**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 residents (Residents #24) reviewed for grievances. Finding included: Resident #24 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident #24 was assessed as severely cognitively impaired. Review of the Grievance /Concern Form dated 6/24/24 indicated a concern that was reported by Resident #24's responsible party (RP) regarding bruising of the resident's left arm, left hand and right forearm. Action indicated was the management was notified, abuse investigation sheet completed, law enforcement was notified and the staff member in question was taken off of the schedule. The form indicated the grievance was under investigation. This was signed by Administrator indicating the grievance was received. There was no indication on the form that indicated the complainant, resident, or family was contacted to inquire if the grievance was resolved to their satisfaction. The grievance was not signed off as resolved. During an interview on 9/16/24 at 11:50 AM, Resident #24's RP indicated she had reported her concerns about the bruising on resident's arms to the Administrator and to the hospital management. The RP stated both the nursing home administration, and the hospital administration were in the same building and under same management. Resident #24's RP stated she had not been made aware as to how her allegation was investigated nor how it was resolved. She explained no written summary of the grievance investigation or resolution was provided to her. During an interview on 9/16/24 at 3:37 PM, the Social Worker (SW) indicated she was the grievance coordinator. When any grievance was received from any resident or family member by any staff, it was directed to the appropriate department for investigation and resolution. Once the grievance was investigated and a resolution was reached, it would be discussed in the morning team meeting with all nursing staff. The SW further indicated that she would notify the family about the resolution and that the resolution was to the satisfaction of the family/ resident. The resolved Grievance was placed in a folder and entered in the log. The Social Worker stated she was not aware of the grievance written on 6/24/24 from Resident #24's RP and hence not documented in the Grievance log. The SW stated the resident's RP concern was investigated as abuse investigation. Due to being investigated as abuse, the investigation was conducted by the Administrator. During an interview on 9/19/24 at 2:20 PM, the Administrator, stated he had spoken with the resident's RP regarding the abuse allegation 1-2 days after the grievance was received. The Administrator further stated the resident's RP was made aware that the abuse allegation was been investigated. The NA involved was suspended and would not be returning to the facility. The NA was an agency staff, and the agency was made aware about it. The Administrator stated he had not documented the resolution as it was an abuse investigation, nor did he record any information regarding his conversation with the family in the grievance form. The investigation findings were sent to the state. He further stated the family was aware of the outcome of the investigation. The family was made aware the allegation was unsubstantiated. The Administrator stated he did not provide them with any written documentation regarding the resolution. He indicated it was an abuse investigation and no findings were discussed with the family. With regards to the grievance given to the Hospital Quality Director, he indicated it was a different entity and unsure of the outcome.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide fingernails and toenails care for 2 of 2 residents, dependent on staff for activities of daily living (ADL) care. (Resident # 37 and Resident #24) Findings included: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired. The assessment indicated that Resident #37 was dependent on staff for Activities of Daily Living (ADL) including personal hygiene, toileting and showers/ bathe self. Review of the care plan dated 6/27/24 indicated the resident was care planned for ADL self-care performance deficit due to impaired balance, activity intolerance, and confusion. Interventions for bathing and showering included checking nail length, trimming and cleaning on bath day and as necessary. The resident was totally dependent on staff to provide bed bath and/or shower. The Skin monitoring: comprehensive Certified Nurse Aide (CNA) shower review for 9/12/24 and 9/16/24 were reviewed. On the form the question does the resident need his/her fingernails/toenails cut? Was marked as NO. Review of the ADL Tracking Documentation for August and September 2024 revealed bathing activity was marked on every Monday and Thursday of the week during the 3 PM- 11 PM shift. The resident was noted to be totally dependent on staff and needed one-person physical assistance. The documentation did not indicate if the resident received a bed bath or shower. During an observation and interview on 9/15/24 at 10:20 AM, Resident #37's fingernails on both her hands were observed to be about 1 to 1 and one fourth inch long from the nail bed. There was some light black deposit under the fingernails. The resident stated she preferred her fingernails trimmed, however there was on one who could trim her nails. During an interview on 9/16/24 at 10:33 AM, Resident #37 indicated she had asked a Nurse Aide (NA) to trim her nails in the morning. The NA had reported to her that her nails would be cleaned and trimmed at 2 PM that day. Resident indicated she wanted her nails cleaned and trimmed so she asked the NA who was assisting her with care that morning. During an observation on 9/17/24 at 8:25 AM, Resident #37 was observed propped up in her bed and turned to her left side. Observation revealed the resident's fingernails were not trimmed. Resident indicated no staff had come back to trim her nails on 9/16/24. On 9/17/24 at 8:38 AM, Nurse #5 was interviewed. Nurse #5 observed Resident #37's fingernails and indicated the resident's nails should have been trimmed. Nurse #5 stated when residents were provided a bed bath or shower, the assigned NA completed a skin and nails check. The NA should indicate on the shower sheets if the nails needed to be trimmed and/or if the nails were trimmed. Nurse stated if the resident was not diabetic then the NAs could trim their nails. However, if the resident was diabetic then the NA needed to inform the assigned nurse. Resident #37 was not diagnosed with diabetes mellitus and the NA should have trimmed her nails. Nurse#5 stated the resident received a completed bed bath the day prior (9/16/24) and should had her nails checked and trimmed. During an interview on 9/19/24 at 10:12 AM, NA #1 indicated she was assigned to Resident #37 and had offered a bed bath on 9/16/24. NA #1 stated the resident did not request her to trim her nails on the 9/16/24. NA indicated skin and nails check were completed during bed bath and/or shower. Nails were trimmed if needed. NA indicated she had not noticed the resident's fingernails and hence had not trimmed them. During an interview on 9/17/24 at 8:44 PM, the Director of Nursing (DON) stated the NAs were responsible to trim residents' finger and toenails when the residents were not diabetic residents. The DON further stated the NAs had to complete a full body check when bed bath or shower was offered. The DON observed Resident #37's fingernails and stated the assigned NAs should have trimmed her nails when a complete bed bath was offered. 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included secondary malignant neoplasm of the bone. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was assessed as severely cognitively impaired. The assessment indicated that the resident was dependent on staff for Activities of Daily living. A revised care plan dated 8/9/24 indicated Resident #24 was care planned for ADL care due to diagnoses of cancer, dementia and depression. Interventions included providing a sponge bath when a full bath or shower was not tolerated. Resident was totally dependent on staff for showers and bed bath. NAs to provide skin inspection daily with care. On 9/15/24 at 10:06 AM, during an observation, Resident #24's toes nails on both feet were observed to be one and a half inches beyond the nail bed. The pinky toe nails on both feet had toenails growing into the toe next to it. On 9/17/24 at 1:25 PM, during the observation of incontinence care, Resident #24's toenails were observed clean and approximately one and a half inches long, with deformities. The resident did not have signs of discomfort. During an interview on 9/19/24 at 10:12 AM, NA #1 indicated she was assigned to Resident #24. NA stated the resident received bath and showers from both facility and hospice staff. NA indicated she did provide the resident a bed bath and had not looked at or noticed the resident's toenails. During an interview on 9/17/24 at 8:38 AM, Nurse #5 stated the resident was under hospice care. Both facility staff and hospice staff provided care for the resident. Nurse #5 stated the hospice staff were responsible for trimming resident's nails. During a telephone interview on 9/19/24 at 8:23 AM, the hospice nurse stated the hospice NAs do not trim the resident's finger or toenails. It was the responsibility of facility nursing staff to provide nail care. During an interview on 9/17/24 at 8:44 PM, the Director of Nursing (DON) indicated the NAs were responsible to trim residents' finger and toenails when the residents were not diabetic residents. The DON further stated the NAs had to complete a full body check when bed bath or shower was offered. The DON stated the nursing staff should be checking and providing nail care to all residents as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interest and needs for 3 of 3 cognitively impaired residents reviewed for activities(Resident #22, Resident #27 and Resident #28). The findings included: 1.Resident #22 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident #14 was coded on the annual Minimum Data Set(MDS) dated 8/24/24 as having cognition impairment and she needed assistance with activities. The MDS also coded Resident 22 's activity interest as very important to participate in favorite activities to include music, religious service and outside events. The resident was coded for total assistance with transfers and locomotion. The annual activity assessment dated [DATE] revealed Resident #'22s preference with interest in listening to music, religious services, and outside events. A focus area on the care plan dated 8/25/24 revealed Resident #22 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The goal included Resident #22 would maintain involvement in cognitive stimulation, social