**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interviews, the facility failed to honor a residents' request to have medications administered at a time that was desired for 1 of 4 residents (Resident #64) reviewed for choices. The findings included: Resident # 64 admitted to facility on 7/16/24 with diagnoses that included chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 was cognitively intact. On 09/10/24 at 12:51 PM an interview was conducted with Resident #64 and he indicated he was concerned with the time he was getting his medications. He indicated he would sometimes receive his morning medications close to lunch time. Resident #64 stated, I have talked numerous times to someone here about my medications and getting them on time, and nothing has changed A review of Resident#64's September electronic medication administration record revealed morning medication times scheduled for 7:00 AM, 8:00 AM, and 9:00 AM. On 09/11/24 at 9:46 AM an interview was conducted with Resident #64 and he stated he had not received his medications yet. An interview was conducted with Nurse #4 on 09/11/24 at 11:46 AM and she indicated, Resident #64 went to the medication cart around 10:30 am and requested his medications. The Nurse indicated she was working her way to Resident #64's room, however she was running behind on the medication pass. She stated, I came in to help out and got here about 8:00 or 8:30 AM, so I'm running behind. Nurse #4 acknowledged Resident # 64's morning medications were administered late. At 11:57 AM on 09/11/24 another Interview was conducted with Resident #64 and he stated, they were making me late for bible study, so I went to ask for my medicines. He indicated he just wanted to get his medications a certain time every day without having to ask for them. On 09/11/24 at 12:00 pm and interview was conducted with the Director of Nursing (DON) and she indicated she would change Resident #64's medication times so he would get them as he preferred. An interview was conducted on 09/12/24 at 10:54 AM with the Administrator and he stated, he expected the Resident to get his medications timely. He indicated it was the Residents' right to get his medications when he wanted them, and we should honor his request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews of the staff, physician, and nurse practitioner, the facility failed to notify the on-call nurse practitioner when a resident had a change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization. Findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses of diabetes, atrial fibrillation on anticoagulant, and end stage renal disease dependent on renal dialysis. On 6/12/24 at 7:30 pm Nurse #1 documented in the neurological assessment form Resident #95 had blood pressure (BP) 135/95, pulse (P) 91, respirations (R) 13, and temperature (T) 97.0. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. There was no headache, seizure, drainage from the ear or nose, or vomiting. On 9/11/24 at 2:49 pm Nurse #1 was interviewed. Nurse #1 stated she had not informed the on-call nurse practitioner (NP) on 6/12/24 at 11:30 pm when the resident had a change in her neurological status starting at 7:30 pm. Nurse #1 stated I do not think I included the pupils and lethargy information when I contacted the NP about the resident's sleepiness. The NP was informed the resident was too drowsy and sleepy to wake up for medication at 7:30 pm and 11:30 pm. Nurse #1 stated she had not thought to notify the NP about the sluggishness of the eyes, lethargy, diaphoresis, and that she had not moved her extremities. The NP directed Nurse #1 to hold the resident's evening medications. On 9/12/24 at 12:35 pm an interview was conducted with the day-shift Nurse Practitioner. The Nurse Practitioner stated she was not on call on 6/12/24. There was a high risk for bleeding when a resident was receiving anti-coagulant. The Nurse Practitioner stated she would want to be called at the time when there was a change in the resident's neurological status. The Nurse Practitioner stated the on-call service for after hours (after 5:00 pm and before 7:00 am) do not know the residents and would be solely reliant on what the nurse reported. The on-call service providers do not have access to the facility's records. On 9/12/24 at 11:30 am an interview was conducted with the Physician. The Physician stated any change in a resident's neurological status needs to be reported immediately to medical staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews of the staff, physician, and nurse practitioner, the facility failed to identify a resident's change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization. Findings included: The resident had medical orders for scope of treatment (MOST) form dated 3/21/22 signed by a representative. Section A was for do not resuscitate. Section B was limited additional interventions: Do not intubate or mechanical ventilate but may consider less invasive airway support such as BiPAP or CPAP (oxygen mask with positive pressure), transfer to hospital if indicated, and avoid intensive care. Sections C and D were to provide antibiotics and intravenous fluids. Resident #95 was admitted to the facility on [DATE] with diagnoses of diabetes, atrial fibrillation on anticoagulant, and end stage renal disease dependent on renal dialysis. Resident #95's care plan dated 5/23/24 documented she had an impaired cognitive function and thought process, was at risk for falls, required hemodialysis, and was receiving anticoagulant for atrial fibrillation (dysrhythmia of the heart). Anticoagulant interventions were to monitor for changes in mental status, changes in vital signs, and lethargy. Resident #95 had an order dated 2/11/24 for Eliquis (anticoagulant) 2.5 mg twice a day. On 9/12/24 at 10:38 am an interview was conducted with Nurse #2. Nurse #2 stated she was assigned to Resident #95 on 6/12/24 from 7:00 am to 7:00 pm. The resident was assessed by the Director of Nursing (DON) and me up to 5:00 pm. The resident was at her mentation baseline. The resident went to dialysis at approximately 10:30 am to 4:00 pm on 6/12/24. The resident had her dialysis as scheduled. Nurse #2 stated at dialysis the resident would have had heparin anticoagulant in the dialysis solution in addition to her twice a day facility provided anticoagulant. Resident #95 had no change on my shift 6/12/24 before dialysis. I last saw the resident about 5:30 pm sitting up in her bed with her meal. On 6/12/24 at 7:30 pm Nurse #1 documented in the neurological assessment form Resident #95 had blood pressure (BP) 135/95, pulse (P) 91, respirations (R) 13, and temperature (T) 97.0. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. There was no headache, seizure, drainage from the ear or nose, or vomiting. On 6/12/24 at 11:40 pm Nurse #1 documented in the neurological assessment form Resident #95 had BP 144/105, P 93, R 14, and T not documented. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. Nurse #1 was unable to assess headache, seizure, drainage from the ear or nose, or vomiting. Nurse #1's nurses' note dated 6/13/24 at 12:20 am of Resident #95. The resident was lying in bed, unlabored breathing, diaphoretic, lethargic, and unarousable. The resident's evening medications were placed on hold due to resident acute changes and inability to arouse to swallow. The nurse practitioner was notified (of the inability to arouse and swallow medication). On 6/13/24 at 3:20 am Nurse #1 documented in the neurological assessment form. Resident #95 was unresponsive with both pupils fixed. The resident had no motor function of all extremities and hand grasp. Nurse #1 was unable to assess whether the resident had a headache, seizure, drainage from the ear or nose, or vomiting. On 9/11/24 at 2:48 pm an interview was conducted with Nurse #1. Nurse #1 stated on 6/12/24 at 7:00 pm Resident #95 had a neurological assessment every 4 hours. The resident was barely responding with labored breathing and was diaphoretic. Nurse #1 stated she could not tell if the change was neurological because the resident had received dialysis earlier that day. Residents were usually worn out after dialysis. Nurse #1 stated she passed the medication to other residents and returned to Resident #95 to administer medications at 11:00 pm. The resident was too sleepy to wake up and swallow her evening medications. The resident's pupils were responsive but slow and she would only moan when attempted to wake. The resident was not moving her extremities and was diaphoretic. Nurse #1 decided she would wait for the resident to wake up and tried again at 11:30 pm. Nurse #1 assessed Resident #95, she was still very tired, not waking up and not moving. Nurse #1 believed the resident was tired from dialysis and had not refused medication before. The resident was not talking, just moaning at 7:30 pm and 11:30 pm assessments. Nurse #1 stated she called the on-call nurse practitioner and informed her the resident was very sleepy and could not swallow evening medication. The nurse practitioner directed Nurse #1 to hold the resident's evening medications. Interview continued: Nurse #1 stated she came back at approximately 3:20 am on 6/13/24 and Resident #95 was unable to wake up and was not moving. The resident had a large amount of saliva in her mouth and her tongue was stuck on the left side and she had extreme diaphoresis. Nurse #1 tried sternal rub and was unable to wake the resident. Nurse #1 called NA #1 into the resident's room and they both could not wake the resident. Nurse #1 stated she called another nurse into the resident's room and this nurse could not wake the resident. The resident was noted to not react to sternal rub, saliva was coming out of her mouth, and her pupils were not reactive and fixed. The resident was not responding at all, she had a weird gurgling noise in her mouth. Nurse #1 stated she called the DON to inform her of the resident's status and was directed to send the resident out. Nurse #1 stated she called 911 around 3:45 am on 6/13/24. Nurse #1 further stated that something was not right with the resident, she was very diaphoretic and needing her clothes changed, and her blood glucose check was 147, but the resident was not responding to anything. She had no muscle control and fixed pupils. Nurse #1 went on to state she thought the resident was sleepy from dialysis. Nurse #1 had not suspected a neurological change because I was not at the facility all day to see the resident. Nurse #1 was aware the prior shift nurse had not observed the resident's lethargy. Nurse #1 stated she received in report the resident was at neurological baseline when she came back from dialysis at 4:30 pm on 6/12/24. The resident's mental status was normal prior to the 7:00 pm to 7:00 am shift on 6/12/24. Everything changed on my shift. Nurse #1 stated the resident's blood pressure was elevated which was not normal for her. On 9/12/24 at 10:30 am an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated she was assigned to Resident #95 on 6/12/24 from 7:00 pm to 7:00 am. NA #1 stated the resident was talking to her but drowsy at 7:00 pm. NA #1 thought the resident was tired from dialysis. The resident was more quiet than normal and remained that way until the next check at 11:00 pm when the resident was not talking, and the NA thought the resident was sleeping and had not tried to wake her. NA #1 stated sometime after midnight the resident could not wake up, not sure the exact time. Around 3:00 am on 6/13/24 Nurse #1 called me into the resident's room to observe the resident. The resident was not able to wake up and not moving. Nurse #1 stated another nurse attempted to wake the resident unsuccessfully. The resident was sent out by EMS to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. Findings Included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included multiple fractures and pressure ulcers. He was discharged to the hospital on [DATE] and did not return to the facility. