**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to allow residents who had been assessed as a safe independent smoker the choice to smoke unsupervised for 2 of 3 residents reviewed for choices (Resident #114 and Resident #117). The findings included: Review of Policy Title: Smoking Agreement signed and dated 12/23/24 by Resident #114 stated independent smoker may smoke in designated areas when they would like to smoke. They must also adhere to the rules as outlined. 1. Resident #114 was admitted to the facility on [DATE] with diagnoses which included tobacco use. Review of Resident #114's quarterly Minimum Data Set (MDS) dated [DATE] revealed his cognition was intact. Review of Resident #114's care plan revised on 04/04/25 revealed Resident #114 was at risk for injuries related to the preference of smoking. The goal was Resident #114's smoking related injuries would be minimized. Review of Resident #114's quarterly smoking assessment dated [DATE] revealed Resident #114 was able to hold the cigarette safely without a device, extinguish cigarette safely, and ambulate independently. Resident #114 was assessed as able to smoke safely independently. An observation conducted on 05/20/25 at 12:30 PM revealed the designated smoking area door posted a sign that stated smoking was allowed from 8:00 AM- 8:00 PM daily. Observation and interview conducted with Resident #114 on 05/20/25 at 2:00 PM revealed Resident #114 was outside in the designated smoking area smoking independently. Resident #114 stated he was upset that times had been put in place and independent smokers were unable to smoke after 8:00 PM. Resident #114 stated he preferred to smoke independently in the evenings after 8:00 PM. An interview conducted with Nurse Aide (NA) #5 on 05/21/25 at 12:10 PM revealed she worked both 1st and 2nd shift. NA #5 stated multiple residents that smoked had complained that they were not able to smoke after 8:00 PM. NA #5 indicated Resident #114 had complained to her. NA #5 indicated she had spoken to multiple nursing staff before and told them that residents were upset. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:40 PM revealed Resident #117 was an independent smoker. The DON and Administrator stated they had not had any complaints from residents having to smoke at assigned times. It was indicated the assign times were implemented several months back and was a decision made by department heads. 2. Resident #117 was originally admitted to the facility on [DATE] with diagnoses which included tobacco use. Review of Resident #117's annual MDS dated [DATE] revealed his cognition was intact and was coded for tobacco use. Review of Resident #117's care plan revised on 03/18/25 revealed Resident #117 was at risk for injuries related to the preference of smoking. The goal was Resident #117's smoking related injuries would be minimized. Review of Resident #117's quarterly smoking assessment dated [DATE] revealed Resident #117 was able to hold the cigarette safely without a device, extinguish cigarette safely, and ambulate independently. Resident #117 was assessed as able to smoke safely independently. Observation conducted on 05/20/25 at 12:30 PM revealed on the door going out to the designated smoking area revealed smoking was allowed from 8:00 AM- 8:00 PM daily. Observation and interview conducted with Resident #117 on 05/20/25 at 2:00 PM revealed Resident #117 was outside in the designated smoking area smoking independently. Resident #117 stated he was upset that times had been put in place and independent smokers were unable to smoke after 8:00 PM. Resident #117 stated he used to be able to go out anytime to smoke and liked to smoke before 8:00 AM and after 8:00 PM. An interview conducted with Nurse Aide (NA) #5 on 05/21/25 at 12:10 PM revealed she worked both 1st and 2nd shift. NA #5 stated multiple residents that smoked had complained that they were not able to smoke after 8:00 PM. NA #5 indicated Resident #117 had complained to her. NA #5 indicated she had spoken to multiple nursing staff before and told them that residents were upset. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:40 PM revealed Resident #117 was an independent smoker. The DON and Administrator stated they had not had any complaints from residents having to smoke at assigned times. It was indicated the assign times were implemented several months back and was a decision made by department heads.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff, Pharmacy Consultant and Medical Director interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medications (Oxycodone) for 2 of 3 residents reviewed for misappropriation of property (Resident #2 and Resident #3). The findings included: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic pain. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately cognitively impaired and received opioid medications. Physician's orders for Resident #2 revealed an order dated 5/28/25 for Oxycodone 5 milligrams (mg) every 8 hours by mouth as needed (PRN) for pain. Resident #2's Medication Administration Record (MAR) for May 2025 revealed that from 7:00 PM on 5/28/25 to 7:00 AM on 5/29/25, Resident #2 did not report pain and did not receive PRN Oxycodone. b. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic pain. The admission MDS assessment dated [DATE] indicated she was moderately cognitively impaired and received opioid medications. Physician's order for Resident #3 revealed an order dated 5/8/25 for Oxycodone 5 mg every 8 hours via feeding tube for pain. Resident #3's MAR for May 2025 revealed that Nurse #5 administered 5 mg of Oxycodone tablet on 5/29/25 at 6:00 AM. The controlled drug form revealed Nurse #5 signed out Oxycodone 5 mg for Resident #3 on 5/29/25 at 6:00 AM. The Initial Allegation Report submitted to the State by the Administrator on 5/29/25 at 11:10 AM revealed an allegation of misappropriation of property was made on 5/29/25 when narcotic discrepancies were found on two residents (Resident #2 and Resident #3) narcotic records involving Nurse #5. The Investigation Report completed by the Administrator on 6/5/25 revealed that on 5/29/25 at 10:30 AM during the audit of narcotic process the Director of Nursing (DON) found that two cards of narcotics and the second page of Narcotic Count Sheet were missing from the C-100 hall medication administration cart: Oxycodone 5 mg tablets (30 tablets for Resident #2 and 54 tablets for Resident #3, 84 total). The DON initiated an investigation, suspended Nurse #5 who was assigned for C-100 hall medication administration cart from 7:00 PM on 5/28/25 to 7:00 AM on 5/29/25, and notified the Medical Director, Law Enforcement, the State, Adult Protective Service (APS), Drug Enforcement Administration (DEA), the Administrator, and Pharmacy. The DON conducted an interview with Nurse #5 who indicated that she counted narcotics during the shift change report with another nurse at the beginning and the end of her shift, and did not realize that two cards of narcotics were missing. The administration interviewed all the RN's, LPN's and Medication Aides, who had work on that specific medication cart, and there were no concerns related to Resident #2's and Resident #3's Oxycodone, and no suspicious behavior or narcotic discrepancies reported. All the staff members who worked on C-100 medication administration cart were sent for urine drug screens with negative results. Law Enforcement did not have charges related to the allegation and did not investigate further. On 6/11/25 at 10:30 AM during an interview, the DON indicated that the discrepancy with the narcotic count for the C-100 medication administration cart was discovered the morning of 5/29/25. She reported that during the narcotic process audit, the DON noted that on C-100 hall, two narcotic cards (30 tablets for Resident #2 and 54 tablets for Resident #3, 84 total) and the second page of the Narcotic Count Sheets were missing from the medication administration cart. The investigation started immediately and Nurse #5, the last nurse, assigned for this cart, was suspended. All medication carts were audited, and no additional missing narcotics were found. Nursing staff conducted pain assessments for all residents, including Residents #2 and #3, and no issues with pain on that shift were reported. Urine drug screen tests were conducted for all the staff who worked on C-100 hall medication administration cart with negative results. The DON interviewed Nurse #6 and Nurse #5, the outgoing and one oncoming nurses for 5/28/25 second shift, who reported no narcotic discrepancy. The DON notified the Medical Director, Law Enforcement, State, APS, DEA, the Administrator, and Pharmacy. The DON reviewed the facility cameras in the C-100 hall area, including the medication administration cart area. On 5/29/25, multiple employees were observed walking past the medication cart, but nobody had touched the medication cart, and no other suspicious behavior was noted. The pharmacy requested to bill the missing medications to the facility. The DON stated that two nurses were responsible for completion of the narcotic count at the change of shifts: one outgoing and one oncoming nurse. She further stated any discrepancy found must be reported immediately and an investigation would be started. On 6/11/25 at 2:45 PM during a phone interview, Nurse #7 indicated that she worked on 5/29/25 from 7:00 AM to 7:00 PM and received the change of shift report from Nurse #5 at 7:30 AM. Nurse #5 did not report a narcotic discrepancy. Nurse #7 indicated Both nurses counted the narcotics on C-100 hall medication administration cart, signed the narcotic book and did not see a problem. A couple of hours later, the DON notified her about two missing narcotic cards from the same medication administration cart. Nurse #7 did not know how the narcotics were lost. On 6/11/25 at 10:40 AM during a phone interview Nurse #5 indicated that from 7:00 PM on 5/28/25 to 7:00 AM on 5/29/25 she was assigned to C-100 hall medication administration cart. Nurse #5 stated that on 5/28/25 at 7:00 PM, she received the shift change report from Nurse #6 and the narcotic count was correct. On 5/29/25 at 7:30 AM, she gave the shift change report to Nurse #7 (agency) and did not find the discrepancy. After an hour and a half, the DON notified Nurse #5 that during the narcotic process audit, it was discovered that two Oxycodone tablets cards were missing from C-100 hall medication administration cart. Nurse #5 reported that during her shift, Resident #3 received her scheduled Oxycodone 5 mg at 6:00 AM, and Resident #2 did not require as needed pain medication. Nurse #5 confirmed that she did not leave the narcotic keys unattended and did not know how the narcotic loss occurred. Law Enforcement did not contact her in regards to missing narcotics. On 6/12/25 at 8:50 AM during a phone interview, Nurse #6 indicated that on 5/28/25 from 7:00 AM to 7:00 PM, she was assigned to C-100 hall medication administration cart. At the end of her shift, she reconciled the narcotics with the upcoming nurse, Nurse #5, and the count was correct. There was no problem with narcotics during her shift. She became aware of