activities as desired. The interventions included to ensure the activities Resident #22 attended was compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities and age appropriate. Invite the resident to scheduled activities. Introduce the resident to other residents in similar activities. The facility developed a list on 8/20/24 of residents who needed assistance to be transported to activities and Resident #22 was identified as person who needed assistance to activities. Record review revealed there were no activity notes available after the assessment 8/24/24 for Resident #22.There were no documented notes of participation in activities for Resident #22 prior to 8/24/24. The activity calendar on 9/15/24 offered the following activities at 10:00 AM coffee time,10:30AM at 11:00 AM gospel hymns, 1:00 PM-2:00 PM, room visits movies and 2:00 PM-4:00 PM activities with Ladystany. Staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. An observation was conducted on 9/15/24 at 9:58 AM, there was an activity calendar posted on the resident's bulletin board where resident could see the events of the day. Resident #22 was observed in bed staring at the wall. Resident#22 reported she does like church/gospel events. She reported the activity person does ask but nursing staff does not usually ask. She indicated no one asked her this morning to go anywhere. The scheduled activity for 9/15/24 at 10:00 AM coffee time, 10:30AM at 11:00 AM gospel hymns, Resident #22 was not up or dressed to participate in any of the scheduled activity of her interest. The activity calendar on 9/16/24 offered the following activities at 10:00 AM devotion, 11:00 AM bowling 11:30 AM snack activity and 2:00 PM-4:00 PM tic-tac-toe. Observations was conducted on 9/16/24 at 10:00 AM, the scheduled activity was devotion and 10:30 AM, Resident #22 was lying in bed, staring at the wall. The television was not on, and the resident reported she had attended some activities in the past but was not able to get herself up and ready for the activity. She stated she depended on staff. She reported staff don't get most residents up on the weekend. She reported she would have liked to participate in the devotion. Staff were observed in other resident rooms providing care. An interview was conducted on 9/16/24 at 1:45 PM, with the Activity Director who stated she developed a list of residents who needed staff assistance and transport to activities on 8/20/24 and provided the information to the management team. She indicated several residents who benefited and enjoyed activities were not ready or transported to activities when scheduled activities on their interest was being conducted. The Activity Director stated she would go room by room asking residents to participate and attend activities, but they would not be ready or get to the activity until nearly the end or not at all. She reported the concern was discussed in the management meetings and the plan was for all staff to ask residents if they wanted to participate and attend activities. The nursing team was in-serviced in August to get the identified resident up for activities and transport them to activities. She further stated was unable to escort all the residents, resulting in the identified residents not participating in activities. She further stated she was unaware she needed to document resident participation in the resident record. The Activity Director stated she only kept resident attendance and primarily the same residents attend the activities. She confirmed after review of the record there had been no documented activities notes since 2022 of resident participation in activities. Observation on 9/16/24 at 2:00 PM, tic -tac-toe in progress: Observation and interview were conducted and revealed Resident #22 remained in bed watching television. Resident #22 stated she would like to participate in activities, but staff did not get her out of bed, and she would have loved to see what was going on. An interview was conducted on 9/17/24 at 4:42 PM, with the Administrator who stated the nurse aides were responsible for asking resident daily if they wanted to get up and participate in facility activities. He reported there was a list of residents identified based on the quality improvement of residents who needed assistance with transport to activities. The identified residents included the residents who would participate in activities either morning or the afternoon scheduled activities. The Nurse Aides and Nursing should be asking all residents and assisting residents to the desire activities. The Nurses would document in the record the resident refusal to participate in activities. An interview was conducted on 9/18/24 at 8:40 AM, with the Staff Development Coordinator who stated all staff were in-serviced on 8/8/24 regarding the quality improvement plan to ensure staff were getting the identified residents who needed assistance with transport to activities up for scheduled activities. Staff were informed to notify the nurse and activity director when a resident refused to get up for an activity and document in the resident record. An interview was conducted on 9/19/24 at 9:43 AM, with Nurse #1 who stated she worked the weekend and during the week stated and she did not receive a report from any of the aides that any resident on the activity list refused to participate in activities. She indicated the training consisted of aides reporting to nursing when a resident refused to get up or participate in activities and she would document in the record the resident refused activities. Staff were expected to assist and transport resident to activities. She indicated nursing would attempt to encourage the resident to participation. An interview was conducted on 9/18/24at 10:00 AM, the Nurse Aide#1 who was assigned to Resident #22 stated everyone was responsible for asking residents if they wanted to get up and participate in activities. She reported when she worked on 9/15/24 she did not report to nursing that any of the resident refused activities. An interview was conducted on 9/19/24 at 9:43 AM, the Director of Nursing stated the staff should be encouraging/offering and assisting residents to participate in their preferred activities of interest daily. The Nurse Aide should notify nursing and the Activity Director of any resident who refused activities.Nursing should be documenting in the resident chart when a resident refused participation in activities. An interview was conducted on 9/19/24 at 1:00 PM, with the Social Worker who stated the resident was identified in the quality improvement program as one of the residents who needed assistance to activities. Several meetings and discussions have been held with nursing and management staff about getting resident up and ready for activities and providing transport to the activities, however the nurses and aides continue to not assist residents. Nurse Aides and Nursing staff have received an in-service in August about assisting residents to activities and reporting directly to nurse when the residents on the identified list refused to get up for activities. Nursing would encourage residents to participate in activities and document in the resident record, however, there had been no consistent follow-up the quality improvement plan. 2. Resident #27 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident #27 was coded on the Minimum Data Set(MDS) dated [DATE] as having cognition impairment and she needed assistance with activities. The MDS also coded Resident #27 's activity interest as very important to participate in favorite activities to include music and news and current events. The resident was coded for total assistance with transfers and locomotion. The annual activity assessment dated [DATE] revealed Resident #'27s preference with interest in listening to music, news, current events bingo, animals, religious events and outside activities. A focus area on the care plan dated revealed Resident #27 had little, or no activity involvement related to physical limitations and depression. The goal included Resident #27 would express satisfaction with type of activities and level of activity involvement when asked. The interventions included invite/encourage the resident's family members to attend activities with resident to support participation. The facility developed a list on 8/20/24 of residents who needed assistance to be transported to activities and Resident #27 was identified as person who needed assistance to activities. Record review revealed there were no activity notes available after the assessment 5/10/24 for Resident #27. There were no documented notes of participation in activities for Resident #27 prior to 5/10/24. The activity calendar on 9/15/24 offered the following activities at 10:00 AM coffee time, 10:30AM at 11:00 AM gospel hymns, 1:00 PM-2:00 PM, room visits movies and 2:00 PM-4 PM activities with Ladystany. Staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. An observation was conducted on the hall at 9:55 AM-10:00 AM at 9/15/24 of the Nurse Aide#1 assigned to Resident #27. The Nurse Aide #1 stated the Aides should offer the resident the opportunity to get up and go to the activities of the day and assist with transport to the activity. The Nurse Aide #1 stated if the nurse aides were providing care, they were unable to take residents to activities at the start of the activities and maybe only able to take the residents toward the end of the activity. The Nurse Aide#1 stated she would let the nurse know when a resident refused activities. Nurse Aide#1 did not state why she did not offer the resident assistance to get up for activities. An observation was conducted on 9/15/24 at 11:30 AM, Resident #27 was in bed she stated she does like to go to activities. She reported on Sunday afternoons her husband and son visits, so going in the morning was fine unless she did not feel well. She reported on the weekends, no one really asks, and she was no sure if activities were happening. She pointed to the calendar on the wall and stated she had not been asked to go to anything in the morning. The activity calendar on 9/16/24 offered the following activities at 10:00 AM devotion, 11:00 AM bowling 11:30 snack activity and 2:00 PM -4 PM tic-tac-toe. An observation was conducted on 9/16/24 at 10:30 AM the scheduled activity was devotion; Resident #27 was in her room and staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. Resident #27 was observed in bed humming some church songs in her room. She stated she really loved church services and music and food parties the facility had down in the activity room. She indicated no one came to and get her out of bed anymore for activities. She stated she could not take herself to activities without assistance so just ended up hanging out in