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Care Area Assessment (CAA) summary identified care plans would be developed for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. Review of the medical record revealed a nutrition care plan dated 11/8/23. There were no other care plans available for Resident #1. During an interview on 5/6/24 at 3:12 pm, MDS Nurse #1 revealed the care plans for Resident #1 had not been completed after checking Resident #1's electronic medical records (EMR). She stated she was not sure why this was not done. She referred the surveyor to another MDS Nurse (#2) who worked remotely. During a telephone interview on 5/6/24 at 3:13 pm, MDS Nurse #2 checked Resident #1's EMR and stated the comprehensive care plan was not done. She stated she was not sure what happened. She stated that she typically completed all the residents' comprehensive care plans right after she completed the MDS CAAs. She did not know how she missed it. During an interview on 5/6/24 at 3:08 pm, the Director of Nursing (DON) stated the comprehensive care plans should be based on the CAAs and completed within seven days from the resident assessment.

Based on record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 5/28/21 and 5/26/23 and the current complaint investigation survey of 5/6/24. This failure occurred for a repeat deficiency originally cited in the area of comprehensive resident centered care plans that was subsequently recited on the current complaint investigation survey of 5/6/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI Program. The findings included: This tag is cross referenced to: F656: Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. During a recertification and complaint investigation survey of 5/28/21, the facility failed to develop a comprehensive person-centered plan of care that included the daily use of an antipsychotic and antianxiety medication for a resident. During a recertification and complaint investigation survey of 5/26/23, the facility failed to develop a care plan with measurable goals and objectives to address nutrition for a resident. An interview was conducted on 5/6/24 at 4:40 pm with the Administrator and the Director of Nursing. The Administrator stated he headed the facility's Quality Assurance and Performance Improvement (QAPI) Committee. The committee consisted of the Director of Nursing (DON), Staff Development Coordinator (SDC), Medical Director, Pharmacist, Dietary Manager, Maintenance Director, and himself. He revealed the facility was working on falls with injuries, pest control, and recently added care plans.

Based on record review, resident and staff interviews the staff failed to report an allegation of employee to resident abuse to the Administrator immediately. This was evident for 1 of 3 residents reviewed for allegations of abuse. (Resident #13). Findings included: The facility's Abuse, Neglect and Exploitation Policy dated 11/1/22 read in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan included: The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A review of a progress note dated 8/14/22 at 11:00 pm read in part, Resident #13 alleged Nursing Assistant (NA #1) grabbed her face and neck. A further review of the progress note read in part on 08/14/22 Resident #13 was heard cursing very loud from her room. Writer was on the hallway passing medicine and heard the resident. The Nursing Assistant (NA #1) stepped out of the room and said, I am trying to help her, but she is cursing me Another NA was sent in the room to help with putting Resident to bed. That was after 10:30 pm. At 11:00 pm the police rang the bell and indicated they had received a call from Resident #13. The police went into the room and came back 10 minutes later and stated he could not find any injury or abuse by looking at the resident. The writer did not find physical injury at the time of assessment. The police left the building and called back to the facility at 12:00 am for information about NA #1 and the witness. Attempts to contact Nurse #1 by telephone were unsuccessful, and a voice message was left for Nurse #1 to return call. No return call was received. During an interview with the Administrator on 5/11/2023 at 1:30pm, he indicated he was notified of the alleged allegation of abuse to Resident #13 on 08/15/22 at 11:44 am. The Administrator indicated he reported the initial allegation to the state on 08/15/22 at 1:00pm. During an interview with the Administrator on 5/11/23 at 3:55 pm, he indicated it was his expectation to follow the abuse policies of the facility. He indicated he expected staff to call him and or the DON immediately with a report of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan with measurable goals and objectives to address nutrition for 1 of 25 residents (Resident # 24). Findings included: Resident #24 was readmitted on [DATE] with diagnoses that included end stage renal disease, and dependence on Hemodialysis. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted to the facility on [DATE]. Resident was assessed as cognitively intact and needed extensive assistance with one-person physical assistance for activities of daily living (ADL). Assessment indicated Resident #24 was receiving dialysis. Review of the Care Area Assessment (CAA) revealed the resident was triggered for Nutrition and Nutrition status to be addressed in care plan. Review of Resident #24's care plan revealed the resident was not care planned for nutrition. During an interview on 5/10/23 at 11:28 AM, the Dietitian (RD) stated the resident was on renal diet and was on supplements to meet protein needs. The RD indicated the resident's care plan related to nutrition must have been missed. The resident needed a care plan as Resident #24 was a dialysis resident, on a special diet and was prone to nutrition related issues. During an interview on 5/11/23 at 8:03 AM, The MDS coordinator stated she was hired at the end of January and did not complete the resident's admission assessment. The MDS coordinator further stated that when the CAA's were triggered, a care plan for the triggered area was completed. The MDS coordinator indicated she reviews the CAA section on the MDS assessment and ensures the triggered areas had care plans completed by the respective departments. She stated Resident #24 was assessed as needing a therapeutic/ special diet and assessment indicated the resident was on Dialysis. She added the resident needed to be care planned for nutrition. MDS coordinator stated as she had not completed the assessment, she was unsure why the care plan was not completed. On 5/11/23 at 3:38 PM, the facility Administrator was interviewed. He indicated it was the expectation that the residents be care planned in detail when CAAs were triggered for continuation of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and resident and staff interviews the facility failed to involve residents and/or resident's representatives in the care planning process for 1 of 1 sampled resident reviewed for care plan participation (Residents # 2). The findings included: Resident #2 was readmitted on [DATE] with diagnoses in part, paraplegia, liver carcinoma and heart failure. A record review of the most recent admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was admitted to the facility on [DATE]. The resident was assessed as cognitively intact and was dependent on staff for most of the activity of daily living. Review of the resident's care plan revealed it was reviewed by staff on 3/9/23, but there was no indication that the resident or resident's family participated in the care plan meeting or in the development of Resident #2's plan of care. During an interview on 5/8/23 at 12:39 PM, Resident #2 stated the facility had not invited the resident to any care plan meeting or to participate in developing the resident's plan of care. Resident #2 indicated she did not participate in her care plan meeting. During an interview on 5/11/23 at 8:15 AM, Social Worker (SW) indicated she reviewed the Assessment Review Date (ARD) for MDS that was given by the MDS coordinator at the beginning of the month. The resident's family/ representatives were contacted and asked if they would like to participate in the care plan meeting via phone or in person. A date was scheduled for the meeting based on their convenience. The SW stated if the resident was their own responsible party, then they were contacted to see if there was anyone, they would like to invite to their care plan meeting. Resident #2 was her own responsible party and care plan meetings were usually conducted in the resident's room. SW was unsure when the previous care plan meeting was conducted for the resident. SW stated there was no documentation to prove the care plan meeting was conducted and who attended the meeting. SW also indicated there was no written information available to indicate the care plan meeting was completed for the resident. During an interview on 5/11/23 at 8:08 AM, the MDS coordinator indicated she sends out a calendar to the SW, indicating all the residents whose ARD's were up for the month. The MDS coordinator stated the SW sets up the care plan meeting dates with residents and resident's family members based on this calendar. The MDS coordinator further stated she was hired in January 2023 and was unable to confirm or deny if any care plan meeting was conducted. The MDS Coordinator stated there was no documentation to prove if a care plan meeting was conducted for Resident # 2 and there was no documentation to indicate who attended the meeting and what was discussed. During an interview on 5 /11/23 at 3:39 PM, The Administrator stated the expectation