaning ice machines was 10/31/2021. The task completion column revealed no action recorded. For due date 11/30/2021, the task completed column revealed marked done on time on 12/8/2021. For due date 12/31/2021, the task completed column was marked done on time on 12/8/2021.

**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 prevent the possible spread of infection as evidenced by failure to conduct hand hygiene during meal tray distribution and properly clean and disinfect a multiple use blood pressure cuff and an oxygen saturation monitor in between uses. This occurred on two (2) of (2) hallways. Findings Include: Review of the facility's policy titled, Infection Control, with a revision date of October 2018 revealed under the policy statement, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility's policy titled, Hand Hygiene, with a revision date of 02/05/2021, revealed that the purpose is to reduce the spread of germs in the healthcare setting. This policy revealed under process that hand hygiene should be performed before and after patient care, after contact with inanimate objects (including medical equipment) in the immediate patient vicinity, antiseptic hand wash or rub (i.e., alcohol-based sanitizer) may be used at any time other than those stated above. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment with a revision date of October 2018 revealed resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. This policy revealed under policy interpretation and implementation, non-critical items are those that come in contact with intact skin but not mucous membranes and non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. Intermediate and low-level disinfectants for non-critical items include ethyl or isopropyl alcohol. An observation on 01/04/22 at 12:00 PM, of lunch tray distribution on the North hallway starting in room [ROOM NUMBER] revealed Certified Nurse Assistant (CNA) #3 did not use hand sanitizer before or after taking the lunch tray to Resident # 41. CNA # 3 assisted CNA # 4 with pulling Resident # 41 up in the bed and repositioning the resident to eat the meal. The State Agency (SA) observed that neither CNA # 3 or CNA # 4 performed hand hygiene before or after assisting Resident #41. CNA #3 then took a lunch tray to Resident #11 and did not perform hand hygiene after entering the room and setting up the food tray and exiting the room. CNA #4 did not perform hand hygiene when she took a meal tray to Resident #45, #47, #32, and #6. An observation on 01/04/22 at 11:30 AM, revealed during the lunch tray service CNA #1 delivered meal trays to residents in room [ROOM NUMBER]B, 103A, 107B, and 114B and did not use hand hygiene upon entrance, exit or prior to entering the next room for all four rooms she entered. CNA #3 delivered meal trays to residents in room [ROOM NUMBER]B, 106A, and 108B, and did not use hand hygiene upon entrance, exit or prior to entering the next room for all three rooms she entered. An interview on 01/04/22 at 12:10 PM, with CNA #3 and CNA #4 confirmed they did not perform hand hygiene in between residents while passing meal trays and after assisting a resident being pulled up in the bed. CNA #3 confirmed she should have used hand sanitizer before entering and exiting the resident's rooms and that if she did not, it could spread germs from one resident to another and make them sick. CNA #4 revealed that everyone does things differently and she does not touch anything in the room. CNA #4 confirmed she had assisted a resident being pulled up in the bed and moved some resident's bedside tables to set up their meal trays and did not perform hand hygiene. CNA # 4 revealed that she performs hand hygiene when she comes onto the hall and when she exits the hall. An interview, on 1/5/22 at 8:25 AM, with CNA #1, confirmed that she did not wash her hands or use hand sanitizer between entering resident rooms when passing out lunch trays. She stated that this could spread germs and make a person sick. She stated that she had in-service training on hand hygiene. An observation on 01/04/22 at 3:53 PM, with CNA #5 revealed she obtained a blood pressure and an oxygen saturation (Sa02) on Resident #18 and then obtained Resident #15's blood pressure and Sa02 with the same equipment. CNA #5 did not clean the blood pressure cuff or Sa02 monitor in between the residents. An interview, on 01/04/22 at 3:59 PM, with CNA #5, confirmed she did not clean the vital sign equipment between residents because she thought she should not use bleach wipes to clean them. An interview on 01/05/22 at 4:15 PM, with the Infection Preventionist (IP) revealed it is the policy of the facility that staff should perform hand hygiene in between residents when handing out meal trays. The IP revealed that all staff had been in-serviced on the need to perform hand hygiene in between resident's when handing out meal trays. An interview, on 01/5/22 at 5:45 PM, with the Director of Nurses (DON) revealed that the staff needs to clean multiple use vital sign equipment with disinfectant wipes. Record review of the facility in-service with the topic of, Infection Control conducted on 4/1/21 included under summary of training session: infection control and prevention, hand hygiene revealed that CNA #3, CNA #4, and CNA #5 attended this in-service. Record review of the facility in-service titled, Handwashing conducted on 12/2/21, included under summary of training sessions: Handwashing is the # 1 prevention of spreading illness to others, when to wash and for how long. The sign in sheet confirmed the in-service was attended by CNA #1, CNA #3, CNA #4, and CNA #5.