bed. Resident #27 further stated she would have liked to go to the devotion activities, but no one asked her if she wanted to get up for activities. Nurse Aide #9 who was assigned to Resident #27 stated she was working with another resident and could not assist with taking resident to the activity. She indicated all residents should be asked if they wanted to participate in activities. She reported she was aware of the list of residents that needed assistance, however, due to care responsibilities she was unable to get residents up early enough prior to the activities. She does her best to get individuals to the remaining activities. An interview was conducted on 9/16/24 at 1:45 PM, with the Activity Director who stated she developed a list of residents who needed staff assistance and transport to activities on 8/20/24 and provided the information to the management team. She indicated several residents who benefited and enjoyed activities were not ready or transported to activities when scheduled activities on their interest was being conducted. The Activity Director stated she would go room by room asking residents to participate and attend activities, but they would not be ready or get to the activity until nearly the end or not at all. She reported the concern was discussed in the management meetings and the plan was for all staff to ask residents if they wanted to participate and attend activities. The nursing team was in-serviced in August to get the identified resident up for activities and transport them to activities. She further stated was unable to escort all the residents, resulting in the identified residents not participating in activities. She further stated she was unaware she needed to document resident participation in the resident record. The Activity Director stated she only kept resident attendance and primarily the same residents attend the activities. She confirmed after review of the record there had been no documented activities notes since 2022 of resident participation in activities. The activity calendar on 9/17/24 offered the following activities at 10:00 AM pet therapy, 10:30 AM perfection , 11:00AM coffee activity and 2:00 PM-4:00 PM bowling. An interview was conducted on 9/17/24 at 1:46 PM, the scheduled activity was bowling at 2:00 PM. Resident #27 reported staff did not come and ask her if she wanted to participate in activities. She reported she enjoyed the bingo, music. There was an overhead announcement but of the activity, but no staff came to the room to ask if she wanted to get up and go to the activity. 3. Resident #28 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident # 28 was coded on the admission Minimum Data Set(MDS) dated [DATE] as having cognition impairment and she needed assistance with activities. The MDS also coded Resident#28 's activity interest as very important to participate in favorite activities to include music, pets group activities, religious services and outside events. The resident was coded for total assistance with transfers and locomotion. The activity assessment dated [DATE] revealed Resident #'28s preference with interest include music, pets group activities, religious services and outside events. The resident was coded for total assistance with transfers and locomotion. The facility developed a list on 8/20/24 of residents who needed assistance to be transported to activities and Resident #28 was identified as person who needed assistance to activities. A focus area on the care plan dated 6/25/24 revealed Resident #28 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The goal included Resident #28 would maintain involvement in cognitive stimulation, social activities as desired. The intervention included invite the resident to scheduled activities. Staff would provide Resident #28 with an activities calendar. Notify resident of any changes to the calendar of activities. Resident #28 needs assistance/escort to activity functions. Record review revealed there were no activity notes available after the7/11/24 assessment for Resident #28. There were no documented notes or participation records for Resident #28 prior to the 7/11/24. The activity calendar on 9/15/24 offered the following activities at 10:00 AM coffee time, 10:30AM at 11:00 AM gospel hymns, 1:00 PM-2:00 PM, room visits movies and 2:00 PM-4:00 PM activities with Ladystany. Staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. The activity calendar on 9/16/24 offered the following activities at 10:00 AM devotion, 11:00 AM bowling 11:30 AM snack activity and 2:00 PM-4 PM tic-tac-toe. An observation was conducted on 9/15/24 at 9:55 AM, Resident #28 was in her resident sitting up in bed. There was no television on, and the resident continued to ask what was going on in the hall area. She reported she liked to go to activities but had to wait for people to come get and get her up and take her down to the room. She indicated no one asked if she wanted to go to the activities. Resident #28 reported she liked to get up every day, enjoyed church music, table activities, bingo and food stuff. The resident was not asked to participate in the scheduled 10:00 AM coffee activity. The assigned Nurse Aide #13 was in another room, all other aides were in other rooms. Observation was conducted on 9/15/24 at 1:59 PM, Resident #28 resident was not in any activity, she was resident was in her room. She stated was not asked to be taken to any of the activities for the day. Resident #28 stated she did not know what was going on and would have like to go to activities, but no one got her out of bed. An observation was conducted on 9/16/24 at 10:30 AM, Resident #28 was in her room yelling out to get out of bed, the assigned Nurse Aide #9 was in another room. resident was not taken to the activity room until 11:30 AM. Nurse Aide #9 stated she was working with other residents and had not been able to get the resident up any early. She further stated the nurse aides should offer the resident the opportunity to get up and go to the activities of the day. The nurse aide stated if the nurse aides were providing care, they were unable to take residents to activities at the start of the activities and maybe only able to take the residents toward the end of the activity. She indicated the weekends were very difficult to get all residents to activities due to limited staff. An interview was conducted on 9/16/24 at 1:45 PM, with the Activity Director who stated she developed a list of residents who needed staff assistance and transport to activities on 8/20/24 and provided the information to the management team. She indicated several residents who benefited and enjoyed activities were not ready or transported to activities when scheduled activities on their interest was being conducted. The Activity Director stated she would go room by room asking residents to participate and attend activities, but they would not be ready or get to the activity until nearly the end or not at all. She reported the concern was discussed in the management meetings and the plan was for all staff to ask residents if they wanted to participate and attend activities. The nursing team was in-serviced in August to get the identified resident up for activities and transport them to activities. She further stated was unable to escort all the residents, resulting in the identified residents not participating in activities. She further stated she was unaware she needed to document resident participation in the resident record. The Activity Director stated she only kept resident attendance and primarily the same residents attend the activities. She confirmed after review of the record there had been no documented activities notes since 2022 of resident participation in activities. An interview was conducted on 9/17/24 at 4:42 PM, with the Administrator who stated the nurse aides were responsible for asking the resident if they wanted to get up and participate in facility activities. He reported there was a list of residents identified based on the quality improvement of residents who needed assistance with transport to activities. The identified residents included the residents who would participate in activities either morning or the afternoon scheduled activities. The Nurse Aides and Nursing should be asking all residents and assisting residents to the desire activities. The Nurses would document in the record the resident refusal to participate in activities. An interview was conducted on 9/18/24 at 8:40 AM, with the Staff Development Coordinator who all staff were in-serviced on 8/8/24 regarding the quality improvement plan to ensure staff were getting the identified residents who needed assistance with transport to activities up for scheduled activities. Staff were informed to notify the nurse and activity director when a resident refused to get up for an activity and document in the resident record. An interview was conducted on 9/19/24 at 9:30 AM, Nurse Aide #13 stated she had been assigned to Resident #28 the weekend and was unable to transport resident to the activity due to assisting other residents. The Nurse Aide #13 stated staff should offer the resident the opportunity to get up and go to the activities of the day. The nurse aide stated if the nurse aides were providing care, they were unable to take residents to activities at the start of the activities and maybe only able to take the residents toward the end of the activity. Nurse [NAME] #13 stated she did not report any residents who refused activities on the weekend due to being busy providing care. An interview was conducted on 9/19/24 at 9:43 AM, the Director of Nursing stated the staff should be encouraging/offering and assisting residents to participate in their preferred activities of interest daily. The Nurse Aide should notify nursing and the Activity Director of any resident who refused activities. Nursing should be documenting in the resident chart when a resident refused participation in activities. An interview was conducted on 9/19/24 at 1:00 PM, with the Social Worker who stated the resident was identified in the quality improvement program as one of the residents who needed assistance to activities. Several meetings and discussions have been held with nursing and management staff about getting resident up and ready for activities and providing transport to the activities, however the nurses and aides continue to not assist residents. Nurse Aides and Nursing staff have received an in-service in August about assisting residents to activities and reporting directly to nurse when the residents on the identified list refused to get up for activities. Nursing would encourage residents to participate in activities and document in the resident record, however, there had been no consistent follow-up the quality improvement plan.