missing narcotics from the C-100 hall medication administration cart the next day (5/29/25). On 6/11/25 at 3:30 PM during a phone interview, the Pharmacist indicated that the pharmacy was notified of the missing narcotic cards by the DON, and helped the facility report the diversion to the DEA. She stated that the Pharmacy Consultant regularly performed monthly random narcotic audits of the medication carts, medication rooms, and did not report issues or concerns before or after this incident. On 6/12/25 at 10:00 AM during a phone interview, the Medical Director indicated that he was notified about the missing narcotics. He asked the staff to assess the residents for the pain. The staff reported that on 5/29/25, Resident #2 did not need her PRN narcotic, and Resident #3 received Oxycodone according to the order. On 6/12/25 at 10:30 AM during a phone interview, the Administrator indicated that her expectation was for the nursing staff to keep the narcotic drawer and medication cart locked at all times when not in use, medication cart keys on nurses at all times, for nursing staff to count narcotics on the cart each shift, and both ongoing and oncoming staff sign off the narcotic count was completed and was correct. The Administrator stated that the allegation of misappropriation of resident property was not substantiated because the investigation was unable to identify how the medications were missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews, the facility failed to develop and implement care plan interventions for 2 of 5 residents reviewed for smoking (Resident #30 and Resident #159). The findings included: 1. Resident #30 was admitted to the facility on [DATE] with diagnoses which included hypertension and nicotine dependence. Review of Resident #30's most current smoking assessment was dated 04/29/25. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact and required limited assistance with activities of daily living (ADL). Review of Resident #30's care plan revealed no goals or interventions regarding Resident #30's smoking. Observation and interview conducted with Resident #30 on 05/20/25 at 2:00 PM revealed Resident #30 smoking independently. Resident #30 indicated he had been smoking since admission. An interview conducted with MDS Coordinator #1 on 05/21/25 at 3:20 PM revealed she was not aware Resident #30 had not been care planned for smoking. MDS Coordinator #1 stated through record review and communication with nursing staff Resident #30 should have been care planned for smoking. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:20 PM revealed Resident #30 smoked independently but they were not aware the resident had not been cared planned for smoking. The interview further revealed all residents that smoked were expected to be care planned for goals and interventions. 2. Resident #159 was admitted to the facility on [DATE] with diagnoses which included hypertension and nicotine dependence. Review of Resident #159's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance for ADL. Review of Resident #159's care plan revealed no goals or interventions regarding smoking. Review of Resident #159's most current smoking assessment was dated 04/29/25. Observation and interview conducted with Resident #159 on 05/20/25 at 2:10 PM revealed Resident #159 smoking independently. Resident #159 indicated he started smoking two weeks after he was admitted . An interview conducted with MDS Coordinator #2 on 05/21/25 at 3:25 PM revealed she was not aware Resident #159 had not been care planned for smoking. MDS Coordinator #1 stated through record review and communication with nursing staff Resident #30 should have been care planned for smoking. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:20 PM revealed Resident #159 smoked independently but they were not aware the resident had not been cared planned for smoking. The interview further revealed all residents that smoked were expected to be care planned for goals and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interviews, the facility failed to shave facial hair for 1 of 3 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] with diagnoses which included stroke, muscle weakness, hypertension, osteoporosis, and dysphagia. Review of Resident #56's care plan, revised 10/18/24, revealed the resident had an ADL self-care performance deficit due to left side hemiplegia (weakness on one side of the body), sequelae of poliomyelitis (Post-Polio Syndrome), muscle weakness, and a need for assistance with personal care. The goal was Resident #56 would receive staff assistance with all aspects of daily care to ensure that all needs are met. Interventions listed for Resident #56 included total assistance with bathing and required staff assistance with grooming and personal hygiene. Review of Resident #56's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bathing and personal hygiene. An observation and interview conducted with Resident #56 on 05/18/25 at 11:55 AM revealed the resident was laying in bed watching television. Resident #56 had several hairs located on her chin, at an estimated length of one inch. Resident #56 stated she did not like having chin hair and she preferred for her chin and face to be kept trimmed. Resident #56 indicated she often had to ask staff to shave her chin for her. An interview conducted with Nurse Aide (NA) # 5 on 05/21/25 at 12:10 PM revealed she had cared for Resident #56 consistently and was assigned to Resident #56 on this date. NA #5 indicated Resident #56 rarely refused care and preferred to have a clean shaved face. NA #5 stated she was unsure why Resident #56's face had not been shaved but it needed to be. An interview conducted with Nurse #3 on 05/21/25 at 12:30 PM revealed she was the nurse assigned to Resident #56 and was not aware the resident had facial hair. Nurse #3 did not recall Resident #56 being resistive to personal care and expected residents to be clean shaved if preferred. A follow up interview with Nurse #3 on 05/21/25 at 2:30 PM revealed she had observed Resident #56 and indicated the resident had long chin hairs that needed to be shaved. Nurse #3 stated she shaved Resident #56 without any issue. An interview conducted with the Administrator and Director of Nursing (DON) on 05/21/25 at 3:40 PM revealed they were unsure why Resident #56 had not been clean shaven and they expected residents to remain clean and shaved as preferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interviews, the facility failed to arrange or coordinate podiatry care for 1 of 3 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #134). The findings included: Resident #134 was admitted to the facility on [DATE] with diagnoses which included stroke and hypertension. Review of Resident #134's care plan, revised 01/08/25, revealed the resident had an activities of daily living self-care performance deficit due to Cerebrovascular Accident (CVA) (stroke). The goal was for Resident #134 to improve the current level of functioning, including improvement in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. Review of Resident #134's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with personal hygiene. The MDS further revealed the resident was coded for not being ambulatory. An interview and observation with Resident #134 on 05/21/25 at 11:30 AM revealed the resident's great toenails on both feet to be extending beyond the end of her toes, and were thick, and yellow in color. Resident #134 stated she had an ingrown toenail and was unable to wear shoes or socks because it was hurting and uncomfortable and had been that way for several days. Resident #134 stated a Nurse Aide had trimmed a couple toenails on her smaller toes a couple days prior but had not been seen by podiatry and would like to have a podiatry visit. An interview conducted with Nurse #5 on 05/21/25 at 3:30 PM revealed she was not aware Resident #134's was supposed to be seen by podiatry last week but was not seen. Nurse #5 further revealed she was unsure why she had not been seen by podiatry but observed Resident #134's toenails and stated they needed to be done. An interview was conducted with the Director of Nursing (DON) and Resident #134 in conjunction with an observation of Resident #134 on 05/21/25 at 2:00 PM. Resident #134 stated she could not wear enclosed shoes due to her toes hurting and the length of her great toenails. The DON revealed the podiatrist the facility used created a list of which residents were to be seen for their visit. The DON indicated Resident #134 had an ingrown toenail and needed to be seen by the podiatrist. The DON further stated she was going to contact the Podiatrist and make sure Resident #134 was seen as soon as possible but she went ahead and put her on the list for the next scheduled podiatry visit on 6/26/25. An interview conducted with the Administrator and DON on 05/21/25 at 3:40 PM revealed Resident #134 had not been assessed by podiatry since admission. The DON stated Resident #134 was on the list to be seen during the previous podiatry visit in May 2025 but was unsure why she had not been seen. The interview further revealed they expected for residents' toenails to remain trimmed and if there were issues, podiatry would be consulted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 5 residents reviewed with urinary catheters (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses which included unspecified hydronephrosis (swelling of one or both kidneys due to a buildup of urine), presence of urogenital implants, and neuromuscular dysfunction of the bladder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. The assessment indicated Resident # 14 was dependent upon staff for all his activities of daily living (ADL). Resident #14 was coded for an indwelling urinary catheter. Resident #14's care plan revised 3/7/25 indicated Resident #14 had a goal of being free from a urinary tract infection due to the presence of an indwelling suprapubic catheter. Interventions included keeping the urinary collection bag below the level of the urinary bladder. An initial observation was conducted on 5/18/25 at 10:39 AM of Resident #14 as he was lying in his bed. The bed was noted to be in a low position. A urinary catheter drainage bag was observed to be hanging off the bedframe on the resident's right side of the bed with a solid, blue-colored privacy flap covering the bag facing the window. The entire bottom of the urinary catheter drainage bag was resting on the floor. Additional observations were conducted on 5/19/25 at 11:25 AM and on 5/20/25 at 4:00 PM. Resident #14's bed was noted to be in the low position, and a urinary catheter drainage bag was observed to be hanging off the bedframe on the resident's right side of the bed. The entire bottom of the urinary catheter drainage bag was resting on the floor during both observations. During an interview with Nurse Aide (NA) #1 on 5/20/25 at 4:19, she stated urinary catheter bags were not supposed to be touching the floor to prevent risk of infection. NA #1 stated she had noticed Resident #14's urinary catheter bag had been on the floor several times during her shift, and she had picked it up and repositioned the urinary catheter drainage bag so that it was not resting on the floor. An interview was conducted with the Director of Nursing (DON) on 5/21/25 at 11:51 AM. She stated she had educated all staff to keep urinary catheter bags off the floor, and there was a hook on the bag to hang it on the resident's bed. The Unit Manager was interviewed on 5/21/25 at 4:50 PM. She stated the resident's urinary drainage bag should not touch the floor. She further stated she had placed a basin underneath Resident #14's urinary catheter bag that day to prevent it from touching the floor since the resident preferred to keep his bed low.