**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. The facility census was 28. 1. Review of the facility's policy titled, Deep Cleaning a Resident Room, undated, showed staff were directed to do the following: -Deep cleaning is the segment of housekeeping that ensures total cleanliness of the resident room. The deep cleaning guarantees that all areas of the resident room and bathroom are cleaned and disinfected. Deep cleaning includes polishing, scrubbing, scrapping, dusting, and disinfecting everything in the resident room; -Spot wipe all walls using approved disinfectant; -Clean all corners, edges, and baseboards. Be sure to remove any buildup around closets, behind beds, furniture, and door jams. Use a scrapper to dig dirt out of corners. Dust mop and wet mop entire room. Review of the facility's policy titled, Housekeeping Department, undated, showed staff were directed to do the following: -The resident room cleaning procedure should be used for all resident rooms to maintain cleanliness and to promote infection control; -Sanitize the inside of the toilet and urinal using the bowl mop saturated with bowl cleaning solution; -Notify your supervisor of any maintenance work. The facility did not provide a policy for ensuring the resident's room were in good repair. Review of the facility's Maintenance Log, showed staff last documented needed repairs on 01/02/2023. 2. Observation on 06/12/23 at 06:13 A.M. showed room [ROOM NUMBER] had a black substance between the floor tiles and a buildup of debris on the baseboards. The bathroom floor had brown stains around the base of the toilet, and tiles separated from the floor. Further observation showed the walls with black marks, chipped paint, gouges. Observation on 06/14/23 at 02:09 P.M., showed the area remained unchanged. 3. Observation on 06/12/23 at 06:20 A.M. showed room [ROOM NUMBER] had a buildup of debris on the floor by the threshold, base boards, and under the sink. The bathroom floor had brown stains around the base of the toilet, and tiles separated from the floor. Further observation showed the walls with black marks, gouges, and several nail holes. Observation on 06/14/23 at 01:54 P.M., showed the area remained unchanged. 4. Observation on 06/12/23 at 06:44 A.M. showed room [ROOM NUMBER] had debris on the floor under the bed, black marks on the bathroom door and wall, black marks on the floor in front of the closet and dresser. Further observation missing trim around the sink and closet. Observation on 06/13/23 at 04:11 P.M., showed the area remained unchanged. 5. Observation on 06/12/23 at 07:31 A.M. showed the wall in room [ROOM NUMBER] had three dime sized holes and five nickel sized anchor support holes. Observation on 06/13/23 at 09:00 A.M., showed the area remained unchanged. 6. Observation on 06/12/23 at 07:44 A.M. showed the Tea Room had two green chairs with large brown stains on the armrests and seat cushions. Further observation showed a wooden framed chair with a large stain on the fabric covered seat. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 7. Observation on 06/12/23 at 10:02 A.M. showed room [ROOM NUMBER] with no base board by the closet and a large patch of canvas-like material on the wall under the window. The materials edges had peeled back and hung from the wall. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 8. Observation on 06/12/23 at 10:56 A.M. showed room [ROOM NUMBER] had a metal door frame with chipped paint and rust build up. The walls had black scuff marks, and the base board peeled away from the wall behind the door. Further observation showed the toilet bowl had a built up black substance. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 9. Observation on 06/12/23 at 11:01 A.M., showed room [ROOM NUMBER] had exposed concrete floor where tile had been removed. Further observation showed the wall beneath the window had a large patch made of canvas-like material on the wall which had started to peel. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 10. Observation from 06/13/23 at 01:46 P.M. showed room [ROOM NUMBER] had a buildup of debris at the threshold and baseboards, and black wheelchair tire prints on the floor. Further observation showed the walls had black marks and gouges, the toilet had brown stains and no sealant around the base, and a ceiling vent cover had started to separate from the ceiling. Additional observation showed an oxygen concentrator with brown steaks down the front of it. Observation on 06/14/23 at 02:03 P.M., showed the area remained unchanged. 11. Observation on 06/13/23 at 03:46 P.M., showed room [ROOM NUMBER] had gouges in the wall and missing trim in the bathroom. 