Based on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin for 1 of 3 medication administration carts, failed to date opened multi-dose vials of insulin medication for 2 of 3 medication administration carts, and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (rehabilitation hall, short and long halls). Findings Included: 1a. On 9/15/24 at 9:15 AM, an observation of the medication administration Rehabilitation Hall cart with Nurse #1 revealed one opened and undated multi-dose vial of Insulin Glargine. A review of the manufacturer's literature indicated to discard Glargine multi-dose vial 28 days after opening. 9/15/24 at 9:40 AM, during an interview, Nurse #1 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this shift. b. 9/15/24 at 9:40 AM, an observation of the Long Hall medication administration cart with Nurse #2 revealed one, opened undated, half-empty multi-dose vial of Novolog insulin, one expired Basaglar Kwik Pen Insulin, opened on 8/15/24, one expired Humalog Pen (insulin), opened on 8/3/24, and one expired Insulin Aspart Flex pen, opened on 9/1/24. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening. On 9/15/24 at 9:40 AM, during an interview, Nurse #2 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this shift. On 9/16/24 at 9:30 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for putting the date of opening on multi-dose medication containers, checking all the medications in medication administration carts for expiration date and remove expired medications every shift. He expected that no expired items or loose pills be left in the medication carts. 2a. On 9/15/24 at 9:15 AM, an observation of the medication administration Rehabilitation Hall cart with Nurse #1 revealed in the second draw of the medication cart there were noted two white loose capsules and one pink round shape loose pills. On 9/15/24 at 9:20 AM, during an interview, Nurse #1 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #1 did not clean the cart before her shift. b. On 9/15/24 at 9:25 AM, an observation of the medication administration Short Hall cart with Nurse #3 revealed in the first draw of the medication cart there was one white and three pink round shape loose pills. On 9/15/24 at 9:25 AM during an interview, Nurse #3 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #3 did not clean the cart before her shift. On 9/16/24 at 9:30 AM, during an interview, the Director of Nursing (DON) expected that no loose pills be left in the medication carts. On 9/16/24 at 10:50 AM, during an interview, the Administrator indicated that all the nurses were responsible for putting the date of opening on multi-dose medication containers, checking all the medications in medication administration carts for expiration date and remove expired medications every shift. He expected that no expired items or loose pills be left in the medication carts.

Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 of the 33 days reviewed for staffing. The findings included: A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 8/17/24 through 9/18/24 was conducted on 9/19/24. A. On 8/24/24 the daily staff posting indicated 1 RN working day shift (7 AM - 3PM). Daily posting also indicated 2 Licensed Practical Nurse (LPN) and 2 NA working night shift (11PM - 7 AM). Review of the nursing staff assignment sheet for 8/24/24 indicated the RN, Nurse #9, working from 7 AM - 7 PM. The RN, Nurse #9, was also assigned to work as a Nurse Aide from 11 PM to 7 AM. Review of the staff clock-in sheet revealed no RN working from 7 AM - 3 PM shift. Further review revealed there was no RN working for the period of 3 PM -11 PM. An RN, Nurse #9, had clocked in at 11:00 PM. There was only one NA clocked in at 11 PM. During an interview on 9/19/24 at 3:15 PM, Nurse #9 indicated she was a Registered Nurse and worked as an NA when needed. She indicated on 8/24/24 she had worked on the floor as an NA and not as an RN. She indicated her assignment was indicated in the assignment sheet. She stated she was not in the facility from 7 AM - 7 PM on 8/24/24. B. On 8/25/24 the daily staff posting indicated 1 RN working day shift (7 AM- 3 PM) and 2 LPNs working evening (3 PM - 11 PM) and night shift (11 PM- 7 AM). Review of the staff clock-in sheet revealed no RN working from 7 AM - 7 PM shift. Review of the nursing assignment sheet did not indicate an RN working the 7 AM -7 PM shift. During an interview on 9/19/24 at 3:44 PM, the scheduler indicated the facility did not have any agency Nurse aides. They however had contract with an agency for nurses. The scheduler stated on days when there was an NA call out and the slot was unable to be filled by another NA then a nurse was called into fill the slot. The scheduler indicated as there was a RN in the building, the regulations for RN for 8 hours a day was met, During an interview on 9/19/24 at 4:34 PM, the Administrator indicated the call out policy was for staff to call the management 2 hours prior to their shift. The scheduler ensures that the call out slots were filled by staff who were willing to work overtime or by another staff not on assignment that day. The Administrator further indicated the facility had no NAs who were from agency. They however had agency nurses working for them. The Administrator stated nurses (both Registered nurse and License Practical Nurse) were called to fill in assigned NA shifts when needed. These Nurses worked as NAs and helped with patient care. The Administrator further stated when there was only one RN in the building and was assigned NA duty, the RN was also responsible to complete her duties as both a Nurse and Nurse Aide. The Administrator stated the requirement for RN for 8 hours was met, when the RN was in the facility and was working a NA.

Based on observation and staff interviews, the facility failed to post the daily nurse staffing information for residents and visitors on 1 of the 4 days of the survey period. The facility also failed to update the daily staffing information to reflect actual staffing changes for 6 of 33 days reviewed for posted nurse staffing information. Finding included: 1. On 9/15/24 (Sunday) during the facility initial tour at 9:20 AM and for multiple observations throughout the day including 1:30 PM and 3 PM, the daily nurse staffing sheet posted near the facility elevator was dated 9/13/24 (Friday). The posting was not updated to reflect the current date, census, and staffing information. During an interview on 9/17/24 at 8:09 AM, the scheduler stated she was responsible for posting the daily staff posting during the weekdays. The scheduler stated she completed the staffing form for the weekend and left the posting sheet in a folder near the nurse's station. She explained the weekend nurses were responsible for posting and updating the daily staffing sheets on the weekend. During an interview on 9/17/24 at 9:49 AM, the Minimum Data Set (MDS) Nurse stated she was the nurse working on 9/15/24. She indicated all nurses over the weekend were responsible for ensuring the staff posting was updated near the elevator. The MDS Nurse stated she forgot to look at the posting and post an updated staff posting. During an interview on 9/17/24 at 1:59 PM, Nurse #3 stated she was hired 3 weeks ago and worked on 9/15/24. She added she was not aware that as a weekend nurse she was responsible for changing the staff posting over the weekend. During an interview on 9/19/24 at 1:14 PM, Nurse #1 stated she was the charge nurse over the weekend of 9/14/24 and 9/15/24. She added she was not aware she was responsible for changing the staff posting over the weekend. 2. Review of the daily nursing staff postings from 8/17/24 through 9/18/24 and staff clock in sheets for the same period was conducted on 9/19/24. The daily posted staffing indicated the facility did not update the posting to reflect staffing changes for the following: - On 8/24/24 the daily staff posting indicated 1 Registered Nurse (RN) and 3 Licensed practical Nurses (LPN) for day shift (7 AM-3 PM). Review of the staff clock in sheets revealed no RN and 2 LPNs were working for day shift. - On 8/25/24 the daily staff posting indicated 1 RN and 3 LPNs for day shift. Night shift (11 PM - 7 AM) indicated 4 Nurse Aides (NA). Review of the staff clock in sheets revealed no RN and 2 LPNs working for day shift. There were only 2 NAs working for the night shift. - On 8/30/24 the daily staff posting indicated 4 NAs working the evening shift (3PM - 11PM). Review of the staff clock in sheet revealed only 3 NAs working. - On 8/31/24 the staff posting indicated 2 RNs working the day shift. Review of the staff clock in sheet revealed only 1 RN working for the day shift. - On 9/1/24 the daily staff posting indicated 4 NAs for day shift, 5 NAs for evening shift and 3 NAs for night shift. Review of the staff clock in sheets revealed 3 NAs working for both day and evening shift. The night shift had only 2 NAs working. - On 9/14/24, the daily staff posting indicated 2 LPNs working the day shift. Review of the staff clock-in sheets revealed only 1 LPN working for the day shift. During an interview on 9/19/24 at 3:44 PM, the scheduler stated the staff schedule was made a month ahead. If any staff had a call out, then the staff posting needed to be updated. She indicated if she was in the facility, she would try to make the changes. During an interview on 9/19/24 at 5:00 PM, the Administrator stated posting should be checked by the charge nurse, scheduler or MDS clerk were responsible for oversight for posted during the weekday. The charge nurse was responsible over the weekend for ensuring that the daily nurse staffing sheet was accurately and was posted daily The Administrator stated the daily staffing sheet should be updated by the scheduler or the charge nurse to reflect the accurate staff working in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete Minimum Data Set (MDS) assessments within the regulated time frame for 2 of 8 reviewed for resident assessment (Resident # 63, and Resident # 210). Finding included: 1.Resident #63 was admitted to the facility on [DATE] with diagnoses that included heart failure and depression. A review of Resident #63's admission MDS assessment dated [DATE] revealed the MDS was incomplete and was still in progress as of 8/22/23. The admission MDS assessment was due on 8/16/23. Review of the discharge return not anticipated MDS revealed the Resident #63 was discharged on 8/23/23. During an interview on 8/22/23 at 2:55 PM, the MDS Nurse stated she was hired on 8/14/23 and was in the process of completing all pending and incomplete MDS assessments. She indicated the assessments should be completed within 14 days from the admission date. During an interview on 8/23/23 at 6:06 PM, the Administrator stated the MDS assessments should be completed and transmitted within the time frame as indicated. The Administrator indicated the facility had hired agency staff to complete MDS assessments. He stated he was in the process of directly hiring a MDS Nurse for the facility. 2.Resident #210 was admitted to the facility on [DATE] with diagnoses that included chronic pulmonary edema and hypothyroidism. A review of Resident #210's admission MDS assessment dated [DATE] revealed the MDS was incomplete and was still in progress as of 8/22/23. The admission MDS assessment was due on 8/14/23. During an interview on 8/22/23 at 2:55 PM, the MDS Nurse stated she was hired on 8/14/23 and was in the process of completing all pending and incomplete MDS assessments. She indicated the assessments should be completed within 14 days from the admission date. During an interview on 8/23/23 at 6:06 PM, the Administrator stated the MDS assessments should be completed and transmitted within the time frame as indicated. The Administrator indicated the facility had hired agency staff to complete MDS assessments. He stated he was in the process of directly hiring a MDS Nurse for the facility.