was that care plan meetings and notifications were per the state/ federal regulations. The Administrator stated the care plan should be reviewed and revised by the interdisciplinary team after each assessment, including comprehensive and quarterly assessments. He further stated residents and/or resident's representatives should be involved in the care plan meeting and make decisions about their care. The Administrator indicated documentation related to the care plan attendance and meeting should be completed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility staff, Nurse Practitioner (NP) interviews, Pharmacist, and record reviews, the facility failed to administer a sedative medication to a resident 6 of 6 nights during the stay in the facility. This occurred for 1 of 22 residents (Resident # 245) whose medications were reviewed. The findings included: Resident # 245 was admitted to the facility on [DATE] with diagnoses that included aftercare following total knee replacement and insomnia. She had a resident-initiated discharge home on 9/30/22. The Minimum Data Set 5-day assessment revealed Ms. Bell was cognitively intact. The care plan dated 9/26/22 revealed Resident # 245 had ADL self-care performance deficit related to generalized weakness and pain due to recent surgery. Review of admission orders dated 9/23/22 revealed Zolpidem Tartrate (Ambien) Tablet 10 milligrams (mg); Give 1 tablet by mouth at bedtime for difficulty sleeping Take 5 to10 mg by mouth at bedtime. It was due to be administered at 9:00 PM. The Electronic Medication Administration Record (EMAR) for Resident # 245 revealed Ambien did not have administration documented on 9/23/22, 9/24/22, 9/26/22, 9/27/22, 9/28/22, and 9/29/22. There were chart codes on the EMAR with the number '9' that indicated 'see nurse note' for 9/23/22, 9/24/22, 9/26/22, 9/27/22, and 9/28/22. On 9/29/22 there was blank medication administration on the EMAR indicating Ambien was not given. Ambien was documented as given on 9/25/22. The Nurse Practitioner (NP) seen Resident # 245 on 9/26/22 and her progress note revealed insomnia was a diagnosis and Ambien 10 mg tablet; 5 to 10 mg to be administered at bedtime. An interview on 05/09/23 at 11:25 AM with Regional Nurse Consultant # 1 revealed she was unable to provide the nurses ' notes documentation for the dates with the number ' 9 ' chart code on the EMAR for 9/23/22, 9/24/22, 9/26/22, 9/27/22, and 9/28/22. She was unable to verify how the Ambien was documented as given on 9/25/22. An interview on 5/11/23 at 8:05 AM was conducted with the Director of Nursing (DON). She indicated she was unaware that Resident # 245 did not receive Ambien during her stay and unaware the Ambien was not delivered from the pharmacy when the admission orders were faxed to them upon admission on [DATE]. She indicated a provider ' s prescription for the Ambien was required to be faxed to the pharmacy. The DON revealed Ambien was not available in the in-house medication dispense (PYXIS) machine. The DON revealed that the nighttime nurses should have contacted the pharmacy, the provider, and herself when they could not locate the Ambien during their medication pass. She further revealed she did not know why the nurse documented the Ambien was given on 9/25/22 because it was not delivered or available in the facility. An interview was conducted on 5/11/23 at 11:58 AM with the NP. She indicated not being able to have scheduled Ambien was not good for Resident # 245 due to her diagnosis of insomnia. The NP explained the nursing staff should have contacted the nighttime on call provider to see if there was an alternative in stock medication such as melatonin if the Ambien was not available during medication pass. She revealed the normal process for obtaining Ambien, which is a controlled substance, was the requirement of a provider ' s prescription to be sent in with the admission orders so it will be delivered upon admission to the facility. The NP stated she was not aware the Ambien was not administered to Resident # 245 and the nursing staff should have addressed the availability of the medication early in her stay at the facility. On 5/12/23 at 8:25 AM during a telephone interview with night nurse # 1 he indicated he did not locate the Ambien during his medication pass to Resident # 245 and did not notify the pharmacy, provider, or the DON. A telephone interview was conducted on 5/12/23 at 10:15 AM with the facility ' s Pharmacist. She revealed the Ambien for Resident # 245 was not delivered to the facility because they did not receive a prescription when the admission orders were faxed in on 9/23/22. The Pharmacist indicated Ambien was a controlled drug that required a prescription to be faxed in so it may be delivered. The Pharmacist also indicated the nursing staff should have contacted the pharmacy when they noticed the medication was not able to be located during medication administration on nights. An interview on 5/12/23 at 11:15 AM with Nurse # 4 who placed the admission orders in the computer for Resident # 245. Nurse # 4 indicated she placed the admission orders in the computer on 9/23/22 and was waiting on resident to arrive to the facility to receive the prescription so she could fax it to the pharmacy. Nurse # 4 revealed the prescription for the Ambien was not in the admission packet when Resident # 245 arrived at the facility from the hospital. Nurse # 4 further revealed that it was the responsibility of the admitting nurse of Resident # 245 to obtain the prescription from the facility ' s provider if it was not included in the admission packet. On 5/12/23 at 11:20 AM during an interview with Regional Nurse Consultant #2, she stated she expected prescriptions for all controlled substances to be obtained by the nursing department and faxed to the pharmacy so the medication could be delivered on the night of admission to the facility. Telephone interviews with the two other night nurses that provided care for Resident # 245 during her stay were unsuccessful. The Medical Director was out of the country and not available for telephone interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Nurse Practitioner, and Medical Director interview the facility failed to follow physician orders to obtain a hemoglobin A1c (HbA1c) every three months as ordered for Resident #33 for 1 of 24 residents reviewed. Findings included: Resident #33 was admitted to facility 3/11/22 and had a diagnosis of type 2 diabetes. Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. A review of Resident #33's care plan dated 3/14/22 revealed Resident had diabetes. Goal was Resident would have no complications related to diabetes. A review of Resident #33's physician orders revealed the following: order dated 9/28/22 Trulicity Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide) Inject 0.75 milligram subcutaneously one time a day every Thursday. order dated 10/10/22 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 30 units subcutaneously every morning and at bedtime. order dated 12/21/22 Humalog KwikPen 100 UNIT/ML Solution pen-injector Inject subcutaneously after meals. A review of physician orders for the month of September 2022 revealed an order to obtain HbA1c (a blood test that measures your average blood sugar levels over the past three months) every three months. A review of lab dated 9/30/22 resulted in HbA1c result of 14.3 and normal range 4.0-6.0. During an interview with the Director of Nursing (DON) on 5/10/23 at 5:35 pm it was indicated there were no other HbA1c lab results for Resident #33. The DON stated she contacted the lab company on 5/10/23 and they informed her there had not been a HbA1c for Resident #33 in December. She indicated the facility had changed lab companies in February and was unable to get information from the company. The DON verified she could only locate the 9/30/22 HbA1c lab result. The DON stated it was her expectation to follow the physician orders for labs as ordered. On 5/11/23 at 10:00 am an interview was conducted with the Medical Director. He indicated he had been working in the facility for little over 2 months. He stated he would expect labs to be conducted as ordered, which included the order for the HbA1c for Resident # 33 to be checked every 3 months as ordered. An interview was conducted on 5/11/23 at 11:48 am with the Nurse Practitioner (NP) and she stated a HbA1c lab was ordered for every 3 months for Resident #33. She indicated the facility had been through several lab companies, and it was difficult to get labs. She stated she expected the HbA1c to be drawn every 3 months as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility staff and record reviews, the facility failed to accurately document a sedative medication for a resident 1 of 6 nights during the stay in the facility. This occurred for 1 of 22 residents (Resident # 245) whose medications were reviewed. The findings included: Review of admission orders dated 9/23/22 revealed Zolpidem Tartrate (Ambien) Tablet 10 milligrams (mg); Give 1 tablet by mouth at bedtime for difficulty sleeping Take 5 to10 mg by mouth at bedtime. It was due to be administered at 9:00 PM. The Electronic Medication Administration Record (EMAR) for Resident # 245 revealed Ambien did not have administration documented on 9/23/22, 9/24/22, 9/26/22, 9/27/22, 9/28/22, and 9/29/22. There were chart codes on the EMAR with the number '9' that indicated 'see nurse note' for 9/23/22, 9/24/22, 9/26/22, 9/27/22, and 9/28/22. On 9/29/22 there was blank medication administration on the EMAR indicating Ambien was not given. Ambien was documented as given on 9/25/22. An interview on 05/09/23 at 11:25 AM with Regional Nurse Consultant # 1 revealed she was unable to verify how the Ambien was documented as given on 9/25/22 since the medication was not delivered to the facility or available in the facility. During an interview on 5/11/23 at 8:05 AM with the Director of Nursing (DON) she indicated she was unaware the Ambien was not delivered from the pharmacy when the admission orders were faxed to them upon admission on [DATE]. She indicated a provider's prescription for the Ambien was required to be faxed to the pharmacy. The DON revealed Ambien was not available in the in-house medication dispense (PYXIS) machine, therefore it was not available to the nurses for emergency backup. She indicated she did not know why the nurse documented the Ambien was given on 9/25/22 at 9:00 PM because it was not delivered or available in the facility. The DON further indicated nurses should not document medications as administered in the EMAR if the medication was not given or available. During an interview on 5/12/23 at 11:20 AM with Regional Nurse Consultant #2 she stated she was unaware of how the Ambien could be administered if the medication was not delivered or available in the facility.