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and Pharmacist interviews, the facility failed to have an effective system and safeguards in place to prevent drug diversion when they did not ensure narcotic medications for discharged residents were secured for 2 of 3 residents (Resident #1 and Resident #271) reviewed for medication management. As a result, a total of 75 doses of Oxycodone (a narcotic medication) 5 milligrams (mg) were unaccounted for. Findings included: a. Resident #122 was admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included diabetes and diabetic neuropathy. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #122 was cognitively intact and received opioid medications. Resident #122 had a Physician's Order dated [DATE] for Oxycodone (narcotic/opioid pain medication) 5 mg every 4 hours as needed for pain. The Medication Administration Record for [DATE] for Resident #122 indicated he received Oxycodone 5 mg as needed for pain on [DATE], [DATE], and [DATE]. On [DATE] a discharge with an anticipated return Minimum Data Set assessment indicated Resident #122 was discharged to the hospital. During an interview with the Director of Nursing (DON) on [DATE] at 11:06 am she stated the pharmacy had notified the facility on [DATE] when the pharmacy tote (a tote bag used to store medications to be returned to the pharmacy) was returned to the pharmacy there was a Narcotic Count Form for Oxycodone 5 mg with 45 doses ordered for Resident #122 and the medication correlating to the form was missing from the tote. The DON stated Resident #122 was discharged to the hospital on [DATE] and his medication should have been sent back to the pharmacy when he was discharged . The DON stated they immediately began an investigation. She stated Nurse #1 and Nurse #2 were interviewed and suspended pending an investigation; Nurse #1 and Nurse #2 both received narcotic drug tests; and the facility changed the process for returning unused narcotic medications to the pharmacy. Nurse #2 was interviewed by phone on [DATE] at 12:40 pm and she stated she counted 45 doses of Oxycodone 5 mg that was ordered for Resident #122 with Nurse #1 after the resident was discharged and placed the medication in the pharmacy tote and placed two numbered zip lock seals on the tote. Nurse #2 stated she left the tote in the Unit Managers office to be picked up by pharmacy. Nurse #2 stated when she worked as the night shift supervisor, she kept the Unit Manager's office door locked. Nurse #2 stated there were several staff (the Unit Managers and Administrative Staff) that had keys to the Unit Manager's office, but she was not aware of anyone leaving the Unit Manager's office unlocked. Nurse #1 was interviewed by phone on [DATE] at 11:37 am and stated she did not remember the date Nurse #2, the night shift supervisor, had asked her to reconcile narcotic medications with her that needed to be sent back to the pharmacy. Nurse #1 stated she did count the medications for Resident #122 with Nurse #2, and they put the medications in the pharmacy tote and placed the numbered zip lock tag on the tote. She stated she did not know when the pharmacy tote was returned to the pharmacy and did not know how long the pharmacy tote was left in the Unit Manager's office before it was sent back to the pharmacy. Nurse #1 stated on [DATE] she was suspended pending an investigation, she was drug tested, she received education regarding returning narcotic medication to the pharmacy, and the facility changed the process for sending unused narcotics back to the pharmacy. The Pharmacist was interviewed by phone on [DATE] at 2:59 pm and stated she received the facility's pharmacy tote on [DATE] and found a Narcotic Count Form for Oxycodone 5 mg, 45 doses, in the returned pharmacy tote. The Pharmacist stated the tote was sealed with two zip tie seals that were numbered, and the Medication Return Form in the tote had the corresponding numbers from the two zip ties. The Pharmacist stated she notified the facility that the narcotic medication was not in the tote when she received it at the pharmacy. The Pharmacist stated the Oxycodone 5 mg should have been secured under two locks to prevent diversion of the medication. During an interview with the DON on [DATE] at 11:06 am she stated that Resident #122 had not been charged for the medication and the medication was provided by the hospital when Resident #122 was admitted to the facility, so they had not considered the missing medication a misappropriation of Resident #122's property. b. Resident #271 was admitted to the facility on [DATE] with diagnoses that included and lung cancer. An admission Minimum Data Set assessment dated [DATE] indicated Resident #271 was cognitively intact and received opioid medications. A Physician's Order dated [DATE] indicated Oxycodone 5 mg for Resident #271 three times a day for pain. The Medication Administration Record for Resident #271 for [DATE] indicated he received Oxycodone 5 mg by mouth three times a day for pain from [DATE] to [DATE]. The medical record indicated Resident #271 died in the facility on [DATE]. The Director of Nursing was interviewed on [DATE] at 11:06 am and she stated during an investigation into missing narcotic medication for Resident #122 they discovered that a medication card of Oxycodone 5 mg that was ordered for Resident #271 was also missing. The Director of Nursing stated the Narcotic Count form for Resident #271's Oxycodone 5 mg with 30 doses was found in an unlocked desk drawer in the Unit Manager's office and the medication correlating to the form was missing. Nurse #2 stated she was the Night Shift Supervisor, and she was responsible for ensuring the narcotic medications were reconciled and sent back to the pharmacy when a resident was discharged . Nurse #2 stated after Resident #271's death, she placed the resident's medication in an unlocked desk drawer in the Unit Manager's office and the door to the office was locked but there were other staff members that had keys to the office. Nurse #2 stated all nurse management and supervisors had access to the office. Nurse #2 stated she kept the door to the office locked when she worked but she did not know if it was left open when she was not working. Nurse #2 stated she did not know that she should keep narcotic medications double locked until they were sent to the pharmacy. During an interview with the Pharmacist by phone on [DATE] at 2:59 pm she stated when the facility investigated the 45 missing doses of Oxycodone 5 mg for Resident #122, they notified her there was another card of 30 doses of Oxycodone missing for Resident #271. The Director of Nursing was interviewed on [DATE] at 11:06 am and she stated that the investigation into the missing Oxycodone for Resident #271 revealed Nurse #2, the night shift supervisor, had placed the medication in the drawer in the Unit Manager's office and had planned to return it to the pharmacy. She stated Nurse #2 stated she was not aware the medication should not be left in the desk drawer which was not locked. The Director of Nursing stated the facility changed the process for sending narcotic medications back to the pharmacy to prevent any further diversion of narcotic medications. The Director of Nursing stated Resident #271 was not charged for the 30 doses of Oxycodone 5 mg since the medication was provided by the hospital when Resident #271 was admitted to the facility and the facility did not investigate it as misappropriated for that reason. The Administrator was interviewed by phone on [DATE] at 2:25 pm and stated the facility should have ensured Resident #271 and Resident #122's narcotic medication was secured with two locks to prevent diversion of narcotic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff and the Pharmacist, the facility failed to store unused narcotics prescribed to Resident #122 and #271 in a separately locked, permanently affixed compartment. The narcotics for Resident #122 were stored in a pharmacy tote with a numbered zip lock tag and the doses for Rsdt #271 were placed in an unlocked desk drawer in the Unit managers office by the Nurse #2, the night shift supervisor. The Unit Manager's office was not always locked and several staff had keys to the office. On 5/1/2025, the Pharmacy identified that 45 doses of oxycodone, 5 milligrams, were missing for Resident #122 when they received the narcotic count sheet without the narcotic medication in the medication tote that was delivered to the pharmacy. The facility initiated an investigation and discovered 30 doses of oxycodone, 5 milligrams, missing for Resident #271. This deficient practice affected two of two discharged residents reviewed for drug storage (Resident #122 and #271). Findings included: The facility's Controlled Medication Storage Policy stated all narcotic medications are stored under double lock in a locked cabinet or safe designated for that purpose. 