Based on record review and staff interviews the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours (hrs.) a day for 1 of 30 days reviewed. (7/23/23). Findings included: Review of the facility daily staffing schedules from 7/20/23 through 8/20/22 revealed the following: On 7/23/23 the staffing sheets indicated the facility census was 54 and 0 (zero) RN on duty. During an interview on 8/22/23 at 11:00 PM, the staff scheduler stated on 7/23/23 there was no RN assigned to the building, however she was made aware that if there was no RN on the schedule then the hospital RN supervisor would be counted as the RN for the nursing home. During an interview on 8/22/23 at 4:00 PM, The Director of Nursing (DON) stated when she was hired, she was informed that the hospital RN supervisor could be counted as the RN for the facility when there was no RN on the schedule. On 8/23/23 at 12:25 PM, the DON gave the surveyor the Job description for Person House Supervisor RN (Hospital). In the document the following was highlighted and read as follows. Nursing care: Demonstrate necessary skill and knowledge to provide care for patients according to division/unit specific competencies. Provide personal patient care to provide comfort and wellbeing to patient, acknowledging physiological and psychological needs. The DON stated based on the Hospital RN supervisor job description, the Hospital RN supervisor was responsible for the nursing home when there was no RN scheduled for the nursing home. During an interview on 8/23/23 at 5:30 PM, the Administrator stated there was a RN supervisor in the hospital and her job description indicated she would overlook both Hospital and Nursing home when there was no RN scheduled.

Based on staff interviews, the facility failed to complete performance evaluations of nurse aides at least once every 12 months and provide in-service education based on the outcome of these reviews for 2 of 2 Nurse Aides (NA) (NA #3 and NA #5). The findings included: During an interview on 8/23/23 at 10:00 AM, NA #3 stated she was hired 4 years ago. NA #3 stated she does not recollect having any performance evaluation for a long time. During an interview on 8/23/23 at 10:30 AM, NA #5 stated she was hired 5 years ago. NA #5 indicated she does not recollect any performance reviews completed annually. During an interview on 8/23/23 at 11:02 AM the Human Resource Staff (HR) stated the staff performance reviews were conducted by the appropriate department. The HR department did not maintain these files. On 8/23/22 at 4:50 PM, the Director of Nursing (DON) and Unit Manager were interviewed. Both DON and Unit Manager indicated they were unsure how staff performance was reviewed or assessed annually. The DON stated she was unable to find any documentation related to annual performance review or any education based on the annual reviews. The DON stated she would be working with the hospital education department to ensure that annual performance reviews were completed for all staff and appropriate education was provided based on these reviews. During an interview on 8/23/23 at 5:30 PM, the Administrator stated he does not have any nursing degree and the performance review for NA's should be completed by the nursing department. Education and training should be based on these reviews.

Based on resident and staff interviews and review of resident council minutes, the facility failed to provide regular resident council monthly meetings (February 2023, March 2023, April 2023, and May 2023) for 4 consecutive months. The findings included: Review of resident council meeting minutes revealed no evidence that resident council meetings were conducted from February through May 2023. The resident council meeting was held on 8/22/23 at 2:00 PM. There were 10 residents identified as alert and oriented who participated in the meeting. The members of the group reported they were regular attendees of the resident council meetings. The residents reported the facility did not have any activity staff for four months to hold resident council meetings (February through May 2023). An interview was conducted on 8/22/23 at 4:00 PM with the Activity Director. The Activity Director stated she started working in the activities department in June 2023. The Activity Director further stated there was no documentation resident council meetings were held from February 2023 through May 2023. During an interview conducted on 8/22/23 at 4:30 PM the Administrator confirmed there were no resident council meetings held for residents per record review from February 2023 through May 2023. The Administrator further stated he assumed the position April 2023 and had difficulty hiring the proper activity staff to ensure resident council meetings were being held. He stated he would be hiring an activity assistant and ensure resident council meetings were being held monthly. The Administrator was unaware of who was responsible for conducting the meetings before the Activity Director returned in June 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interests and needs to enhance the quality of life for 1 of 2 residents reviewed for activities (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE]. The diagnoses included cognitive and communication deficits. The annual Minimum Data Set (MDS) dated [DATE] coded Resident #45's cognition as moderately impaired. The resident's activity preferences indicated the following were very important: religious services, going outside for fresh air, listening to music, keeping up with the news and being around animals. He was also coded for total assistance with transfers and locomotion. The activity assessment completed by the former Activity Director, Activity Director #2, dated 4/5/23 revealed Resident #45's preference in group activities with interest in religious devotion, music, sports, bingo, community outings, pet therapy outdoor activities, current events, movies, and social events. On 8/23/23 at 10:00 AM a phone interview was attempted with the former activity director, Activity Director #2, who completed Resident #45's most recent activity assessment. She was unable to be reached. The care plan related to activities for Resident #45 dated 4/5/23 revealed conflicting information with the activity assessment of the same date (4/5/23). The care plan identified the problem as Resident #45 has little or no activity involvement related to disinterest, resident wishes not to participate. The goal included the resident would express satisfaction with type of activities and level of activity involvement when asked. The interventions included staff would explain to Resident #45 the importance of social interaction, leisure activity time. Encourage the residents' participation by talking about the activities allocated for the day. Remind the resident he may leave activities at any time and is not required to stay for entire activity. The resident prefers the following radio stations: Oldies and Gospel. The resident prefers the following TV channels: Westerns. A review of Resident #45's record from 4/5/23 through 8/19/23 revealed no evidence of the resident attending any activities. Review of the activity calendar for Sunday 8/20/23 revealed the only activity noted was independent activities. On Sunday, 8/20/23, Resident #45 was observed in bed in his room watching television during the following times: 9:00 AM, 10:30 AM, 1:00 PM, and 2:30 PM. Review of the activity calendar on 8/21/23 indicated the following activities were listed: 10:00 AM coffee hour, 11:00 AM gospel hymns, and 2:00 PM activity of choice. Observation was conducted of Resident #45 on 8/21/23 at 11:00 AM, the time that the activity of gospel hymns was scheduled. Resident #45 was in his room and staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. During an interview and observation on 8/21/23 at 11:10 AM, Resident #45 was observed in bed humming some church songs in his room. He stated he really loved church services and music and food parties the facility had down in the activity room. He indicated no one came to and get him out of bed anymore for activities. He stated he could not take himself to activities without assistance so just ended up hanging out in bed. Resident #45 further stated he just hummed his favorite songs. A telephone interview was conducted on 8/21/23 at 1:57 PM with Resident #45's responsible person. The responsible person stated she would like for the resident to participate in more activities and had been told by staff (no name or date was identified) when she called to check on Resident #45 that he participated in activities in the past. She explained that she had not seen him out of bed much lately during her visits in the past two months. She stated he may or may not want to participate but was not certain how often he was even asked. She further stated he loved church and food related things/activities. He liked to socialize with other