Based on resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and/or respond to concerns voiced by residents during Resident Council meetings for 9 of 10 months (July 2022, August 2022, October through, December 2022, and January, February, March, and April 2023). Findings included: The Resident Council meeting minutes for July, August, October, November, and December 2022 revealed no concerns or grievances were documented from residents. The minutes indicated Resident #38, Resident #29, Resident #2, and Resident #55 attended these meetings. During an interview with the current Activities Director on 05/12/23 at 12:00pm, she stated she began working at the facility in April 2023. She indicated she oversaw the Resident Council meetings and documented the minutes, but no concerns or grievances were brought up in the April 2023 Resident Council meeting. The Activities Director was not able to locate resident council minutes from January 2023 to present. A telephone interview was attempted on 05/12/23 at 12:32pm with the previous Activities Director, but she was not available for interview. On 05/10/23 at 2:03pm a Resident Council meeting was held and attended by 10 alert and oriented members of the resident council (Resident #38, Resident #29, Resident #2, Resident #55, Resident #41, Resident #76, Resident #78, Resident #10, Resident #34, and Resident #70). During the meeting the residents were notified that based on review of the Resident Council minutes for July, August, October, November, and December 2022 no concerns were voiced by the residents and minutes from January 2023 through April 2023 were requested for review but were not able to be located by the facility. The residents in attendance reported that concerns had been reported at each meeting for the last year as well as each meeting of 2023. Residents #38, #29 and #2 stated that concerns with food, pests, cleanliness of rooms were ongoing concerns that had been reported for months. The residents stated that their concerns had not been resolved and they were unaware of efforts to resolve their concerns as they remained ongoing, and the issues had not improved. The Administrator was interviewed on 05/11/23 at 2:59pm. He spoke about the process for concerns/grievances reported during the Resident Council minutes. He explained that the Resident Council minutes were to include any concerns/grievances reported during the meetings and the Activities Director was to put all of these concerns/grievances on a grievance form and submit them to him for follow-up. Resident Council members would be updated on the status of the previous month's complaints at the next Resident Council meeting. He revealed that he was not aware that the former Activities Director had not been recording concerns/grievances on the Resident Council minutes or putting group grievances on the facility grievance form so the facility could provide the Resident Council members a response to their concerns.

Based on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 5/12/23. This was for a deficiency that was cited in the area of Development/implement a Comprehensive Care plan on 5/28/21 and recited on the current recertification and complaint survey on 5/12/23. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 6/16/22. This was evident by the deficiency in the areas of maintain an effective pest control program originally cited on the recertification and recited on the current recertification and complaint survey of 5/12/23. The repeated citations during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included The tags were cross referenced to: F 656 Based on record review and staff interview, the facility failed to develop a care plan with measurable goals and objectives to address nutrition for 1 of 25 residents (Resident # 24). During the previous survey on 5/28/21, the facility failed to develop a comprehensive person-centered plan of care that included the daily use of an antipsychotic and antianxiety medication. This was evident for 1 of 5 residents reviewed for unnecessary medications. F 925 Based on observations, record review, resident and staff interview the facility failed to provide a pest free living environment for 4 of 4 residents residing in the facility. (Resident #243, Resident #38, Resident #2, and Resident #18). During the previous survey on 6/16/22, the facility failed to provide a pest free living environment for 8 of 91 residents residing in the facility. On 5/12/23 at 3:50 pm, during interview with the Corporate Consultant Nurse, her expectation for the facility do not have repeat tags. She indicated that the facility to have monthly quality assurance meetings with team. She added that the Administrator to had received the corporate quality assurance forms and she would be reviewing them.

Based on observations, record review, resident and staff interview the facility failed to provide a pest free living environment for 4 of 4 residents residing in the facility. (Resident #243, Resident #38, Resident #2, and Resident #18). Findings Included: a. During the facility tour on 5/8/23 at 10:00 AM, an observation was made of a roach crawling on the 100 hallway. b. During a Resident Council meeting on 5/10/23 at 10:00 AM, residents who attended the meeting (Residents #38, Resident #18, and Resident #2) reported that the facility had issues with pests in their room. There were roaches in their rooms and in the hallways. Resident #38 (President of Resident Council) was interviewed on 5/10/23, at 4:00 PM. The resident indicated that the facility had issues with pests. Resident #38 stated she saw a roach crawling on the wall beside the bathroom door in her room last night (on 5/9/23). Resident #38 indicated she had been complaining in the Resident Council meeting for months and that concerns had not been addressed. c. On 5/8/23 at 11:39 AM, Resident #243 was interviewed, and the resident reported that roaches were crawling on the light fixture and on the ceiling in his room. He indicated a roach had fallen on him. The resident stated the roach was crawling on him, and he had a fall trying to get away from it. Resident #243 indicated he reported it to the nurse on duty. Review of the admission Minimum Date Set Date May 203 indicated Resident #243 was assessed as cognitively intact. During a second interview with Resident #243 on 5/10/23 at 2:00 PM, the resident stated he had observed roaches again last night (5/9/23). The resident indicated he was upset with roaches in his room. During an interview on 05/12/23 at 8:00 AM, Nurse #10 indicated she was assigned to the resident during the night of 5/8/23. Nurse #10 stated she did not see roaches in Resident #243's room on the day of his fall. She, however, stated she had seen roaches occasionally during the night in the hallways. Nurse #10 indicated she had reported these issues with the roaches to the Director of Nursing (DON) and the Administrator. d. Resident #2 was interviewed on 05/12/23 at 11:30 AM and indicated that the facility had issues with roaches for a year. She indicated that the roaches crawled on her bed, side table and privacy curtain during the late evening on 5/11/23 and early morning on 5/12/23. Resident #2 also indicated that this information had been discussed in Resident Council, however nothing was done. Resident #2 also indicated she reported this information to staff assigned to her regularly. She added the cockroaches appeared during the evening and early morning most of the time. Interview on 5/11/2023 at 10:30 AM, Nurse Aide (NA)# 10 indicated she had observed roaches on the hallway. NA #10 added she had reported the sightings to the Administrator and Director of Nursing. Interview was conducted with Nurse #10 and Nurse #11 together on o 5/12/23 at 11:30 PM. Both nurses indicated they were assigned to 100-hall indicated and worked during the night shift. Nurses stated the facility had issues with roaches for years. Both nurses indicated they avoid putting anything on the floor because of these roaches crawling on them. Nurse #10 and Nurse #11 indicated they had reported this issue and both DON and Administrator were aware of this. Nurses reiterated that the roach issues were bad. Review of the pest control contract dated from July 2022 to May 2023, revealed in part, service would be provided monthly for roach and rodent elimination. Insecticide could be used in vacant resident rooms upon request. Review of the pest control contract for the month of April 2023 revealed weekly visits to the facility. Review of a pest control service report from July 2022 to May 2023 revealed insecticide was applied to target roaches. This was applied to fire door introduction point, front door introduction point, interior hallways, interior kitchen area, interior laundry / housekeeping areas, and some vacant rooms. Review of the pest control service did not include treatment of Resident #243's, Resident #38's, or Resident #2's rooms during the month of May 2023. During an interview on 5/12/23 at 1:00 PM, the Pest Control Technician stated he had been providing pest control services at the facility for seven months. He stated he treated the facility on 5/5/23 and had not seen any signs of living roaches. He explained he saw dead roaches in the common area and vacant rooms. He explained he sprayed insecticide on interior areas the best he could. The technician added he could only treat a resident room if it was vacant. He stated the facility did not routinely request him to treat specific resident rooms. He indicated he would work with the facility to come up with a plan to eliminate pests and this plan would need to be weekly treatments if not several days during the week. During an interview on 5/12/23 at 3:54 