1. Resident #122 was admitted to the facility on [DATE] and had a recent readmission on [DATE]. Resident #122 had a Physician's Order dated 2/6/2025 for Oxycodone 5 mg every 4 hours as needed for pain. On 3/25/2025 a discharge with an anticipated return Minimum Data Set assessment indicated Resident #122 was discharged to the hospital. Nurse #1 was interviewed by phone on 5/22/2025 at 11:37 am and stated she did not remember the date Nurse #2, the night shift supervisor, had asked her to reconcile narcotic medications with her that needed to be sent back to the pharmacy. She stated she did count the medications for Resident #122 with Nurse #2, and they put the medications in the pharmacy tote (a plastic bin that medications are place in to transport to and from the pharmacy) and placed the numbered zip lock tag on the tote. She stated she did not know when the pharmacy tote was returned to the pharmacy and did not know how long the pharmacy tote was left in the Unit Manager's office before it was sent back to the pharmacy. Nurse #2 was interviewed by phone on 5/22/2025 at 12:40 pm and she stated she counted 45 doses of Oxycodone 5 mg that was ordered for Resident #122 with Nurse #1 and placed the medication in the pharmacy tote with the numbered zip lock tag on the tote which Nurse #2 stored in the unit managers office. She stated she did not remember the date they put the medication in the pharmacy tote and did not know the date the pharmacy tote was sent to the pharmacy. Nurse #2 stated when she worked as the night shift supervisor, she kept the door to the Unit Manager's office locked at all times, but she knew there were several staff that had keys to the Unit Manager's office, but she was not aware of anyone leaving the Unit Manager's office unlocked. The Pharmacist was interviewed by phone on 5/23/2025 at 2:59 pm and she stated when the facility's pharmacy tote was received in the pharmacy on 5/1/2025 the zip lock seals were in place and the Narcotic Return Form for Oxycodone 5 mg (45 doses) was not in the pharmacy tote. The Pharmacist stated she notified the facility's Director of Nursing (DON). During an interview with the DON on 5/22/2025 at 11:06 am she stated the pharmacy had notified the facility on 5/1/2025 when the pharmacy tote was returned to the facility there was a Narcotic Count Form for Oxycodone 5 mg with 45 doses ordered for Resident #122 and the medication was missing from the tote. The DON stated at that time the narcotics that were being sent back to the pharmacy were being stored in the Unit Manager's office and the door was not always locked, several people had keys to the office, and the medications were kept in an unlocked desk drawer. The DON stated they were not able to determine when the misappropriation occurred, but they had changed the process for sending narcotics back to the pharmacy. The DON stated the facility had installed a safe in the DON office, which was observed during the interview, and the process for storing and returning narcotic medications had changed. The DON stated the Assistant Director of Nursing (ADON) counted all narcotics that should be returned to the pharmacy (either when a resident was no longer taking them or the resident was discharged ) and placed them in the safe and they were kept in the safe until the pharmacy courier picked them up to return them to the pharmacy. The DON stated she and the ADON put the seals on the pharmacy tote after they counted the medications again and sent them with the courier to the pharmacy. 2. Resident #271 was admitted to the facility on [DATE]. A Physician's Order dated 3/12/2025 indicated Resident #271 should have Oxycodone 5 mg three times a day for pain. Nurse #2 was interviewed by phone on 5/22/2025 at 12:40 pm and stated she was the Night Shift Supervisor, and she was responsible for ensuring the narcotic medications were reconciled and sent back to the pharmacy when a resident was discharged . Nurse #2 stated she put Resident #271's medication in an unlocked desk drawer in the Unit Manager's office and the door to the office was locked but there were other staff members that had keys to the office. Nurse #2 stated all nurse management and supervisors had access to the office. Nurse #2 stated she kept the door to the office locked when she worked but she did not know if it was left open when she was not working. The Director of Nursing was interviewed on 5/22/2025 at 11:06 am and she stated during an investigation into the missing narcotic medication for Resident #122 they discovered that a medication card of Oxycodone 5 mg that was ordered for Resident #271 was also missing. The Director of Nursing stated the Narcotic Count form for Resident #271's Oxycodone 5 mg with 30 doses was found in an unlocked desk drawer in the Unit Manager's office and the medication was missing. The Director of Nursing stated Nurse #2, the night shift supervisor, had placed the medication in the drawer and had planned to return it to the pharmacy. The DON stated Nurse #2 stated she was not aware the medication should not be left in the desk drawer which was not locked. The Administrator was interviewed by phone on 5/22/2025 at 2:25 pm and stated the facility should have ensured Resident #271 and Resident #122's narcotic medication was secured with two locks to prevent diversion of narcotics. The facility submitted a plan of correction for past noncompliance but it was not acceptable to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of the use of continuous positive airway pressure (CPAP) machine for 2 of 3 residents whose MDS assessments were reviewed (Residents #1 and #2). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea and acute respiratory failure with hypoxia. Resident 1's plan of care, dated 1/9/25, indicated oxygen therapy related to continuous positive airway pressure (CPAP) for obstructive sleep apnea with an intervention to encourage to wear the CPAP as ordered by the physician. Resident #1 had an active physician's order, dated 9/2/24, for CPAP machine to apply at bedtime and remove when awake for sleep apnea. Review of the Medication Administration Record (MAR) for September 2024 - January 2025 revealed Resident #1 used the CPAP machine as ordered with often refusal episodes. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/14/25, revealed Resident #1 was cognitively intact and was not coded for use of a CPAP machine or non-invasive mechanical ventilator. On 2/12/25 at 8:35 AM, during the observation and interview, Resident #1 had a CPAP machine located on the nightstand near bed. Resident #1 indicated she had the CPAP machine for a long time and used it at night while sleeping. On 2/12/25 at 1:55 PM, during the phone interview, MDS Nurse #1 indicated that if Resident #1 used the CPAP, it should have been coded as non-invasive mechanical ventilator on the Quarterly MDS assessment. MDS Nurse #1 continued she was not aware she had to answer the mechanical ventilation area in order to accurately code Resident #1 for use of the CPAP. On 2/12/25 at 2:10 PM, during an interview, the Administrator expected the MDS nurses to be responsible for coding Resident 1's MDS assessment accurately. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea. Resident 2's plan of care, dated 12/13/24, indicated oxygen therapy related to continuous positive airway pressure (CPAP) for obstructive sleep apnea with an intervention to encourage to wear the CPAP as ordered by the physician. Resident #2 had an active physician's order, dated 8/2/24, for CPAP machine to apply at bedtime and remove when awake for sleep apnea. Review of the MAR for December 2024 - January 2025 revealed Resident #2 used the CPAP machine as ordered. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/15/24, revealed Resident #2 was moderately cognitively impaired and was not coded for use of a CPAP machine or non-invasive mechanical ventilator. On 2/12/25 at 11:20 AM, during the observation and interview, Resident #2 had a CPAP machine located on the bedside table. Resident #2 indicated he had the CPAP machine for years and used it at night while sleeping. On 2/12/25 at 1:55 PM, during the phone interview, MDS Nurse #1 indicated that if Resident #2 used add the CPAP, it should have been coded as non-invasive mechanical ventilator on the Significant Change MDS assessment. MDS Nurse #1 continued she was not aware she had to answer the mechanical ventilation area in order to accurately code Resident #2 for use of the CPAP. On 2/12/25 at 2:10 PM, during an interview, the Administrator expected the MDS nurses to be responsible for coding Resident 2's MDS assessment accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff, Nurse Practitioner (NP) and the Medical Director, the facility failed to protect a resident from non-significant medication errors for 1 of 3 residents reviewed for medication administration (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, dementia, anxiety disorder, heart failure and chronic kidney disease. Review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired. Review of the of the Medication Administration Record (MAR) for October 2024, revealed that on 10/18/24 at 9:58 AM, Resident #1 received his prescribed medications, including seroquel, 25 mg (milligrams), zoloft, 25 mg, acidophilus 1 tablet, Anoro Ellipta Inhaler (inhaler for asthma/COPD) 1 puff, ferrous sulfate 325mg, magnesium oxide 400 mg, multivitamin 1 tablet, proscar 5 mg, vitamin B12 500 mcg (micrograms), vitamin C 500 mg, and flomax 0.4 mg. Review of Resident 2's physician's orders for October 2024 revealed medications, including metformin (anti-diabetic medication) 500 mg, aspirin (nonsteroidal anti-inflammatory medication) 81 milligram (mg), Levocarnitine (nutritional supplement) 500 mg, Baclofen, 5 mg (muscle relaxant medication). The Incident Report, created by Nurse #1 and dated 10/18/24 at 12:40 PM, revealed Nurse #1 went to the common area, where [Resident #1] was seated. She addressed [Resident #1] by the name of [Resident #2], and [Resident #1] replied yes. Nurse #1 gave [Resident 2's] medications to [Resident #1] including metformin 500 mg, aspirin 81 mg, levocarnitine 500 mg, and baclofen 5 mg. Nurse #1 realized the medication administration error, obtained the vital signs, which were within normal limits. Nurse #1 called the Unit Manager, the Provider, family member and continued frequent monitoring. During a phone interview on 11/5/24 at 10:10 AM Nurse #1 indicated she was an agency nurse and 10/18/24 was her second time in the facility. During the medication administration on 10/18/24 between 9:00 AM and 10:00 AM she gave Resident #1 his prescribed morning medications. Nurse #1 continued the morning medication pass and at approximately 11:00 AM she prepared medications for Resident #2. Nurse #1 went to the common area and addressed Resident #1 by Resident #2's name and the resident replied yes, which she felt the response indicated he was Resident #1. Nurse #1 gave Resident 2's medications to Resident #1. When Nurse #1 returned to her medication administration cart to document, she realized she accidently gave the wrong medications to Resident#1. Nurse #1 immediately called the Unit Manager and assessed Resident #1. The resident was not in distress and his vital signs were within normal limits. Nurse #1 notified the Nurse Practitioner (NP #1) and Resident #1's family. NP #1 gave an order to check the resident's vital signs every four hours, monitor for hypotension (low blood pressure), bradycardia (low heart rate), and notify provider of any abnormal results. She reported the medication administration error to Nurse #2 during the shift change report. The nurses' note dated 10/18/24 at 12:40 PM indicated Nurse #1 reported the medication administration error for Resident #1 to Nurse Practitioner (NP) #1 and NP #1 provided new orders to check vital signs every four hours for the current shift, and continue monitoring. On 11/5/24 at 11:30 AM and interview with Nurse #5 (Unit Manager) revealed she received report from Nurse #1 on 10/18/24 at 12:30 PM about accidentally administering Resident #2's medications to Resident #1. Upon assessment together with Nurse #1, the resident was not in distress, seated in bed, and stated he was fine. The resident's vital signs were within normal limits: BP 112/52, pulse 63 beats per minute, and respirations 17 breath per minute. Nurse #1 notified the Nurse Practitioner (NP) and family. NP ordered to check resident's vital signs every four hours and report the abnormalities. On 11/5/24 at 1:50 PM a phone interview was conducted with Nurse Practitioner (NP) #1. NP #1 indicated on 10/18/24 she was informed of the medication administration error by Nurse #1. At the time of the report Resident #1 was stable, with no distress and NP #1 ordered to check