people. Observation and interview were conducted on 8/21/23 at 2:30PM and revealed Resident #45 remained in bed watching television. Resident #45 stated he would like to participate in activities but staff did not get him out of bed and he would have loved to see what was going on. He indicated staff had not asked if he wanted to attend any activities today. The activity calendar on 8/22/23 indicated the following activities were listed: 10:00 AM sittercise (sitting exercise), 10:30 AM bible trivia, 11:00 AM reminisce and 3:00 PM bingo. Observations on 8/22/23 of Resident #45 were conducted during the timeframes of each of the following activities: 10:00 AM sittercise, 10:30 AM bible trivia, 11:00 AM reminisce and 3:00 PM bingo. Resident #45 was observed in bed during each of the activities. Staff were observed walking past the resident's room. An interview was conducted on 8/22/23 at 1:22PM, Nurse Aide #3 who was assigned to Resident #45. She stated she did not get the resident up for any activities on 8/22/23 because she was busy with other responsibilities. She added Nurse Aides were responsible for asking the residents if they wanted to attend activities and get them ready. Nurse Aide#3 stated when she had a few minutes, the resident would be taken to the activity room. Nurse Aide #3 indicated she was aware Resident #45 liked to participate in activities. An interview was conducted with Nurse Aide #5 on 8/22/23 at 2:30 PM. Nurse Aide #5 stated the assigned nurse aide should offer their residents the opportunity to get up and go to the activities of the day. Nurse Aide #5 stated the independent activities were of the resident choice on the weekend. Nurse Aide #5 further stated when there were activities of choice, the residents do what they want. Nurse Aide #5 further stated Resident #45 does like to attend activities and she was not assigned to Resident #45 on 8/22/23 and did not offer to take the resident to any activities today. An observation was conducted on 8/22/23 at 3:00 PM of bingo progress as indicated on the activity schedule. Resident #45 was not observed in the activity. An interview was conducted with the current activity director, Activity Director #1 on 8/22/23 at 11:00 AM. She stated she previously was the activity director at the facility and had left for several months prior to returning to the position in June 2023. She revealed upon her return she discovered there were no activity notes completed, there were incomplete resident assessments for activity preferences and there were limited activities during the week and weekends. Activity Director #1 stated she had worked with Resident #45 in the past and knew Resident #45 enjoyed and participated in religious activities, food activities and social events. She stated because she conducted the activities herself, she could not bring everyone down to the activity room and leave the other residents unattended in the room. Activity Director #1 added the expectation was for the nurse aides to assist bring residents to the activities. Activity Director #1 confirmed when she returned to the position in June of 2023, Resident #45 did not have any documentation that he participated in group activities or received any 1:1 activities of his preference. She further stated she did not have any documentation of activities that were done February 2023 through May 2023 for Resident #45. She stated since she returned, the activity calendar included more activities during the week and on the weekends. An interview was conducted with the Director of Nursing (DON) on 8/22/23 at 2:40 PM. The Director of Nursing stated she had only been working in the facility two weeks. The Director of Nursing indicated she was not aware of an issue with residents being asked if they wanted to participate in activities. The Director of Nursing stated all residents should be offered 1:1 and group activities daily and nurse aides should assist residents to activity. The Director of Nursing reviewed Resident #45's activity assessment done on 4/5/23 with the resident's preferences and confirmed Resident #45 should have been offered to participate in the activities that were offered on the schedule available based on Resident #45's preferences. An interview was conducted on 8/22/23 at 4:30 PM, the Administrator stated he began working at the facility April 2023 and was aware the activity program was not fully operational. He explained there was a lack of programing for resident activities during the week and weekends, inconsistent completion of activity assessments/preferences and no quarterly documentation of resident participation in activities. He was currently in the process of revitalizing the entire program with the hiring of the recent activity director, Activity Director #1, in June 2023 and activity assistant will be hired in the near future to create a more effective program for all residents during the week and weekends. He indicated There was no start date identified for the activity assistant.

Based on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (200 short hall and 200 long hall). Findings Included: 1. On 8/20/23 at 9:10 AM, an observation of the long hall medication administration cart on 200 hall with Nurse #2 revealed in the second draw of the medication cart there were noted one white loose capsule and two blue round shape loose pills. On 8/20/23 at 9:20 AM, during an interview, Nurse #2 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #2 did not clean the cart before her shift. On 8/24/21 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for checking all the medications in medication administration carts for expiration date and remove expired medications every shift. She expected that no expired items or loose pills be left in the medication carts. 2. On 8/20/23 at 9:30 AM, an observation of the short hall medication administration cart on 200 hall with Nurse #3 revealed one, half-empty multi-dose vial of Novolog insulin, opened on 7/2/23. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening (7/30/23). On 8/20/23 at 9:35 AM, during an interview, Nurse #3 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this shift. On 8/24/21 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for checking all the medications in medication administration carts for expiration date and remove expired medications every shift. She expected that no expired items or loose pills be left in the medication carts.

Based on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. This practice had the potential to affect food served to all residents. The findings included: During a kitchen tour on 8/20/23 at 9:50 AM, the following observations were made with the Dietary Manager: a. The 8- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were substantial amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 4-compartment ovens had a heavy grease buildup, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being cooked. There was a dried grease buildup observed on the fronts of the ovens and on the walls on the inner walls of the oven or on the walls behind the oven. c. The fryer had dried brown/yellow liquid matter encrusted on edges inside and outside. The fryer had heavy grease and food build-up inside and outside, and food products behind the fryer. An interview was conducted on 8/20/23 at 9:50 AM. The Dietary Manager (DM) presented a checklist of the kitchen cleaning schedule. She stated staff were required to wipe down ovens, stove, and fryer daily after each meal and deep cleaned weekly. The DM further stated she was responsible for ensuring the kitchen staff kept the equipment clean and orderly. She added the kitchen equipment should be wiped down daily and cleaned weekly in accordance with the kitchen cleaning checklist. The DM confirmed the identified kitchen equipment had not been cleaned. Follow-up observation on 8/22/23 at 11:33 AM, was made of the identified kitchen equipment. The equipment remained the same as the initial tour on 8/20/23. Some areas have been worked on but not yet complete. An interview was conducted on 8/22/23 at 11:34 AM, the [NAME] stated there was a cleaning checklist. All staff were required to clean equipment in accordance with the clean checklist daily. The identified equipment had not been consistently cleaned therefore, there would be a buildup of grease. All staff were responsible for wiping down equipment after each use. An interview was conducted at 11:40 AM on 8/22/23, The Chief [NAME] stated the kitchen staff were required to wipe down kitchen equipment after each meal and deep cleaned weekly in accordance with the kitchen cleaning checklist. The Chief [NAME] stated he was responsible for ensuring the kitchen staff kept the equipment clean and orderly and to ensure the tasks were completed. He presented the last completed individual area cleaning schedule dated 8/14/23, which did not include the ovens, fryers, and stoves.