12. Observation on 06/13/23 at 03:53 P.M., showed room [ROOM NUMBER] and room [ROOM NUMBER] shared a bathroom. The bathroom trim had missing paint and the toilet had rust around the base. 13. Observation on 06/13/23 at 03:59 P.M. showed room [ROOM NUMBER] had a black substance on the floor in front of the closet and dresser and paint missing from trim. 14. Observation on 06/13/23 at 04:04 P.M. showed room [ROOM NUMBER] had black marks on the walls. 15. Observation on 06/13/23 at 04:17 P.M. showed room [ROOM NUMBER] and room [ROOM NUMBER] shared a bathroom. The toilet had rust around the base. 16. Observation on 06/13/23 at 04:18 P.M., showed room [ROOM NUMBER] had debris and black marks on the floor, and loose trim. The walls had black marks and gouges, and the toilet had rust around the base. During an interview on 06/14/23 at 09:28 A.M., Certified Nurse Aide (CNA) D said he/she told the charge nurse if he/she saw something he/she needed maintenance to repair. The CNA said the facility did not have a full time maintenance person. The CNA said the facility had a maintenance book at the nurse's station. The CNA said the facility has not had a maintenance person in a long time. During an interview on 06/14/23 at 10:14 A.M., Licensed Practical Nurse (LPN) E said if something needed repaired staff should notify maintenance. The LPN said there was a maintenance log at the nurse's station. The LPN said he/she had noticed the rust and missing paint on door frames but had not reported it to maintenance. The LPN said staff told maintenance when repairs were needed. The LPN said he/she had not noticed the missing base boards, or the canvas material peeling off of the walls, but would expect staff to report those things to him/her and they had not During an interview on 06/14/23 at 10:50 A.M., the Maintenance staff member said he/she did the maintenance and paperwork at the facility. He/She said staff told him/her verbally what needed to be repaired and there was a maintenance book by the nurse's station. He/she checked the maintenance book every day, unless staff told him/her about something that needed repair. Staff reported the base boards coming off but he/she had not ordered the replacements. He/She said no one reported missing pieces of tile or canvas material peeling off of the walls to him/her. The maintenance staff member said he/she had not noticed the stained chairs in the Tea Room. During an interview on 06/14/23 at 1:29 P.M., Director of Nursing (DON) said staff should tell him/her or the administrator if something needed repaired. The DON said the facility still did not have a full time maintenance person. The DON said he/she had not seen the peeling canvas on walls, missing base boards, or damage on the walls in room. The DON said he/she had not noticed the stained chairs in the Tea Room. The DON said he/she would expect the staff to report these issues to the maintenance staff and the chairs be disposed of. The DON said maintenance does rounds of the rooms, but he/she is not sure how it is scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to revise care plans for five residents (Resident #6, #11, #12 #21, and #66) with interventions to prevent falls. The facility census was 30. 1. Review of the facility's, Care Plan Comprehensive Policy, dated March 2015, showed the policy directed staff as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -A well developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation). -Managing risk factors to the extent possible or indicating the limits of such interventions. -Evaluating treatment of measurable goals, timetables and outcomes of care. -Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: -At least quarterly. -When changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #6's Quarterly MDS (Minimum Data Set), a federal assessment tool, dated 3/14/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from one staff for transport, bed mobility, walking in room, dressing, toileting, and personal hygiene; -Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture), and seizure disorder; -Had two or more falls with injury since last assessment. Review of the resident's care plan, last reviewed 1/15/21, showed staff documented the resident was at risk for falls and are directed to: -Be aware of the resident's risk for falls and to provide supervision/physical assistance with Activities of Daily Living (ADLs); -Be aware the resident displayed impulsive behaviors and was unaware of his/her own physical limitations; -Keep resident within line of sight as much as