his vital signs every four hours with continued monitoring for hypotension and bradycardia. NP #1 did not expect a long-term systemic (overall) negative effect, or changes in mental status due to the resident having received the wrong medications. NP #1 stated had planned to assess Resident #1 the next day (10/19/24). On 11/6/24 at 11:20 AM, during the phone interview, the Medical Director indicated that he was notified about the medication administration error that occurred for Resident #1. He did not expect negative outcome from the non-significant medications administered to Resident #1. The facility implemented the following corrective action plan for identified deficient practice: All current residents in the facility with orders for medication had the potential to be affected by the deficient practice. On 10/18/24 the Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a 100% (percent) audit on all current alert and oriented residents with brief interviews for mental status (BIMs) of 13 or greater (indicating the resident was interviewable) to ensure there were no issues with medication administration. This was completed on 10/18/24. The results included: 100 of 100 residents with medication orders had no concerns with medication administration. On 10/18/24 A body audit was completed by the DON, Assistant DON (ADON), and Unit Managers, on all non-verbal, non-alert residents with BIMS of 12 or lower to ensure there were no issues related to medication administration. This audit consisted of signs or symptoms related to change in condition, increased confusion, or mental status changes. The results included: 48 of 48 residents with no signs or symptoms, which were felt may indicate issues related to a possible error in medication administration. On 10/18/24 the DON implemented corrective action for those residents which included: no corrective action needed; no deficient practice identified. On 10/18/24 The DON, ADON, unit managers, and Staff Development Coordinator (SDC) began interviewing nurses and medication aids during med pass observations on if they had performed medication errors. The results: 46 of 46 Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and med aids denied medication errors including giving medications to the wrong resident. On 10/18/24 The DON reviewed all incident reports for the last 14 days to identify any recent medication errors. The results: 0 of 8 incident reports were related to medication errors. Education: On 10/18/24, the Staff Development Clinician (SDC) began in-servicing all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and medication aides, (including agency) on Preventing Medication Error policy. This training included all current staff including agency. This training included: Following the 6 rights of medication administration The right person The right medication The right dose The right time The right route The right documentation The Director of Nursing ensured that any of the above identified staff who did not complete the in-service training by 10/22/24 would not be allowed to work until the training was completed. This education will be ongoing and included in our new hire and agency orientation packet for all RNs, LPNs, and medication aids. The DON, Assistant DON, unit managers, and SDC, will monitor medication administration passes 3 times weekly for 2 weeks and monthly for 3 months for using the Quality Assurance (QA) monitoring tool Med Pass Audit. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, Minimum Data Set Coordinator, Therapy, Health Information Management, and the Dietary Manager. On 10/18/24 the decision was made to initiate this into the QA process and to review it in QA. The completion date of the corrective action plan: 10/23/24 On 11/8/24, the facility's corrective action plan was validated on-site by record review, observations, and interviews. Individual interviews with a sample of residents revealed they received their prescribed medications without concern. A medication administration observation was conducted on 11/8/24. The observation consisted of administration of medications for 3 different residents, by 2 nurses. The nurses and the medication aides were observed implementing the rights of medication administration before administering the medications from start to finish. No concerns were identified. Interviews with nurses and the medication aides revealed they were required to complete in-services for the 5 rights of medication administration and the facility's new process for medication administration. Review of the in-service documents dated 10/18/24 and 10/23/24 noted the DON completed the in-person in-services for the 6 rights of medication administration and the facility's new process for medication administration with nurses and medication aides. An interview with the DON on 11/8/24 revealed that the in-services were provided to Nurse #1 and all other nurses and medication aides that had not worked since the medication error, as well as to any new nurses and medication aides before they were allowed to administer medications. The corrective action plan's completion date of 10/23/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #8 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and participated in his assessment. The care plan was last reviewed on 1/9/24. During an interview with Resident #8 on 2/12/24 at 9:42 AM and he indicated he had not been invited to care plan meetings but would like to be included in the development of his care plan and participate in the process. During an interview with Social Worker #1 on 02/14/24 at 03:05 PM he indicated that Resident #8 had not been invited to a care plan meeting. He further revealed that he meets with each resident every quarter for an assessment and if the resident has an issue or concern then he will schedule a care plan. He further explained that Resident #8 did not have any concerns, so he did not offer a care plan meeting to Resident #8 or his resident representative. The Administrator was interviewed on 2/14/2024 at 2:50 pm and she stated typically there was an admission care plan meeting, quarterly care plan meeting, and care plan meetings when a resident or family member has concerns. The Administrator stated she was not aware the care plan meetings were not being done until Social Worker #1 told her after he was interviewed. The Administrator stated she was given a calendar of the scheduled Care Plan meetings and was not aware invitations were not being sent to the residents and family members and the Care Plan meetings were not completed. Based on record review, staff interviews and resident interview the facility failed to provide the resident the opportunity to participate in the care planning process for 2 of 2 residents (Resident #31 and #8). Findings included: 1. Resident #31 was admitted to the facility on [DATE] with diagnoses of quadriplegia and chronic pain. An annual Minimum Data Set (MDS) assessment completed 12/27/2023 indicated Resident #31 was cognitively intact and participated in his assessment. Resident #31 was interviewed on 2/12/2024 at 12:09 pm and he stated he had not been invited to a care plan meeting during his stay at the facility. During an interview with Social Worker #1 on 2/14/2024 at 2:27 pm he stated Resident #1 had not been invited to a care plan meeting. He stated he meets with each resident every quarter for an assessment and if the resident indicates they have an issue he would notify the other disciplines as needed and they meet with him individually. Social Worker #2 further stated the facility does not provide care plan meetings with the interdisciplinary team members unless there is a concern brought up by the resident or the resident's family member. Social Worker #1 further indicated there was no invitation sent out to the residents or family members from the facility and the facility does not document who attends care plan meetings when the resident or family member requests a care plan meeting. The Administrator was interviewed on 2/14/2024 at 2:50 pm and she stated typically there is an admission care plan meeting, quarterly care plan meeting, and care plan meetings when a resident or family member has concerns. The Administrator stated she was not aware the care plan meetings were not being done until Social Worker #1 told her after he was interviewed. The Administrator stated she was given a calendar of the scheduled Care Plan meetings and was not aware the invitations were not being sent to the residents and family members and the Care Plan meetings were not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff, and resident interviews the facility failed shave facial hair for a female resident that was dependent on staff for activity of daily living (ADL) care needs in 1 of 5 residents (Resident #70) reviewed for ADL care. The findings included: Resident #70 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. A review of the quarterly Minimum Data Set (MDS) 1/29/24 revealed Resident #70 had moderate cognitive impairment, was able to communicate her needs, had no behaviors or rejection of care, and required extensive assistance of one staff member for personal hygiene and bathing. A review of the care plan for Resident #70, dated 1/29/24, had a focused area for activities of daily living (ADL) with interventions that included to assist resident with all aspects of daily care to ensure that all needs were met and to anticipate needs. A second focused area was for refusing staff to provide showers and medications with interventions that included to report all refusals of care to the nurse, document refusals, and if care was refused to return at later time and attempt again. A review of progress notes from 1/12/24-2/12/24 revealed no documentation of refusing facial hair removal by staff. An observation of Resident #70 was made on 2/12/24 at 9:50 AM. Resident #70 was observed sitting outside of her room in a wheelchair, dressed in street clothes and had gray and white facial hair covering her chin about ¼ inch long. A second observation and a resident interview was conducted on 2/14/24 at 12:47 PM. Resident #70 was observed to still have the ¼ inch long facial hair covering her chin. Resident #70 revealed that she preferred to get the facial hair shaved but that staff had not shaved it for her. An interview was conducted with Nursing Assistant (NA) #1 on 2/14/24 at 2:15 PM. NA #1 was the assigned NA for Resident #70 on 2/12/24-2/14/24. She revealed that Resident #70 relied on nursing staff to assist with all ADL's which included shaving of facial hair. On 2/14/24 at 2:19 PM an interview was conducted with the A Wing Nurse Manager #1. She revealed that the nursing assistant assigned to Resident #70 (NA #1) was responsible for assisting her with all personal hygiene needs. A follow up interview on 2/15/24 at 3:06 PM with the A Wing Nurse Manager #1 revealed that NA #1 did offer facial hair removal to Resident #70 on 2/15/24 and she accepted the care without refusal. On 2/15/24 at 9:20 AM an interview was conducted with the Administrator. She revealed that staff were required to assist residents who were dependent on staff for ADL's.