PM, the Corporate Consultant Nurse revealed the Administrator was aware of the pest issues in the facility. The Corporate Consultant Nurse also indicated that the expectation was when any resident complains of pests, the Pest Control company would service their room and surrounding areas. Administrator was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, family, staff and resident interviews the facility failed to treat a resident in a dignified manner by not keeping a resident ' s room clean and odor free. Resident #25 expressed feelings of embarrassment and did not want her family to visit her in her room because the room had dirty floors, missing baseboards where she had seen cockroaches crawling out of and a continuous strong odor. This was evident for 1 out of 4 residents reviewed for dignity. Findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, chronic kidney disease, acute kidney failure, and unsteadiness on feet. Review of Resident #25 ' s quarterly Minimum Data Set (MDS) dated [DATE] revealed her cognition was intact, was able to communicate her needs and was occasionally incontinent of bowel and bladder. Review of Resident #25 ' s care plan dated 04/12/22 identified she required extensive one-to-two-person assistance with bed mobility, dressing, personal hygiene and toilet use. She was totally dependent on staff for bathing. An observation of room [ROOM NUMBER] on 6/12/22 at 11:30 revealed several brown substances on the floor in front of Resident #25 ' bed. A whole was observed in the center of the floor. There was no baseboard present on Resident #25 ' s side of the room. The baseboard that was present in the room was black in color. Upon entering room [ROOM NUMBER] there was a very strong urine odor that was present during entire observation. Additional observations of room [ROOM NUMBER] were conducted on 6/13/22 at 1:19 pm, 6/14/22 at 10:00 am and 6/14/22 at 1:30 pm. During each of these observations there was a strong urine odor present in the room. The dark brown substances remained on the floor in front of Resident #25 ' s bed and there was a small whole in the center of the floor. Sections of the baseboard were missing and the baseboard that was present was black in color. An observation was conducted of room [ROOM NUMBER] on 6/14/22 at 2:30 pm with the Administrator and Corporate Representative. The Administrator and Corporate Representative indicated the room had a strong urine odor that needed to be taken care of. The Administrator stated the floorboard needed to be replaced and the entire room cleaned. Resident #25 and her roommate were temporarily moved to another room so room [ROOM NUMBER] could be thoroughly cleaned, and repairs made. An interview was conducted with a family member (FM) on 06/14/22 at 3:30 PM, who indicated she had visited Resident #25 on 5/15/22. The FM explained when she had visited previously, they would meet in the lobby of the facility. She continued on 5/15/22 she wanted to surprise Resident #25 and when she walked into her room she was hit with a strong odor of urine; she added it hit her in face even with her mask on. The FM indicated the room was just nasty with what looked like feces on the floor close to the resident ' s bed and a whole in the center of the floor. The FM stated the baseboard appeared to be rotten and popping off and she observed cockroaches coming out of the baseboard. She indicated Resident #25 told her the room was like this all the time. The FM stated when she left the facility, she cried all the way home because Resident #25 was a great person and did not deserve to be living in that type of environment. She stated after her visit she reported the living conditions of Resident #25 ' s room to the state. An interview was conducted with Resident #25 on 06/15/22 at 11:00 AM. Resident #25 indicated she was very glad to be in a clean room and no issues with roaches. She added she had not seen any roaches and the room and bathroom were clean. Resident #25 indicated her family could come and see her in this room and she wouldn ' t be embarrassed She added there was something wrong with her other room and the staff kept the door closed all the time. An interview was conducted with Nursing Assistant (NA) #28 who indicated she had worked with Resident #25 and was not aware the resident felt so embarrassed by her other room. She added Resident #25 never complained to her about the conditions of her room. An interview was conducted with the Administrator on 06/16/22 at 4:06pm who indicated all residents needed to be treated with dignity and respect and their rooms needed to be always clean and odor free if possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to provide nail care for a resident that was dependent on staff for provision of activities of daily living (ADLs). This was evident for 1 of 2 residents reviewed for ADL care (Resident #17). Findings Included: Resident #17 was admitted to the facility on [DATE] and diagnoses included contracture of the right hand. A quarterly Minimum Data Set (MDS) dated [DATE] for Resident #17 identified he was totally dependent on staff for personal hygiene. His cognition was severely impaired, and he had no behaviors of rejection of care during the look-back period. A care plan with a review date of 2/17/22 identified Resident #17 had an ADL (activities of daily living) self-care deficit related to bilateral upper and lower extremity contractures. Interventions included to provide extensive assistance with grooming and to check nail length, trim and clean on bath day and as necessary. An observation of Resident #17 on 6/13/22 at 2:45 pm revealed the resident ' s fingernails on his left hand were approximately 1 ½ to 2 inches in length. Some nails had dark brown substances under the nail bed. The resident ' s right hand was contracted into a fist; only a few nails on the right hand could be observed, and they were also 1 ½ to 2 inches long. An observation on 6/14/22 at 11:10 am of Resident #17 revealed the resident ' s fingernails on his left hand remained long and with some dark brown substance under the nail bed. The resident ' s right hand remained in a fist position and those nails that could be observed also remained long. An interview on 6/16/22 at 11:32 with Nursing Assistant (NA) #2 revealed she was the NA for Resident #17. She stated she did trim the resident ' s nails and believed she had done this on 6/14/22. NA #2 explained she performed nail care on the residents every few days and as needed. She added Resident #17 was cooperative with care and didn ' t resist when she provided nail care. An interview on 6/16/22 at 4:45 pm with the Administrator revealed he expected residents to receive routine nail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to apply a splint for contracture management as recommended by therapy and ordered by the physician. This was evident for 1 of 1 resident reviewed for range of motion (Resident #17). Findings Included: Resident #17 was admitted to the facility on [DATE] and diagnoses included contracture of the right hand. A quarterly Minimum Data Set (MDS) dated [DATE] for Resident #17 identified no impairment in range of motion and his cognition was severely impaired. A care plan with an initiation date of 2/11/22 for Resident #17 identified he had an ADL (activities of daily living) self-care performance deficit related to bilateral upper / lower extremity contractures. Review of the physician ' s orders for Resident #17 revealed an order dated 5/13/22 to apply splint to right hand; ensure it is on in the AM and off in the PM. Check the skin under the brace. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] identified discharge recommendations included to wear right resting hand splint. Splint / brace program established and trained staff with splint to be worn 4 to 5 hours daily. An observation of Resident #17 on 6/13/22 at 2:45 pm revealed his right hand was contracted into a fist. There was no splint in place on the right hand. An observation on 6/14/22 at 11:10 am of Resident #17 revealed his right hand was contracted into a fist and there was no splint in place on his right hand. An observation on 6/15/22 at 9:26 am of Resident #17 revealed his right hand was contracted into a fist and there was no splint in place on his right hand. Review of the treatment administration record (TAR) for Resident #17 revealed an order to apply splint to right hand in the AM and remove in the PM. The TAR for 6/13/22, 6/14/22 and 6/15/22 was signed off as being applied at 8:00 am each of these days by Nurse #3. An interview was conducted with Nursing Assistant (NA) #2 on 6/16/22 at 11:28 am. She stated she was the NA for Resident #17 and routinely provided care for him. NA #2 indicated the resident did have a splint for his right hand, but his hand had been swelling and he hasn ' t worn the splint in several weeks. She added the nurse and therapy staff were aware of this. NA #2 stated the resident was very cooperative with care and he would let you apply the splint. An interview on 6/16/22 at 1:30 pm with Nurse #3 revealed she had signed the TAR for splint application on 6/13/22, 6/14/22 and 6/15/22. She explained Resident #17 had an order for a splint to his right hand and therapy would apply the splint daily. Nurse #3 indicated the splint wasn ' t on when she signed the TAR today, but she wasn ' t sure if it was on when she signed the TAR on 6/13/22 and 6/14/22. She added therapy applied the splint she just signed off on the TAR. An interview on 6/16/22 at 1:50 pm with the Rehab Director (RD) revealed Resident #17 had been seen by OT and recommended / ordered a splint be worn daily on his right hand. She stated the resident has always had some swelling