Based on observations, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey on 1/7/22 in order to achieve and sustain compliance. This was for a recited deficiency on a recertification survey on 8/23/23. The deficiency was in the area of medication storage and kitchen sanitary condition. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: The tag was cross referenced to: F761: Based on observations and staff interviews, the facility failed to remove expired multi-dose vial of insulin, stored in 1 of 3 medication administration carts (200 hall); failed to discard several loose pills that were identified in the medication cart's draw for 1 of 3 medication administration carts (200 hall). During the previous recertification surveys on 1/7/22, the facility failed to lock an unattended medication administration cart for 2 of 3 carts reviewed for medication storage (Rehabilitation Hall cart and Long Hall cart) and failed to lock the controlled substances storage drawer on 1 of 3 carts (Rehabilitation Hall cart). F812: Based on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. This practice had the potential to affect food served to all residents. During the previous recertification surveys on 1/7/22, the facility failed to ensure the following kitchen equipment was clean: the stove, the oven, two compartment hot box and two compartment cold box. The facility failed to clean the cooler and discard rotten vegetables, expired juice, and unlabeled produce from 1 cooler. The facility failed to remove dented cans from use. On 8/23/23 at 6:20 PM, the Administrator indicated that all the citations would be reviewed, and a plan of correction would be put in place. The Administrator continued that the Quality Assistance and Assurance (QAA) committee met monthly, identified areas of concern, conducted the root cause analysis, created the plan of correction, and discussed the outcome. The Interdisciplinary Team will continue monitoring until the deficient area concerns will be resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews and record review, the facility failed to repair toilet in resident room and clean resident room for 1 of 14 rooms(room [ROOM NUMBER]). The findings included: Review of the individual housekeeping checklist for housekeeper #1 and housekeeper #2 documented the required cleaning task for resident rooms dated 1/4/22, room [ROOM NUMBER] had toilet issues, maintenance was called for clean up at 11:30 AM, the Mop section of the form coded as M2 mop floor was done for room [ROOM NUMBER]. There was nothing documented for room in 240. An observation was conducted on 01/05/22 10:19 AM, the floors in resident room sticky/dirty, old cups food on floor and toilet broken. There was water on the floor and stain tile around the base of toilet. Observation on 1/5/22 at 5:15 PM, both residents in room eating dinner and the condition of the floor remained unchanged. The same towel behind resident bed, cups that were on the floor. The bathroom floor was very sticky with dried urine like stains under toilet, floor craves had not been cleaned in sometime. Observation on 1/06/22 08:29 AM, with Maintenance Director the toilet for room [ROOM NUMBER] revealed the toilet was flushing properly. The Maintenance Director stated it was discovered that paper towels and wipes were clogging the toilet and needed to be snaked out several times. Both residents in room stated the toilet was now working properly. The Maintenance Director stated he did periodic room rounds for basic repairs and expected residents or staff to let him know when things were not working in resident room. He stated he became aware of the toilet situation on 1/4/22 and began working on the situation. The floor in resident room was still dirty, sticky with old food from previous night remained on the floor. old towel behind the bed, there was spilled fluids under beds, old paper, and cups. Observation on 1/6/22 at 9:45 AM, the Housekeeper #1 and the Administrator confirmed the condition of the floor in the resident ' s room with the dried foods/liquids on the floor, old towels under resident bed and toilet leaking again on the floor. An interview with the Administrator 1/6/22 at 9:45 AM, who stated the expectation was for the housekeeping supervisor to make sure all resident rooms were cleaned and check behind the staff to ensure housekeeping keep rooms cleaned. Maintenance was responsible for making sure all resident toilets, call lights etc. were working properly. An interview was conducted on 1/6/22 at 9:45 AM, the Housekeeper #1 (HK) stated in the presence of the administrator that she had gone in the room and swept and mopped the room and cleaned the bathroom on 1/5/22. During the observation it was confirmed the sticky floors, towel behind the bed, dried food and liquids remain on the floor. Both residents confirmed no-one had been in the room for several days. An interview was conducted on 1/6/22 at 10:00 AM, HK #1 stated she had not cleaned the resident room on 1/4/22 or 1/5/22. She stated she was not assigned to the room. An observation on 1/6/22 at 10:18 AM, the Environmental Service Director observed the condition of the resident floors and bathroom and confirmed the room needed to be deep cleaned. An interview was conducted on 1/6/22 at 10:18 AM, the Environmental Service Director (EVSD)stated the staff had a check list which should be followed daily. The checklist included high low dusting, sweeping, and mopping. Before the end of the shift a (evening)PM freshen up cleaning would be done. EVSD stated she was responsible for ensuring that her staff were following the cleaning checklist in accordance too the rooms that were assigned. The EVSD confirmed that HK#1 was assigned to the room and reported the floors had been mopped in the bathroom. EVSD stated she was unable to check behind the floor staff assignment on 1/5/22. Review of the daily huddle book for staff in-service dated 11/30/21 revealed a maintenance reporting process in-service documented staff must promptly report/place work order into maintenance of any issues with equipment or needed repairs to maintenance to ensure all repairs are done and resolved. A follow-up interview was conducted on 1/6/22 at 10: 20 AM, the Maintenance Director stated he rechecked the toilet and did not know where the leak was coming from the toilet, and he suspected the gentlemen in the room may have urinated on the floor. He further stated he did not see or feel any cracks in the bowl or back of the toilet during his inspection. Observation of the floor revealed the floor was warping around the base of the toilet and the tiles were heavily stained and buckling at the edges. Maintenance Director also entered resident room and bathroom and confirmed the floors were dirty and extremely sticky.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. On 01/06/22, during a continuous observation on Long Hall at 08:13 AM - 08:15 AM, the medication administration cart was unlocked and unattended with the push button in the sticking out position. The cart was located next to room [ROOM NUMBER] and facing into the hall. Nurse #7, assigned to the medication administration cart, was not observed in the Long Hall. d. On 01/06/22 at 08:28 AM, Nurse #7 left the medication administration cart on Long Hall unlocked and unattended with the push button in the sticking out position. Nurse #7 went to the medication storage room located on Rehabilitation Hall and to a resident room. Nurse #7 returned to the unlocked medication cart at 08:34 AM. e. On 01/06/22, during a continuous observation on Long Hall at 12:31 PM - 01:41 PM, the medication administration cart, located next to room [ROOM NUMBER], was unlocked and unattended, with the push button in the sticking out position. Nurse #7 returned to the medication administration cart at 01:41 PM. In an interview with Nurse #7 on 01/06/22 at 01:41 PM, she stated she was responsible for the medication cart on Long Hall. Nurse #7 indicated she thought she had locked the medication cart before leaving it to assist staff with an emergency. Nurse #7 stated she normally locked the medication administration cart when she left it unattended. An interview was conducted with the Director of Nursing (DON) on 01/07/22 at 02:03 PM. She stated medication administration carts should be locked when left unattended. If there was a problem locking the medication administration cart, the DON or pharmacy should immediately be notified. 2. On 01/07/22, during an observation of the medication administration cart on Rehabilitation Hall, the DON and Nurse #4 opened the cart for medication storage review. Controlled substance Drawer #1 was unlocked. Nurse #3 was responsible for the Rehabilitation Hall medication cart and Nurse #4 called her to return to the cart. A controlled substance count was immediately completed by Nurse #3 and Nurse #4 and revealed the medication count was correct. The DON stated the controlled substance drawer should have been locked. In an interview on 01/07/22 at 03:48 PM, Nurse #3 stated controlled substance Drawer #1 gets stuck and she had to beat it down to close it. Review of the medication storage policy dated 01/01/13 revealed controlled substances should be kept in a separate compartment within locked medication carts and have a different key or access device. An interview was conducted with Administrator #1 on 01/07/22 at 05:20 PM. He indicated it was the nurses' responsibility to have the medication administration cart locked if the nurse needed to leave the cart. Controlled substances should be double locked. Based on observations and staff interviews, the facility failed to lock an unattended medication administration cart for 2 of 3 carts reviewed for medication storage (Rehabilitation Hall cart and Long Hall cart) and failed to lock the controlled substances storage drawer on 1 of 3 carts (Rehabilitation Hall cart). The findings included: 1. a. On 1/4/22, during the continuous observation on Rehabilitation Hall at 6:15-6:35 PM, the medication administration cart, located next to room [ROOM NUMBER], was unlocked, unattended, with push button in the sticking out position. The Nurse #2, assigned for the medication administration cart, was not observed on the Rehabilitation Hall. On 1/6/22 at 12:30 PM, during the phone interview, Nurse #2 indicated that on 1/4/22, she left the medication administration cart to reposition the resident in room [ROOM NUMBER]. Nurse#2 stated she should have not walked away from the cart without pushing the lock button in the lock position. b. On 1/6/22, during the continuous observation on Rehabilitation Hall at 2:12 PM- 2:28 PM, the medication administration cart between room [ROOM NUMBER] and nurses ' station, was unlocked, unattended with push button in the sticking out position. The Nurse #3, assigned for the medication administration cart, was not observed on the Rehabilitation Hall. On 1/6/22 at 2:45 PM, during an interview, Nurse #3 indicated that she left the medication administration cart to assist the residents in room [ROOM NUMBER] and #269. Nurse#3 stated she should have not walked away from the cart without pushing the lock button in the lock position. On 1/7/22 at 4:50 PM, during an interview, the Director of Nursing (DON) indicated that the nurses were responsible for keeping the medication cart locked at any time, when they were not at the cart.