possible when awake. -Review showed the care plan did not contain direction for staff in regards to the use of a helmet. Review of the resident's Physician Order Sheet (POS), dated 3/13/22, showed an order to wear a helmet while up in wheel chair and to check and remove it every two hours for redness, soreness. Review of the resident's Fall Assessment Tool, dated 3/13/22, showed staff assessed the resident as a high fall risk. Observation on 4/18/22 at 10:38 A.M. showed the resident sat in his/her wheelchair. He/She wore a safety helmet. Observation on 4/18/22 at 1:29 P.M. showed the resident wore a safety helmet. Observation on 4/19/22 at 1:43 P.M. showed the resident wore a safety helmet. During an interview on 4/19/22 at 8:22 A.M., Certified Nursing Assistant (CNA) G said the resident has worn a helmet since March of this year, because he/she fell out of his/her wheelchair. He/She said staff check it every two hours to make sure it does not cause problems. During an interview on 4/19/22 at 08:43 A.M., Registered Nurse (RN) B said staff removed the helmet every two hours to check for wear on the resident's head. 3. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe Cognitive Impairment; -Diagnosis of heart failure; -Required extensive assistance from two staff for bed mobility, transfers, dressing and toileting; -Required extensive assistance from one staff for locomotion on and off the unit and eating; -Had one fall without injury since last assessment. Review of the resident's Fall Risk Assessment Tool, dated 4/8/22, showed the staff assessed the resident as a high fall risk. Review of the nurse's notes, dated 1/26/22, showed staff documented the resident was found wrapped in blankets on the side of the bed on the floor. Review of the nurses notes, dated 3/23/22, showed staff documented the resident was found on the floor next to his/her bed. Review of the care plan, dated 4/14/22, showed it did not contain interventions for the resident's falls on 1/26/22 and 3/23/22. 4. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe Cognitive Impairment; -Diagnosis of Non-traumatic Brain Dysfunction; -Required extensive assistance from two staff for bed mobility, dressing, toileting, personal hygiene and transfers; -Required extensive assistance from one staff for locomotion on and off the unit; -Had one fall without injury since last assessment. Review of the resident's Fall Risk Assessment Tool, dated 11/10/21, showed the staff assessed the resident as a high fall risk. Review of the nurse's notes, dated 12/24/21, showed staff documented the resident was found on the floor by his/her bed. Review of the Care Plan, dated 2/17/22, showed it did not contain an intervention for the resident's fall on 12/24/21. 5. Review of Resident #21's quarterly MDS, dated [DATE], showed staff assessed resident as follows: -Severe Cognitive Impairment; -Diagnosis of Non-traumatic Brain Dysfunction; -Required extensive assistance from two staff for bed mobility, transfers and walking; -Required extensive assistance from one staff for locomotion on and off the unit, dressing, toileting, and personal hygiene. -Had one fall without injury since last assessment. Review of the resident's Fall Risk Assessment Tool, dated 2/24/22, showed the staff assessed the resident as a high fall risk. Review of the the resident's nurse's notes, dated 1/12/22, showed staff documented the resident slid out of his/her wheelchair. Review of the the resident's Care Plan, dated 2/24/22, showed it did not contain an intervention for the residents fall on 1/12/22. 6. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed resident as follows: - Severe Cognitive Impairment; - Diagnoses of Non-traumatic Brain Dysfunction, diabetes, arthritis, and Dementia; -Required extensive assistance from one staff for bed mobility, transfers, dressing, toileting and personal hygiene; -Had falls prior to admission. Review of the resident's Fall Risk Assessment Tool, dated 2/16/22, showed the staff assessed the resident as a high fall risk. Review of the resident's nurse's notes, dated 3/3/22, showed staff documented the resident slid out of his/her wheelchair. Review of the resident's Care Plan, dated 3/17/22, showed it did not contain an intervention for the resident's fall on 3/3/22. During an interview on 4/20/22 at 10:46 A.M., CNA G said if a resident is a fall risk and they look in the care plan for interventions. He/She said everything we need to know is in the resident's care plan. During an interview on 4/20/22 at 10:54 A.M., RN B said interventions for residents at high risk for falls are in the care plans. During an interview on 4/20/22 at 11:08 A.M., the Director of Nursing (DON) said falls are discussed in a weekly meeting where interventions are discussed by the staff and implemented. He/She said the facility is aware interventions are not being documented in care plans, because the facility is behind. He/She said the expectation is after every fall interventions are implemented or reevaluated for effectiveness. During an interview on 4/20/22 at 11:29 P.M., the Administrator said the care plans should have interventions for falls to direct staff on how to individually care for the residents. He/She said the facility is aware there is a care plan breakdown.