in the right upper extremity and the splint would help reduce the swelling. The RD added no one from therapy told nursing to not apply the splint because of swelling. She stated the therapy staff did not apply the splint; this was a nursing function once the resident was discharged from therapy. An interview on 6/16/22 at 4:55 pm with the Administrator revealed he expected splints to be applied per therapy recommendation and physician ' s orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8.An observation on 6/13/22 at 11:45 am of room [ROOM NUMBER] Bed A revealed the privacy curtain had dried brown stains running down the curtain. Resident #63 who was present during the observations stated another resident who was confused came into her room about 3 months ago and spilled her chocolate supplement shake on her privacy curtain. A follow-up observation of room [ROOM NUMBER] Bed A on 6/14/22 at 11:50 am revealed the privacy curtain had been cleaned with no stains noted. During these observations the floor was noted to be sticky throughout the room. An observation on 6/16/22 at 9:48 am of room [ROOM NUMBER] revealed there were drink wrappers and used straws on the floor. The floor was also noted to be dirty and sticky. The Housekeeping Director indicated she was short a housekeeper today on that side of the facility and she would be doing that assignment shortly. An interview with the Housekeeping Director (HD) on 6/16/22 at 1:40 pm revealed the housekeepers should check the resident ' s privacy curtains every day for stains. She added if they have spills or stains on them, they should be taken down to be washed and replaced with a clean curtain. The HD stated she kept a small number of clean privacy curtains to be used while the stained ones were being washed. She added she knew some of the floors in resident ' s rooms needed more attention and to be cleaned with the buffer. The Regional Housekeeping Director stated their goal was to schedule 2 resident rooms per week to be deep cleaned including having the floors stripped and waxed. He added the housekeeping staff were in-serviced this week on expectations for cleaning. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. 7.An observation on 6/13/22 at 10:49 pm of room [ROOM NUMBER] revealed there were papers, food crumbs and black substances on the floor throughout the entire room. One of the drawers was broken on the dresser. An observation on 6/13/22 at 11:37 am of room [ROOM NUMBER] revealed the floor strip entering the bathroom was missing exposing the floor. The privacy curtain for Resident #5 was noted with multiple brown, tan and orange-colored stains. Resident #5 was present in the room during the observation and indicated he had been asking for the strip to be replaced for 4 years, but it had never been done. He stated he did not know what the stains were on his privacy curtain. Follow-up observations on 6/14/22 and 6/15/22 of room [ROOM NUMBER] revealed paper, food particles and black stains were present on the floor. room [ROOM NUMBER] ' s privacy curtain remained with multiple stains An observation of rooms [ROOM NUMBERS] on 6/16/22 at 2:30 pm was conducted with the Regional Nurse Consultant. The Regional Nurse Consultant stated she had informed the staff to check the privacy curtains and she would get right on the concerns that were identified in the rooms. An interview with the Housekeeping Director (HD) on 6/16/22 at 1:40 pm revealed the housekeepers should check the resident ' s privacy curtains every day for stains. She added if they have spills or stains on them, they should be taken down to be washed and replaced with a clean curtain. The HD stated she kept a small number of clean privacy curtains to be used while the stained ones were being washed. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. Based on observations, resident and staff interview the facility failed to ensure the floors in the resident ' s rooms were kept clean, free of stains and in good repair (room [ROOM NUMBER], 103, 148, 155, 162 and 116). The facility failed to maintain the ceiling (room [ROOM NUMBER]), the resident furniture (room [ROOM NUMBER] and 162), the window blinds (room [ROOM NUMBER]), the thermostat controls (room [ROOM NUMBER]) and the baseboard (room [ROOM NUMBER]) in good repair. The facility failed to keep the privacy curtains (room [ROOM NUMBER] and 116) and bed linens (room [ROOM NUMBER]) clean and free of stains. The facility failed to identify and resolve a strong, lingering urine odor in a resident ' s room (room [ROOM NUMBER]). Findings Included: 1.An observation of room [ROOM NUMBER] on 6/13/22 at 10:50 am revealed the floor was very sticky. There were 2 sections on the ceiling approximately 3 to 4 feet in length over each resident bed that had brownish stains. Follow-up visits conducted on 6/14/22 and 6/15/22 of room [ROOM NUMBER] revealed the floor remained sticky and the brownish stains remained present on the ceiling. An interview with the Maintenance Director (MD) on 6/16/22 at 1:30 pm revealed he was aware of the ceiling damage in room [ROOM NUMBER]. He stated he was trying to arrange to have the gutters cleaned and assess for any roof damage before he did the ceiling repair. An interview with the Housekeeping Director (HD) and Regional Housekeeping Director on 6/16/22 at 1:40 pm revealed the facility had 4 housekeepers per day and 2 floor technicians. The HD indicated she had some openings in the past, but all positions were full now. The HD explained she expected each resident room to be cleaned daily including emptying trash, cleaning / sanitizing bathrooms and room surfaces, low and high dusting and sweeping / mopping the floors. She added she knew some of the floors in resident ' s rooms needed more attention and to be cleaned with the buffer. The Regional Housekeeping Director stated their goal was to schedule 2 resident rooms per week to be deep cleaned including having the floors stripped and waxed. He added the housekeeping staff were in-serviced this week on expectations for cleaning. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. 2.An observation on 6/13/22 at 11:15 am of room [ROOM NUMBER] revealed the bedside dresser and the built-in dresser were damaged with drawers missing. The wheelchair for Resident #37 had plastic peeling off both arm rests. The floor in the room was sticky and there were black stains present throughout the floor. Follow-up observations of room [ROOM NUMBER] on 6/14/22 and 6/15/22 revealed the damaged dressers with missing drawers, the same wheelchair was present with peeling plastic on the arm rests and the floor remained sticky with black stains present. An interview with the Maintenance Director (MD) on 6/16/22 at 1:30 pm revealed he was aware of the damaged dresser drawers in room [ROOM NUMBER]. He stated the resident had pulled the drawers off before and he would need to replace them again. An interview with the Housekeeping Director and Regional Housekeeping Director on 6/16/22 at 1:40 pm revealed the facility had 4 housekeepers per day and 2 floor technicians. The HD indicated she had some openings in the past, but all positions were full now. The HD explained she expected each resident room was cleaned daily including emptying trach, cleaning / sanitizing bathrooms and room surfaces, low and high dusting and sweeping / mopping the floors. She added she knew some of the floors in resident ' s rooms needed more attention and to be cleaned with the buffer. The Regional Housekeeping Director stated their goal was to schedule 2 resident rooms per week to be deep cleaned including having the floors stripped and waxed. He added the housekeeping staff were in-serviced this week on expectations for cleaning. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. 3.An observation of room [ROOM NUMBER] on 6/13/22 at 12:18 pm revealed the window blinds were on top of the resident ' s closet and there were no blinds present on the window. Resident #184 was present during the observations and indicated they fall off his window last week and the staff haven ' t put them back up yet. Follow-up observations of room [ROOM NUMBER] on 6/14/22 and 6/15/22 revealed the window blinds remained on the top of the closet. An interview with the Maintenance Director (MD) on 6/16/22 at 1:30 pm revealed he was aware the window blinds were down in room [ROOM NUMBER], and he would get them hung back up. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. 4.An observation on 6/13/22 at 2:45 pm of room [ROOM NUMBER] Bed B revealed there was a floor mat next to Resident #17 ' s bed. There was a dried dark brown circular stain present on the floor mat; approximately the size of a 50-cent piece. A follow-up observation on 6/14/22 at 10:25 am revealed the dark brown stain remained on Resident #17 ' s floor mat. An interview with the Housekeeping Director and Regional Housekeeping Director on 6/16/22 at 1:40 pm revealed the facility had 4 housekeepers per day and 2 floor technicians. The HD indicated she had some openings in the past, but all positions were full now. The HD explained she expected each resident room was cleaned daily including emptying trach, cleaning / sanitizing bathrooms and room surfaces, low and high dusting and sweeping / mopping the floors. She added she knew some of the floors in resident ' s rooms needed more attention and to be cleaned with the buffer. The Regional Housekeeping Director stated their goal was to schedule 2 resident rooms per week to be deep cleaned including having the floors stripped and waxed. He added the housekeeping staff were in-serviced this week on expectations for cleaning. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. 