Based on record review, observations, and staff interviews the facility failed to follow their policy regarding transmission-based precautions for 1 of 2 residents (Resident #93) reviewed for contact precautions. A nursing staff member, Nurse #2, entered Resident #93's room, who was on contact precautions, without the required Personal Protective Equipment (PPE) including gloves and a gown, she was observed to check the resident's blood pressure, touch the resident's clothing, touch the resident's bed linens, repositioned the resident's ventilator tubing, touched the side rails, and then proceeded to provide care to Resident #93's roommate (Resident # 58) without washing her hands or using hand sanitizer. Upon completion of providing care to Resident #93's roommate (Resident #58), Nurse #2 then exited the residents' room without washing her hands or using hand sanitizer. Findings included: The facility's Infection Prevention and Control Standards Policy last reviewed 12/2023 indicated the facility's employees must adhere to all policy and procedures related to infection prevention, including standard and transmission-based precautions. The facility's Infection Prevention and Control Standards Policy further indicated contact precautions would be put into place if the route of transmission is not completely interrupted using standard precautions alone. The facility's Hand Hygiene Policy last reviewed 12/2023 indicated the facility's employees must practice hand hygiene when entering and leaving a resident's room and when providing resident care. A Physician's Order dated 2/9/2024. Resident #93 was on Contact Precautions for Extended Spectrum Beta-Lactamase (ESBL) a bacterium in her urine that was resistant to antibiotics. During an observation of Resident #93 on 2/12/2024 at 12:54 pm a contact precaution sign was noted on her door (which stated staff should wear a gown and gloves when entering the room and removed before exiting the room). Personal protective equipment (PPE), including gowns and gloves, were in a bin hanging from her door. Nurse #2 was observed to enter the room which was under contact precautions without donning a gown nor donning gloves. The nurse proceeded to check Resident #93's blood pressure, touch the resident's clothing, touch the resident's bed linens, repositioned the resident's ventilator tubing, touched the side rails. Without washing her hands nor using hand sanitizer in between residents, Nurse #2 touched Resident #58's side rails, clothing, and bed linens, and repositioned her ventilator tubing. Nurse #2 then left the room without washing her hands or using hand sanitizer. Nurse #2 was interviewed on 2/12/2024 at 1:00 pm and stated she did not put on a gown or gloves on because Resident #93 had a catheter. She stated she thought she sanitized her hands after caring for Resident #93, but she realized now she did not. She stated she knew she should wash her hands or use hand sanitizer between residents when she was providing care. On 2/12/2024 at 1:17 pm Nurse #2 returned and stated Resident #93 no longer had a catheter and was on contact precautions because she had a bacterium in her urine that is resistant to antibiotics. She stated she should have put a gown and gloves on before entering Resident #93's room and removed the gown and gloves and washed her hands before providing care to Resident #58. Nurse #3 who was assigned to Resident #93 was interviewed on 2/14/2024 at 12:39 pm and she stated Resident #93 had been on contact precautions and an antibiotic since 2/9/2023. She stated the staff should wear gloves and a gown before going into the room and providing care to Resident #93. She stated they should also remove the gown and gloves and wash their hands before caring for Resident #93's roommate. On 2/14/2024 at 12:26 pm Unit Manager #1 was interviewed, and she stated Resident #93 was ventilator dependent and was put on contact precautions on 2/9/2023 when they received the culture and sensitivity for her urinalysis which showed Resident #93 had bacterium in her urine that was resistant to antibiotics. Unit Manager #1 stated staff should put on a gown and gloves before entering the room to provide care for Resident #93 and should remove the gown and gloves and wash their hands before providing care for her roommate. The Administrator was interviewed on 2/16/2024 at 2:57 pm and she stated Nurse #2 should have followed the guidelines Disease Control and Prevention's (CDC) guidelines for personal protective equipment should be used and for handwashing when providing care for Resident #93 who was on contact precautions.

Based on observations and staff interviews, the facility failed to ensure meal trays used to serve residents' meals were in good condition for 1 of 1 tray line observation. This practice had the potential for cross contamination of food from chipped and cracked meal trays. Findings included: During a visit to the kitchen on 2/14/24 at 12:45 p.m., 33 meal trays with chipped, rough edges were observed stacked on the meal tray line, ready for use, during the plating of meals prepared for the residents. The Dietary Manager was present for the observation and did not offer an explanation or comment why the chipped/rough edged meal trays were stacked on the trayline, ready for use by the residents receiving plated meals in their rooms. On 2/15/24 at 11:16 a.m. the Administrator acknowledged some of the meal trays were chipped with rough edges. She revealed that prior to this survey the facility ordered more meal trays.

Based on observations and staff interviews, the facility failed to ensure the area surrounding 1 of 1 trash compactor remained free from garbage, refuse, and standing water. Findings included: During the initial tour of the facility on 2/12/24 at 10:00 a.m. a large trash compactor was observed outside, behind the facility. The area surrounding the trash compactor was littered with used plastic gloves, plastic cup lids, plastic straws, cardboard boxes, broken plastic pieces and pieces of plaster/tile. There were also 2 plastic trash barrels without lids, filled with trash less than three feet from the trash compactor. The follow-up observation on 2/14/24 at 1:10 p.m., revealed the area surrounding the trash compactor contained trash and debris scattered on the ground, including soiled plastic gloves, plastic cup lids, straws, face masks, and a broom lying in a pile of broken plaster. Also, behind the trash compactor, there was one uncovered trash barrel filled with trash and standing water. During an interview on 2/14/24 at 1:15 p.m., the Dietary Manager (DM) acknowledged the trash and debris surrounding the trash compactor needed cleaning. She revealed she was unsure which department was responsible for maintaining the trash compactor and its surrounding area. On 2/14/24 at 1:20 p.m., the Housekeeping Supervisor revealed the housekeeping floor technicians were responsible for maintaining the garbage disposal area, ensuring any trash/debris was removed from the ground. After observing the debris and trash surrounding the trash compactor, the Housekeeping Supervisor stated that the area would be cleaned immediately.

Based on observations, record review, and staff interview 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 the recertification survey completed on 6/14/21. This was for 2 deficiencies that were cited in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) and Infection Prevention & Control (F880) that were cited on the recertification survey on 6/14/21 and then recited on the current recertification and complaint survey of 2/15/24. The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referred to: F812: During the recertification survey on 2/15/24, the facility failed to ensure meal trays used to serve residents' meals were in good condition for 1 of 1 tray line observation. This practice had the potential for cross contamination of food from chipped and cracked meal trays. During the recertification survey on 6/14/21, the facility failed to sanitize dishware for meal service by failing to ensure the wash and final rinse cycles of the dishwashing machine operated at accurate temperatures. Also, the facility failed to maintain sanitary conditions in the kitchen by not ensuring opened food items in the refrigeration/freezing units and dry storage areas were resealed, labeled, and dated; and by failing to ensure the food preparation areas, food storage areas, and food service equipment were maintained clean and free from debris. The facility also failed to ensure the food items stored in the snack/nourishment refrigerators in 2 of 2 residents' nourishment rooms were clean, and food items not provided by the facility were dated and labeled. These practices had the potential to affect food served to residents. F880: During the recertification survey on 2/15/24, the facility failed to follow the Centers for Disease Control and Prevention's (CDC) transmission-based precautions for 1 of 2 residents (Resident #93) reviewed for contact precautions. A nursing staff member, Nurse #2, entered Resident #93's room, who was on contact precautions, without the required Personal Protective Equipment (PPE) including gloves and a gown, she was observed to check the resident's blood pressure, touch the resident's clothing, touch the resident's bed linens, repositioned the resident's ventilator tubing, touched the side rails, and then proceeded to provide care to Resident #93's roommate (Resident # 58) without washing her hands or using hand sanitizer. Upon completion of providing care to Resident #93's roommate (Resident #58), Nurse #2 then exited the residents' room without washing her hands or using hand sanitizer. During the recertification survey on 6/14/21, the facility failed to ensure staff performed hand hygiene prior to entering a resident's room and after providing personal assistance to another resident during meal tray delivery in 2 of 2 observations of one staff member. During an interview on 2/15/24 at 3:15 PM with the facility's administrator. She stated that the QA members were made up of Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Practitioner and the Medical Director were always invited to attend. She stated that she and the director of nursing were aware of the concerns regarding this survey and the repeat of several citations. She stated that all of the issues will be looked into, and a thorough plan of correction will be drawn up and implemented to ensure these citations would not be repeated again in the future.