Based on interview and record review, facility staff failed to implement facility communicable disease policies and procedures to ensure all employees were screened appropriately and in a timely manner for tuberculosis (TB). The facility failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed and on file for five out of ten employee files reviewed. The facility census was 30. 1. Review of the facility's TB Screening for Long Term Care Employees Guidelines, undated, showed the following: -All employees will be screened for TB; -Once the decision has been made to employ an individual, the first step PPD will be administered by the nursing department, documented on the employee immunization record, and must be read prior to or no later than the employment start date; -All PPDs will be documented on the staff immunization record, including new hires; -Documented evidence of prior PPD will be maintained with facility employee immunization records; -The guidelines stated second step PPD given seven to twenty one days after the first if the first dose is negative along with an employee risk screening tool. 2. Review of the Business Office Manager's (BOM)'s employee file showed: -Hire date of 12/28/21; -First step PPD administered on 1/24/21 and read on 1/27/21; -The file did not contain documentation a second PPD dose was administered 7 to 21 days after the first dose. 3. Review of The Activity Director's (AD)'s employee file showed: -Hire date of 3/2/22; -First step PPD administered on 2/23/22; -The file did not contain documentation the first PPD was read, or results; -The file did not contain documentation a second PPD was administered. 4. Review of Laundry Aide C's employee file showed: -Hire date of 4/25/19; -First step PPD administered 4/22/19 and read on 4/25/19; -Second step PPD administered on 6/9/19 and read on 6/12/19, more than 7 to 21 days after the first step. 5. Review of [NAME] D's employee file showed; -Hire date of 4/18/19; -First step PPD administered 4/15/19 and read on 4/18/19; -Second step PPD administered on 6/9/19 and read on 6/12/19, more than 7 to 21 days after the first step. 6. Review of Nurse Aide (NA) E's employee file showed: -Hire date of 3/24/22; -First step PPD administered 3/22/22 and read on 3/25/22, one day after the hire date; -The file did not contain documentation a second PPD was administered. During an interview on 4/20/22 at 11:01 A.M., the Minimum Data Set (MDS) Coordinator said he/she was in charge of staff testing for TB, the facility policy was a two step upon hire and annually thereafter. The first step was to be read in 48-72 hours and the second step within two weeks. If the two week window was missed, he/she said you have to start over with the two step process. He/She said he/she did not think any tests had been missed. He/she said if TB tests are missed they must have got overlooked. During an interview on 4/20/22 at 11:08 A.M., the Director of Nursing (DON) said the MDS coordinator was responsible for staff TBs. He/She said the expectation was two step upon hire and then annually. He/She said all staff have their first step read before their first day. The facility should administer the second step within 14 days or two weeks from the first step and if it's not done in that time frame they do not start over, they just complete the second step. He/She said it was easy to forget the second step, but does not know why the TBs would not all be up to date. During an interview on 4/20/22 at 11:29 A.M., the Administrator said the facility was required to administer a two step TB test upon hire and then annually. There should be two weeks in between the first and second step, and if the second step was out of the required time frame then the process must start over. He/She said all results need to be read within 48-72 hours and done before staff are allowed to work on the floor. He/She said he/she was not sure why the TBs would be missed and thinks it's a documentation error.