5.An observation of room [ROOM NUMBER] Bed A on 6/13/22 at 3:00 pm revealed the sheets on Resident #30 ' s bed had a dried dark red stain approximately the size of a 50-cent piece. Resident #30 who was present during the observation stated sometimes he scratched his skin, and it bled onto the sheet. He added the staff did not change his sheets regularly. Resident #30 stated he would like to be able to control the temperature in his room and the thermostat hadn ' t worked in months. An observation of the thermostat revealed you could turn it on and off, but not adjust the temperature. Follow-up observations of room [ROOM NUMBER] on 6/14/22 at 10:20 am and 6/15/22 at 12:20 pm revealed the dried dark red stain was still present on Resident #30 ' s sheet. On 6/15/22 at 12:20 Resident #30 indicated the nursing assistant was going to change his sheet after he ate lunch. An interview with the Administrator and Maintenance Director (MD) on 6/16/22 at 1:30 pm revealed the MD had requested 5 new thermostats from the previous Administrator and had never received them. He stated he was aware room [ROOM NUMBER] ' s thermostat needed to be replaced. The Administrator stated he expected residents to have clean linens on their beds. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance. 6.An observation of room [ROOM NUMBER] on 6/12/22 at 11:30 revealed several brown substances on the floor in front of Resident #25 ' bed. A whole was observed in the center of the floor. There was no baseboard present on Resident #25 side of the room. The baseboard that was present in the room was black in color. Upon entering room [ROOM NUMBER] there was a very strong urine odor that was present during entire observations. Additional observations of room [ROOM NUMBER] were conducted on 6/13/22 at 1:19 pm, 6/14/22 at 10:00 am and 6/14/22 at 1:30 pm. During each of these observations there was a strong urine odor present in the room. The dark brown substances remained on the floor in front of Resident #25 ' s bed and there was a small whole in the center of the floor. Sections of the baseboard were missing and the baseboard that was present was black in color. An observation was conducted of room [ROOM NUMBER] on 6/14/22 at 2:30 pm with the Administrator and Corporate Representative. The Administrator and Corporate Representative indicated the room had a strong urine odor that needed to be taken care of. The Administrator stated the floorboard needed to be replaced and the entire room cleaned. An interview with the Administrator on 6/16/22 at 4:50 pm revealed he expected the resident ' s rooms to be clean and maintained in good repair as you would your own home. He added the staff needed to utilize the maintenance reporting system in the electronic medical record system to report repair issues to maintenance.

Based on record reviews and staff interviews the facility failed to have a Registered Nurse scheduled for 8 hours a day, 7 days a week for 5 of 32 days reviewed. (02/26/22, 05/05/22, 05/06/2), 5/07/22 and 05/27/22). Findings included: A review of the nursing schedule dated 02/26/22 and 05/01/22 through 05/30/22 revealed no Registered Nurse was scheduled on 02/26/22, 05/05/22, 05/06/22, 05/07/22, and 05/27/22. An interview conducted with the Scheduler on 06/18/22 at 2:45 pm revealed there should have been a Registered Nurse scheduled on all days missing. The Scheduler stated she worked with staff agencies to ensure coverage and that she likely overlooked the schedule for those days. An interview conducted with the former Director of Nursing on 06/18/22 at 3:09 pm stated she expected the facility to have a Registered Nurse on duty for 8 hours a day, 7 days a week. An interview conducted with the Administrator on 06/18/22 at 3:09 pm revealed he expected the facility to schedule a Registered Nurse for 8 hours per day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, staff interview, and dental service representative interview, the facility failed to offer dental services for 1 of 2 residents (Resident #21) who had follow-up recommendations for dental services. Findings include: Resident #21 was admitted to the facility on [DATE]. Review of Dental note dated 10/7/21 read, in part, Resident #21 was referred to an outpatient service to have tooth #32 extracted. Will follow up next visit. Future limited oral evaluation (Future indicates follow ups or treatments planned for future visits). Review of Dental note dated 11/23/21 read, in part, Resident #21 had an evaluation to see if tooth #32 had been extracted. Left PA (prior approval) for a new upper denture since patient stated they lost the upper denture. Resident #21 had no dental pain. Resident #21 ' s annual MDS (Minimum Data Set) dated 4/1/22 revealed Resident had moderate cognitive impairment. Further review of the MDS revealed Resident did not have broken, or loosely fitting dentures, cavities or broken teeth, mouth, or facial pain during the assessment period. The electronic medical record indicated Resident #21 ' s payor source was Medicaid. A review of Resident #21 ' s care plan revealed no care plan for dental issues. The medical record from 11/24/21 through 6/14/22 revealed no evidence of any further dental appointments for Resident #21. An interview was conducted on 06/13/22 at 11:57 am with Resident #21 and it was indicated they had no mouth or facial pain and needed upper denture replaced due to them being misplaced while in the facility. Resident indicated it had been a long time since having upper dentures and wanted them replaced. Resident #21 indicated they had reported this to staff but could not remember any names. On 06/14/22 at 4:36 PM an interview was conducted with the facility Social Worker. She was asked if Resident #21 had a follow up dental appointment to have his tooth extracted as recommended in the 10/7/21 and 11/23/21 dental notes. She indicated she was unsure if this was completed and she had to contact the facility dental service. On 06/16/22 at 2:02 PM a follow up interview was conducted with the facility Social Worker, and she stated the facility dental service had never received the requested information from the facility for Resident #21 to receive services and had not had the follow up appointment. She indicated the plan was to move forward with the dental service to get Resident #21 the services needed. The Social Worker revealed she was new to the facility and to her knowledge there was no protocol in place for scheduling following up appointments as recommended for dental needs. On 06/16/22 at 02:17 pm an interview was conducted with the dental service representative, and she indicated that the dental provider referred the resident for an outpatient dental visit to have the tooth extracted, but the facility had not sent in the information required to schedule the outpatient appointment. She stated the required documents for prior approval were not received from the facility and Resident #21 was not able to be seen. An interview was conducted on 06/16/22 at 4:09 PM with the facility Administrator and he indicated his expectation was for the facility to do their part and follow through with what was recommended by the dentist. He stated, we have a new contract with the dental service and will move forward in providing the care that is needed to our residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 5/28/21. This was for 1 deficiency that was cited in the area of provision of activities of daily living (ADLs) for dependent residents (F677) on 5/28/21 and recited on the current recertification and complaint survey of 6/16/22. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 9/27/19. This was evident for 3 deficiencies in the areas of provision of ADL care for dependent residents (F677), provide RN (Registered Nurse) coverage 8 hours a day / 7 days a week (F727) and maintain an effective pest control program (F925) originally cited on the recertification and complaint survey on 9/27/19 and recited on the current recertification and complaint survey of 6/16/22. The duplicate citations during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: 1. F677 - Based on observations, record review and staff interview the facility failed to provide nail care for a resident that was dependent on staff for provision of activities of daily living (ADLs). This was evident for 1 of 2 residents reviewed for ADL care (Resident #17). During the recertification and complaint survey 5/28/21 the facility failed to provide nail care for a resident that was dependent for activities of daily (ADL) care. This was evident for 1 of 4 residents reviewed for ADL care (Resident #40). An interview on 6/16/22 at 3:50 pm with the Administrator revealed this was his first week at the facility. He stated he planned to have monthly quality assurance meetings with his team. He added he had received the corporate quality assurance forms and he would be reviewing them. The Administrator indicated he was not aware of any QAPI (quality assurance and performance improvement) plans in place at the facility. 2. F-677 - Based on observations, record review and staff interview the facility failed to provide nail care for a resident that was dependent on staff for provision of activities of daily living (ADLs). This was evident for 1 of 2 residents reviewed for ADL care (Resident #17). During the recertification and complaint survey 9/27/19 the facility failed to provide bathing for a resident that was dependent for activities of daily living (ADL) care. This was evident for 1 of 3 residents (Resident #28) reviewed for ADL care. An interview on 6/16/22 at 3:50 pm with the Administrator revealed this was his first week at the facility. He stated he planned to have monthly quality assurance meetings with his team. He added he had received the corporate quality assurance forms and he would be reviewing them. The Administrator indicated he was not aware of any QAPI (quality assurance and performance improvement) plans in place at the facility. 