Based on record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following a complaint survey completed on 01/20/22 and a recertification and complaint investigation survey completed on 11/15/22. This was for one deficiency in the area of the supervision to prevent accidents and subsequently recited during the complaint survey dated 12/18/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program. Findings included: This tag is cross referenced to: F 689 - Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner and failed to ensure fall mat was in place for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 sustained a fall from his bed after the Nurse Aide walked away after raising the height of the bed and failed to ensure the fall mat was placed next to his bed when she left to retrieve items from his closet. The fall resulted in a 6.5 centimeter laceration to the forehead, 2 centimeter laceration to the nose, 1.5 centimeter laceration to the upper lip, 1 centimeter laceration inside of the mouth, and an 8 millimeter parenchymal hematoma corresponding in location to a previous hematoma (Resident #1). The resident was sent to the Emergency Department and discharged the following day where he required sutures for his lacerations. During the facility's recertification survey of 11/22/22, the facility failed to provide care in a safe manner and/or implement fall safety interventions developed and care planned by its interdisciplinary team (IDT) for 4 of 5 residents reviewed for falls. During the facility's complaint survey dated 01/20/22, the facility failed to ensure 1 of 2 residents requiring extensive assistance with bed mobility and bathing was provided care safely to prevent injury. An interview was completed on 12/18/23 at 2:43 PM with the Administrator. She stated that the repeat citation could be because even though agency staff were educated before taking an assignment, they were not familiar with the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interviews, the facility failed to honor a resident's (Resident #1) bathing preference for 1 of 3 residents reviewed for choices. The findings included: Resident #1 was admitted to the facility on [DATE]. A review of Resident #1's care plan dated, 6/28/2023, identified a focus area that the Resident had an activities of daily living self-care performance deficit. The interventions included: 1. The Resident required assistance with bathing. 2. Resident #1 required total assistance of two staff members for transfers with a mechanical lift. 3. Allow the Resident to make decisions about the treatment regime, to provide a sense of control. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, required extensive assistance of one staff member for personal hygiene and bathing. She had range of motion impairment on both sides of the upper and lower extremities. The Resident had no rejection of care during the lookback period. A review of the electronic medical record for Resident #1 revealed she was schedule for showers twice a week on Thursday and Sunday. The staff were provided a question, Shower completed. The answers included 1) yes, 2) no, 3) Resident not available, 4) Resident refused, 5) Not applicable. The shower documentation for the following dates revealed: 1. 6/29/2023 No shower completed. 2. 7/9/2023 Resident refused. 3. 7/13/2023 No shower completed. 4. 7/23/2023 Resident refused. An interview was conducted with Resident #1 on 7/25/2023 at 3:24 p.m. and she revealed in the past month she had received a shower 3 of the 8 scheduled showers. She added she had not refused to take a shower and preferred a shower to a bed bath because it felt like a spa day. She stated she was told by the agency Nursing Assistant (agency NA) #1 that the NA was unable to conduct a shower on 7/23/2023 because getting her into a mechanical lift was difficult and there was not enough staff. She stated this had been occurring for several months and she had not reported this to anyone in a long time because when she reported it in the past it had not made a difference. An observation of Resident #1 was conducted on 7/25/2023 at 3:26 p.m. and she had on a hospital gown (Resident's choice), groomed hair, nails trimmed and free of debris. An interview was conducted with the Agency NA #1 on 7/25/2023 at 1:32 p.m. and she revealed on the date of 7/23/2023 she had completed all the assigned bed baths for her assignment but had not provided showers to the residents that had scheduled showers on that date. She revealed it was difficult to locate a second NA if a resident required two staff assistance with a mechanical lift. She indicated the facility had scheduled shower days for some residents on Sundays and she found it difficult to complete showers on a Sunday. She indicated Resident #1 was on her assignment on 7/23/2023 and required two staff for assistance with a mechanical lift for transfers. She added Resident #1 preferred a shower and was offered a bed bath instead on 7/23/2023. She stated she had not requested a Nurse to assist or to locate assistance to transfer Resident #1. An interview was conducted with the Director of Nursing on 7/25/2023 at 3:52 p.m. and she revealed it was her expectation that an NA reach out to the hall nurse if she required a second staff member to be available and was unable to locate a staff member. She added that all residents should receive the scheduled shower on the shower days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a clean-living environment for 1 of 3 rooms (room [ROOM NUMBER]) reviewed for environment. The findings included: An observation was conducted on 7/5/2023 at 2:08 p.m. of room [ROOM NUMBER]. A dried dark yellow/brown substance was observed on the left side of the A bed, 10 inches in diameter, that extended under the head of the bed. On the wall there were 7 streaks of a dried yellow/brown substance. The lines were 8 inches long. An observation was conducted on 7/6/2023 at 11:38 a.m. of room [ROOM NUMBER]. The dried yellow/brown substance remained on the left side of the bed and on the wall. An interview was conducted with the Housekeeping Supervisor on 7/6/2023 at 1:30 p.m. and he revealed he had responded to a need in room [ROOM NUMBER] on 6/18/2023 as the weekend manager on duty. He added while he was in the room, a family member had expressed concerns with the condition of the floors in room [ROOM NUMBER]. An observation was conducted on 7/6/2023 at 3:50 p.m., with the Director of Nursing (DON), of the floors in room [ROOM NUMBER]. The dried yellow substance remained on the floor and the wall. An interview was conducted with the DON on 7/6/2023 at 3:50 p.m. and she stated the dried yellow/brown substance on the floor and the wall appeared to be spilled, dried, tube feeding and should not have been left on the floor or wall. She stated the Nursing staff should have cleaned the tube feeding when it was discovered it had leaked or spilled.

Based on observations and dietary staff interviews, the facility failed to maintain sanitary conditions in the kitchen by not ensuring the kitchen remained clean and free from the debris of peeling wall plaster and broken tile; by not properly storing brooms and mops after use; and by not ensuring cases of food items were not used to keep the door of the storage room open. Also, the refrigeration unit in 1 of 2 nourishment rooms (C-unit) was contained sticky residue and food items that were not purchased by the facility were not labeled with a resident's name, room number or dated. The findings included: 1a. During two observations of the kitchen on 7/6/23 at 8:45 a.m. and 7/7/23 at 12:45 p.m. at the entrance of the walk-in cooler, there were peeling wall plaster with holes and broken tile to the lower wall and baseboard. This resulted in small dust particles of plaster and tiles collecting on the kitchen floor. An interview with the Dietary Manager on 7/6/23 at 8:55 a.m. revealed a dietary work order request (which included the damaged wall) was given to the Maintenance Director two months prior to this observation. During an interview on 7/7/23 at 1:55 p.m. the Maintenance Assistant revealed the Maintenance Director was on vacation and did not inform him of any request or work order plan for the damaged wall in the kitchen. 1b. On 7/6/23 at 8:47 a.m. during the tour of the kitchen, 2-brooms, 2-mops and 2-dustpans were observed leaning upright against a wall in the kitchen's preparation area. The heads of the brooms and the mops were on the floor. On 7/7/23 at 1:00 p.m. during a second observation of the kitchen, 2-brooms, 2-mops and 2-dustpans remained leaning upright against a wall in the kitchen's preparation area. The heads of the brooms and the mops were on the floor. On 7/7/23 at 1:40 p.m., Dietary [NAME] #1 stated the brooms, mops and dustpans should have been stored in the chemical room, not in the kitchen. 1c. During an observation of the dry storage room on 7/7/23 at 1:15 p.m., 1-case of nutrition supplement drinks was on the floor against the opened door of the dry storage room. During an interview on 7/723 at 1:25 p.m., Dietary Staff #1 revealed he placed the case of supplement drinks on the floor against the door to keep the door open because the door handle broke and he would have been unable to exit the room. He stated that this occurred during the meal service tray line service. On 7/7/23 at 1:28 p.m., Dietary [NAME] #2 stated that cases of food items were never to be placed on the floor, for any reason. 2. On 7/6/23 at 2:15 p.m., an observation of the residents' nourishment room on the C-Unit of the facility was conducted. There were sticky, brown substances in 2 of the 2 crispers in the refrigerator and a pink, sticky substance spread throughout the bottom inside the refrigerator. Also, there was 1-large plastic bag of assorted food items stored in the refrigerator and 1-opened package of breakfast wraps stored in the freezer section of the refrigeration unit. Both items were not labeled with a resident's name, room number, or date stored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to notify an emergency contact of a resident transfer out of the facility (Resident #3). Resident #3 was transferred to the hospital with an altered mental status. His emergency contact was not notified and was not aware he was at the hospital until Resident #3 contacted her the following day. This deficient practice occurred for 1 of 2 residents reviewed for notification of changes. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses cognitive impairment, diabetes mellitus, encephalopathy. His most recent minimum data set showed that he had moderate to severe cognitive impairment. He only required supervision for mobility, transfers, and eating. Resident #3 and his niece were both listed as contacts in his chart. During a record review on 2/2/22 at 11:25 AM, Nurse #1 documented that Resident #3 presented with altered mental status on 1/28/23 at 5:00 PM. She documented that increased confusion was observed. Vitals, including blood sugar, were within normal range. An ambulance was called and Resident #3 was transported to the hospital for evaluation. There was no documentation stating the responsible party was notified. Multiple attempts to contact Nurse #1, who was an agency nurse, were unsuccessful. During an interview with the administrator on 2/2/22 at 2:15 PM, she stated she had a soft file concerning that incident and that she was currently working on a plan of correction. She stated she had been made aware by Resident #3's emergency contact that she was not aware Resident #3 had been sent to the hospital until he contacted her asking for a ride back to the facility on 1/29/23. The administrator also stated that during their investigation, Nurse #1 stated that Resident #3 told her that he was taking his cell phone with him and would contact someone later. Nurse #1 also stated Resident #1 was the only one listed on the account and that was wasn't anyone else to contact. During an interview with the admissions coordinator on 2/2/22 at 2:45 PM, she was able to pull up the history portion of Resident #3's chart and it showed his niece was entered as an emergency contact into his chart on 12/30/23 at 10:34 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide necessary care and services of a urinary catheter when a Nurse (Nurse #02) failed to clean a resident's catheter prior to inserting an irrigation syringe. This occurred for 1 of 3 residents (Resident # 01) reviewed for catheter care. The findings included: A review of the facility policy, titled, Restorative Nursing - Bladder irrigation dated 01/2023 provided the policy and procedures for two types of intermittent urine bladder irrigation techniques, closed intermittent and open intermittent. The open irrigation provided the following steps: 1. Apply gloves. 2. Open sterile irrigation tray: establish sterile field and pour required amount of sterile solution into sterile solution container. Replace cap on large container of solution. 