Based on observations, staff interviews and record review, the facility failed to ensure the following kitchen equipment was clean: the stove, the oven, 2 compartment hot box and 2 compartment cold box. The facility failed to clean the cooler and discard rotten vegetables, expired juice, and unlabeled produce from 1 cooler. The facility failed to remove dented cans from use. Findings included: 1.During an initial kitchen tour on 1/5/22 at 7:45 AM, the following observations were made: a. The 9-burner stove had a large volume of heavy grease build up on the stove burners, walls, and fronts of the stove. There were large amounts of burnt foods, dried liquid encrusted and splatters throughout the stove area. The stove continued to have encrusted burners with heavy grease build up and food debris. b. 4 ovens had a large volume greasy buildup, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where foods were being cooked. There was a large volume of dried grease buildup was observed on the fronts of the ovens and on the walls. c. The 2-compartment hot box where warm food was stored, had large volumes of dried brown/yellow liquid matter encrusted on edges inside/outside. d. The 2-compartment cold box where cold food was stored, had large volumes of dried food and liquid matter encrusted on the edges inside/outside. An interview was conducted on 1/5/22 at 7:55 AM, the Kitchen Supervisor stated he was responsible for ensuring the kitchen staff kept the equipment clean and orderly. He added the kitchen equipment should be cleaned weekly in accordance too the kitchen cleaning checklist. 2. During an observation on 1/5/22 at 7:50 AM, the cooler had dried foods and liquids splattered on the sides of cooler. The following rotten vegetables were mixed in with fresh vegetables: 1 full container of tomatoes, 1 full container of cucumbers, 1 opened bag of spinach not labelled, 1 open bag of basil not labelled. The cooler also contained 2 full gallon containers of orange juice and opened and half full gallon of orange with expiration date 12/18/21 on it. A Follow-up observation was conducted on 1/6/22 at 11:29 AM, revealed the cooler still had the container of rotten tomatoes, cucumbers, opened/unlabeled package of basil. The 2-compartment hot box and cold box and oven had not been cleaned. 3. During an observation on 1/5/22 at 7:55 AM, the dry storage area revealed a rack of dented cans along with regular cans. The following dented cans were found on the rack: 1 can of spaghetti, 5 cans of pears, 3 cans of mandarin oranges and 3 cans of red beans. An interview was conducted on 1/6/22 at 11:40 AM, the Dietary Manager (DM) stated the stock person was responsible for checking all produce once it ' s delivered. The staff should check the produce and discard any spoiled or rotten products. In addition, all items in refrigerator/freezers should be labelled. Any expired products or juices should be discarded. The dented cans should be moved from the primary shelves and later discarded by the end of the week. The DM stated the expectation was for the kitchen staff to follow the kitchen cleaning checklist. The DM stated the 3 supervisors were responsible for ensuring the kitchen team maintained sanitary conditions in the kitchen. The supervisors should be doing shift checks before and after each shift to ensure all tasks were completed. During an interview on 1/6/21 at 11:42 AM, the Kitchen Supervisor stated he was responsible for monitoring and checking behind the kitchen staff to ensure they were completing the checklist and ensuring all sanitation procedures were being followed. The Supervisor stated they had been checking behind the staff weekly to ensure the cleaning was done. During an interview on 1/7/18 at 5:00 PM, the Administrator stated the expectation would be for the kitchen manager to ensure all kitchen cleaning protocols be in place and followed in accordance too kitchen sanitation guidelines.

Based on observations and staff interviews the facility failed to maintain one of one walk-in freezer in good working condition. The kitchen ' s walk-in freezer had accumulated ice on the freezer floor and door. The findings included: An initial tour observation was conducted on 1/5/22 at 7:45 AM, the walk-in freezer had an ice buildup on the corner left side of the floor and the door also had an ice buildup around and near door frame. Follow-up observation 1/6/22 at 11:29 AM, the walk-in freezer still had the ice buildup on the floor and door of the freezer. During an interview on 1/6/22 at 11: 40 AM, the Dietary Manger (DM) stated she was informed by the kitchen staff upon her arrival between (1/5/22) 7:30 AM/8:00 AM, that the freezer was not working or holding chunks of ice. The DM stated that she reported the problem to the maintenance director and the administrator. The DM indicated she was informed by maintenance director someone would be contacted to repair the freezer; however, she was unaware of when the repair would take place. During an interview on 1/7/22 at 5:00 PM, the Administrator indicated he was unaware of the freezer with the ice buildup in the freezer. The Administrator stated dietary manager should find someone to repair the freezer.

Based on observations, staff, family interviews, and record review, the facility failed to set up screening stations for signs and symptoms of COVID-19 near each entrance or provide clear instruction how to reach the screening room for 3 facility State Surveyors and 1 Federal Surveyor before entering the facility for 1 of 4 on-site survey days. This failure occurred during a global COVID-19 pandemic. Findings included: Record review revealed the Standard Operation Procedure, updated on 11/4/21, indicated that for indoor visits, all visitors will receive instructions regarding visitation protocols and will be screened for COVID-19 symptoms prior to each visit. On 1/4/22 at 6:10PM, during the observation of the hospital ' s main entrance, the door was automatically opened. There were no staff members present, no screening station/log, or directions for the screening process in the lobby of the main entrance to the hospital. The nursing facility is referred to as the Extended Care Unit, (ECU) and was located on the hospital's second floor. On the way from the main entrance of the hospital to the ECU, there was no posted information about the location of COVID-19 screening for the ECU. At 6:15 PM, four surveyors entered the ECU from the back elevator without COVID-19 screening. The three state surveyors self- screened prior to entering the hospital entrance. All four surveyors walked through the back hallway to the closest nurses ' station and introduced themselves. Record review of the ECU ' s COVID-19 visitor/vendor screening log form revealed the name, temperature, yes/no section for the health-related questions, and signature. On 1/4/22 at 6:15 PM, during the observation on the hallway near the back elevator, there was no COVID-19 screening station noted. There were no residents observed on the hallway near the back elevator. Nurse #1, the charge nurse on duty, escorted the team to the conference room in the Rehabilitation hallway. There were no residents observed on the Rehabilitation hallway when the surveyors entered the conference room. The surveyor team leader asked if the ECU had a COVID-19 screening process for visitors. Nurse #1 found that the survey team did not receive COVID-19 screening and took the four surveyors through two hallways to the opposite end of the ECU, to the screening room. On 1/4/22 at 6:20 PM, during the observation in the screening room, located on the hallway near the dining room, the room was set up for COVID-19 screening with electronic temperature terminal and screening logbook. Nurse #1 explained the procedure and helped with screening of the survey team. On 1/4/22 at 6:55PM, during an interview, Nurse #1 indicated that after 5PM on weekdays and anytime on weekends, all visitors used the Emergency Department ' s entrance, where they received COVID-19 screening, including temperature check and health-related questions. Nurse #1 stated all the visitors should complete COVID-19 screening before entering the ECU. On 1/5/22 at 7:30AM, during an interview, the Administrator indicated that during business hours, the front desk employee asked the visitors to take an elevator to the second floor, follow the directions posted to reach the white double door for COVID-19 screening room to enter the ECU. After 5 PM and anytime on weekends, the main hospital entrance was closed, and the visitors used the Emergency Department ' s entrance to get inside. The Administrator could not explain the reason why the main entrance was not closed on 1/4/22 at 6:10PM. He confirmed that the visitors should come to the ECU only after COVID-19 screening. On 1/5/22 at 12:00PM, during an interview, Nurse #4, who was the infection control nurse, indicated that she was responsible for Infection Control and Prevention Program in the ECU. She indicated the room for COVID-19 screening was set up on the hallway near the dining room and included electronic temperature terminal and screening logbook. Nurse #4 confirmed that all the visitors must complete COVID-19 screening prior to entering the ECU. On 1/6/22 at 10:50 AM, during an interview, the Chief Executive Officer (CEO) and Chief Nursing Officer of the hospital, the Administrator, and the Director of Nursing (DON) indicated that the visitors must enter the ECU from one door, which was located on the hallway near the dining room. Behind that door, there was a room set up for the COVID-19 screening, where the visitors had to complete the temperature check, health-related questions and sign the screening log prior to entering the ECU. After 5 PM and anytime on weekends, the main hospital entrance was closed, and the visitors used the Emergency Department ' s entrance to get in. The administrator of the hospital and ECU mentioned that the COVID-19 screening system should not allow the visitors to enter the ECU without COVID-19 screening.