3. F727 - Based on record reviews and staff interviews the facility failed to have a Registered Nurse scheduled for 8 hours a day, 7 days a week for 5 of 32 days reviewed. (02/26/22, 05/05/22, 05/06/2), 5/07/22 and 05/27/22). During the recertification and complaint survey 9/27/19 the facility failed to staff Registered Nurse (RN) coverage for 8 consecutive hours daily during 3 out of 3 months reviewed for RN coverage (6/2019, 7/2019 and 8/2019). An interview on 6/16/22 at 3:50 pm with the Administrator revealed this was his first week at the facility. He stated he planned to have monthly quality assurance meetings with his team. He added he had received the corporate quality assurance forms and he would be reviewing them. The Administrator indicated he was not aware of any QAPI (quality assurance and performance improvement) plans in place at the facility. 4. F925 - Based on observations, record review, resident and staff interview the facility failed to provide a pest free living environment for 8 of 91 residents residing in the facility. (Resident #58, Resident #5, Resident #25, Resident #34, Resident #49, Resident #77, Resident #10 and Resident #74) During the recertification and complaint survey 9/27/19 the facility failed to maintain an effective pest control program (room [ROOM NUMBER] and hallway between room [ROOM NUMBER] and room [ROOM NUMBER]). An interview on 6/16/22 at 3:50 pm with the Administrator revealed this was his first week at the facility. He stated he planned to have monthly quality assurance meetings with his team. He added he had received the corporate quality assurance forms and he would be reviewing them. The Administrator indicated he was not aware of any QAPI (quality assurance and performance improvement) plans in place at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A meeting was held with the facility Resident Council on [DATE] at 11:31 am. Resident #34, Resident #49, Resident #77, Resident #10 and Resident #74 were present. All residents present identified issues with bugs in their rooms. Resident #49 stated the facility had an issue with roaches for more than a year. She added a roach crawled on her yesterday while she was sitting in her chair. Resident #49 indicated the Administrator was aware of the issue, but they haven ' t seen any changes. All residents present agreed the facility had an issue with roaches that had not been remedied. Review of the resident council minutes dated [DATE] revealed in part, a grievance was lodged during the meeting regarding pest control. The contract exterminator company was contacted and made a visit to the facility on [DATE]. Review of the pest control contract dated [DATE] revealed in part, service would be provided monthly for cockroach and rodent elimination. Insecticide could be used in vacant resident rooms upon request. Review of a pest control service report dated [DATE] revealed insecticide was applied to target cockroaches. This was applied to fire door introduction point, front door introduction point, interior hallways, interior kitchen area, interior laundry / housekeeping areas, and room [ROOM NUMBER]. An interview on [DATE] at 2:30 pm with the pest control technician revealed he had been providing pest control services at the facility for a year or two. He stated he treated the facility on [DATE] and did not see any signs of live cockroaches. He explained he sprayed insecticide to interior areas the best he could. The technician added he could only treat a resident room if it was vacant, and he had treated room [ROOM NUMBER] on this visit. He stated the facility did not routinely request him to treat specific resident rooms. He indicated he would work with the facility to come up with a plan to eliminate pests. An interview on [DATE] at 4:50 pm with the Administrator revealed he would work with their pest control technician to try and eliminate the roaches. Based on observations, record review, resident and staff interview the facility failed to provide a pest free living environment for 8 of 91 residents residing in the facility. (Resident #58, Resident #5, Resident #25, Resident #34, Resident #49, Resident #77, Resident #10 and Resident #74). Findings Included: 1. During the tour on [DATE] at 11:11 am an observation was made of a roach crawling on the floor of room [ROOM NUMBER]. Resident #58 who was present in the room during the observation stated they were not able to see any pests due to vision problems. Review of the facility maintenance logs from [DATE] to present did not identify any pest issues for room [ROOM NUMBER]. Review of the pest control contract dated [DATE] revealed in part, service would be provided monthly for cockroach and rodent elimination. Insecticide could be used in vacant resident rooms upon request. Review of a pest control service report dated [DATE] revealed insecticide was applied to target cockroaches. This was applied to fire door introduction point, front door introduction point, interior hallways, interior kitchen area, interior laundry / housekeeping areas, and room [ROOM NUMBER]. An interview on [DATE] at 2:30 pm with the pest control technician revealed he had been providing pest control services at the facility for a year or two. He stated he treated the facility on [DATE] and did not see any signs of live cockroaches. He explained he sprayed insecticide to interior areas the best he could. The technician added he could only treat a resident room if it was vacant, and he had treated room [ROOM NUMBER] on this visit. He stated the facility did not routinely request him to treat specific resident rooms. He indicated he would work with the facility to come up with a plan to eliminate pests. An interview on [DATE] at 4:50 pm with the Administrator revealed he would work with their pest control technician to try and eliminate the roaches. 2. An observation of room [ROOM NUMBER] on [DATE] at 9:03 am revealed a roach was crawling on the wall bedside the bathroom door. An interview on [DATE] at 9:10 am with NA #1 revealed she saw roaches on occasion and would try and kill them. NA #1 added she had reported the sightings to the previous Administrator and Director of Nursing. Review of the facility maintenance logs from [DATE] to present did not identify any pest issues for room [ROOM NUMBER]. Review of the pest control contract dated [DATE] revealed in part, service would be provided monthly for cockroach and rodent elimination. Insecticide could be used in vacant resident rooms upon request. Review of a pest control service report dated [DATE] revealed insecticide was applied to target cockroaches. This was applied to fire door introduction point, front door introduction point, interior hallways, interior kitchen area, interior laundry / housekeeping areas, and room [ROOM NUMBER]. An interview on [DATE] at 2:30 pm with the pest control technician revealed he had been providing pest control services at the facility for a year or two. He stated he treated the facility on [DATE] and did not see any signs of live cockroaches. He explained he sprayed insecticide to interior areas the best he could. The technician added he could only treat a resident room if it was vacant, and he had treated room [ROOM NUMBER] on this visit. He stated the facility did not routinely request him to treat specific resident rooms. He indicated he would work with the facility to come up with a plan to eliminate pests. An interview on [DATE] at 4:50 pm with the Administrator revealed he would work with their pest control technician to try and eliminate the roaches. 3.During the tour on [DATE] at 11:30 AM, two dead roaches were observed in the bathroom in room [ROOM NUMBER]. Resident #25 who was present during the observation indicated she had observed roaches coming from the missing baseboard on her side of the room. She stated the baseboard was rotten and popping up and someone removed it, but it has never been replaced. An interview was conducted with a family member (FM) on [DATE] at 3:30 PM, who indicated she had visited Resident #25 on [DATE]. The FM indicated she observed roaches coming out of the baseboard during her visit. A review of the facility maintenance logs from [DATE] to present for pest control revealed no concerns for room [ROOM NUMBER]. Review of the pest control contract dated [DATE] revealed in part, service would be provided monthly for cockroach and rodent elimination. Insecticide could be used in vacant resident rooms upon request. Review of a pest control service report dated [DATE] revealed insecticide was applied to target cockroaches. This was applied to fire door introduction point, front door introduction point, interior hallways, interior kitchen area, interior laundry / housekeeping areas, and room [ROOM NUMBER]. An interview on [DATE] at 2:30 pm with the pest control technician revealed he had been providing pest control services at the facility for a year or two. He stated he treated the facility on [DATE] and did not see any signs of live cockroaches. He explained he sprayed insecticide to interior areas the best he could. The technician added he could only treat a resident room if it was vacant, and he had treated room [ROOM NUMBER] on this visit. He stated the facility did not routinely request him to treat specific resident rooms. He indicated he would work with the facility to come up with a plan to eliminate pests. An interview on [DATE] at 4:50 pm with the Administrator revealed he would work with their pest control technician to try and eliminate the roaches.