3. Position waterproof drape under catheter. 4. Aspirate the ordered amount of solution into irrigating syringe. 5. Move sterile collection basin close to client's thigh. 6. Wipe connection point between catheter and tubing with antiseptic wipe before disconnecting. 7. Disconnect catheter from drainage tubing, allowing urine to flow into sterile collection basin; cover open end of drainage tubing with sterile protective cap and position tubing so it stays coiled on top of bed. 8. Insert tip of syringe into lumen of catheter and gently instill solution. 9. Withdraw syringe, lower catheter, and allow solution to drain into basin. Repeat, instilling solution and draining several times until drainage is clear of clots and sediment. 10. If solution does not return, have client turn onto side facing nurse; if changing position does not help, reinsert syringe and gently aspirate solution. 11. After irrigation is complete, remove protector cap from drainage tubing adapter, cleanse adapter with alcohol swab, and reinsert adapter into lumen of catheter. 12. Anchor catheter to client's leg or thigh with tape or Velcro multipurpose tube holder. 13. Assist client into a comfortable position. 14. Lower bed to lowest position, and position side rails accordingly. 15. Dispose of contaminated supplies, remove gloves, and perform hand hygiene. Resident #1 was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the urine bladder with a urine catheter in place. A review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed he had severe cognitive impairment, required total assistance of staff with toilet use and personal hygiene, and had an indwelling urine catheter. A review of Resident #1's care plan dated 10/31/2022 had a focused area identified that read, Resident #1 had an indwelling catheter in place for a neurogenic bladder. The interventions included Resident #1 required total assistance of staff with all aspects of personal hygiene. A review of Resident #1's physician orders included to Irrigate the urine catheter with 50 milliliters (ml) of normal saline three times a day for urine retention. An observation was conducted on 2/2/2023 at 9:40 a.m. of Nurse #02 during the ordered urine catheter irrigation for Resident #1. The Nurse preformed hand hygiene, donned a pair of gloves, and opened a 60 ml sterile irrigation syringe. She then opened the normal saline and drew up 50 ml of normal saline. She walked over to Resident #1's bedside and explained the procedure to the Resident. She lifted the Resident's blanket, disconnected the urine collection bag tubing from the catheter and then inserted the syringe into the open area. She did not cleanse the site prior to inserting the syringe and did not check to ensure the urine from the bladder was emptied. She then slowly pushed the normal saline into the catheter. She removed the syringe and reconnected the drainage bag tubing to the catheter without cleansing the tubing tip. An interview was conducted with Nurse #02 at 2/2/2023 at 9:44 a.m. during the observation while she flushed the urine catheter for Resident #1. When she finished flushing and reconnected the tubing, she was asked if she had cleansed the catheter tip prior to inserting the irrigation syringe. She responded, No, I probably should have. When asked if she cleansed the tip of the drainage bag tubing prior to reinserting into the catheter, she replied, No, because I held it in my hand. When asked if she received education at the facility on flushing a catheter, she revealed she had received education on the care of a catheter and the insertion of a catheter but had not received education on how to conduct a flush (irrigation) of a catheter. An interview was conducted with the Assistant Director of Nursing (ADON) and the Corporate Nurse Consultant on 2/2/2023 at 10:18 a.m. and the ADON revealed if she was going to provide a urinary catheter flush, she would conduct hand hygiene, don gloves, set up the equipment/supplies, draw up the sterile normal saline, inform the resident what procedure she was going to do, disconnect the drainage bag tubing from the catheter, cleanse the catheter with alcohol or another antiseptic solution (provided in the irrigation tray), and then insert the tip of the syringe into the tubing. She stated she would disconnect the syringe and cleanse both the catheter and the drainage tubing prior to reinserting into the catheter. The Corporate Consultant revealed keeping the catheter system closed and assessing the sample port in the closed system irrigation was the preferred method but if using the open catheter flush system, she agreed with the ADON statement for the process. The ADON and the Corporate consultant stated they would provide catheter care and irrigation education immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident and staff interviews, the facility failed to provide showers as scheduled for 1 of 2 sampled residents (Resident #14) reviewed for choices. Findings included: Resident #14 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: osteomyelitis of the vertebra, sacral and sacrococcygeal region, paraplegia, and diabetes mellitus with diabetic neuropathy. The quarterly Minimum Data Set, dated [DATE] indicated Resident #14 was cognitively intact, required total assistance with bed mobility, transfers, hygiene, and bathing. The care plan dated 9/14/22 revealed Resident #14 had an activity of daily living self-care performance deficit related to paraplegia. Interventions included: required two staff assistance with all transfers and bed mobility; required total assistance with bathing; required total assistance using total mechanical lift for transfers; and offer choices in daily care. Review of the facility's Shower Schedule maintained at the nursing station on A-Wing indicated Resident #14 was to receive a shower during first shift every Monday and every Thursday. The schedule sheet included: Assure all showers are completed as scheduled. If a resident refuses, it must be documented in (electronic health record). Review of the Personal Care sheets from 9/1/22 through 9/26/22 indicated Resident #14 only received a shower on 9/16/22. During an interview on 9/26/22 at 3:51 p.m. Resident #14 confirmed his shower days as Mondays and Thursdays. The resident stated that when he asked the nursing assistant about receiving his shower on Thursday, 9/22/22 and again on Monday, 9/26/22 she told him the facility did not have enough help so that he could receive a shower. He indicated he had not received a shower in a couple of weeks. An interview with nursing assistant (NA#3) on 9/28/22 at 3:10 p.m. revealed 9/27/22 was the first time she worked with Resident #14 since 8/24/22 or 8/25/2022. She stated the resident was scheduled to receive a shower on Mondays and Thursdays, in the mornings. NA#3 recalled being informed by the resident that another nursing assistant told him there weren't enough staff to give him a shower. NA#3 stated the resident also informed her Nurse #3 gave him a shower on the previous night (Tuesday, 9/27/22). She was unsure if the resident received his scheduled shower on Monday (9/26/22) because she worked on a different hall. During an interview on 9/28/22 at 3:35 p.m., Nurse #3 stated she and a nursing assistant (no name provided) gave Resident#14 a shower the previous night (9/27/22) during second shift. He was scheduled to receive showers on Mondays and Thursdays during day shift. She stated on Tuesday, 9/27/22 she asked the resident if he received his scheduled shower on Monday, 9/26/22 and was told he only received a wash-up, and he would like to receive a shower. The resident also informed her that he did not receive a shower on Thursday (9/22/22). Nurse#3 revealed that on 9/28/22 she met with the nursing assistant who failed to provide the resident with his showers. She stated the nursing assistant informed her that she (nursing assistant) had requested two other nursing assistants for assistance with providing the resident with a shower on Monday (9/26/22) but was unable to name the two that she asked. The nursing assistant was unable to recall why she did not provide the resident with a shower on Thursday (9/22/22). Nurse #3 stated she informed the nursing assistant that she should have requested her (Nurse #3) assistance as she had helped nursing assistants with providing resident care many times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and nurse practitioner interviews, the facility failed to revise a care plan for 2 of 2 residents (Resident #2 and Resident #335) reviewed for falls. Findings included: 1. Resident #2 was admitted on [DATE] with a diagnosis of cerebral infarction. A Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was totally dependent on staff for bed mobility and required 2 staff members for assistance. A progress noted dated 12/12/21 at 12:10 PM revealed the Resident fell off the bed while a nurse aid (NA) provided incontinence care. The most recent care plan dated 6/23/22 revealed Resident #2 was at increased risk for falls related to limited mobility. The two interventions noted were that the Resident ' s risk for falls would be minimized through current interventions x 90 days and anticipate and meet the Resident ' s needs as much as possible. An interview on 9/29/22 at 2:45 PM with MDS Nurse #1 revealed the facility administrative staff reviewed falls during the daily resident review meeting. She explained interventions appropriate for falls were updated in the care plan during the meeting. She stated she did not update the care plan for Resident #2 after his fall on 12/12/21. She further stated she did not have a reason for not updating his care plan. In an interview with MDS Nurse #2 on 9/29/22 at 2:45 PM she revealed it was her responsibility to update Resident #2 ' s care plan after his fall. She stated she did not know why she did not update his care plan. She further stated the MDS staff needed to focus better on updating care plans after falls. She explained she needed to update Resident #2 ' s care plan with appropriate interventions. In an interview with the Assistant Administrator on 9/30/22 at 3:00 PM she stated that she expected the resident ' s care plan to be reviewed and revised with appropriate interventions following a fall. 2. Resident #335 was admitted to the facility on [DATE] with diagnoses epilepsy (seizure disorder), and persistent vegetative state. A progress note dated 4/30/2022 at 10:33 PM stated that Resident #335 was observed laying on the floor next to his bed. No injury occurred. A Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #335 was totally dependent on staff for bed mobility and required 2 staff members for assistance. The most recent care plan dated 5/20/22 revealed Resident #335 was at increased risk for falls related to limited mobility. The interventions noted were that the Resident's risk for falls would be minimized through current interventions x 90 days, anticipate and meet the Resident's needs as much as possible, and monitor frequently. This was unchanged from his last care plan review dated 2/22/22. An interview on 9/29/22 at 2:45 PM with MDS Nurse #1 revealed the facility administrative staff reviewed falls during the daily resident review meeting. She explained interventions appropriate for falls were updated in the care plan during the morning meetings. She stated she was unsure why Resident #335's care plan was not updated to include his recent fall with new interventions. In an interview with Assistant Director of Nursing on 9/29/22 at 2:45 PM she stated that they discuss incidents in their morning meetings. She stated the Director of Nursing did comment on the incident report to add bolsters to Resident #335's bed after he was found on the floor. She stated she did not know why he care plan was never updated following the incident. In an interview with the Assistant Administrator on 9/30/22 at 3:00 PM she stated that she expected the resident's care plan to be reviewed and revised with appropriate interventions following a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 5 residents (Resident #27) reviewed with indwelling urinary catheters. The findings included: Resident #27 was admitted to the facility on [DATE] with re-entry from a hospital on 8/29/22. His cumulative diagnoses included acute urinary retention, benign prostatic hyperplasia (an enlarged prostate gland), and a history of urinary tract infections (UTI). A review of Resident #27 ' s most recent Minimum Data Set (MDS) was an annual assessment dated [DATE]. This MDS indicated the resident had intact cognitive skills for daily decision making. The resident was reported to be occasionally incontinent of bladder. Resident #27 was seen by a urologist on 9/9/22 due to urinary retention. The urologist ' s recommendations included placement of a urinary catheter if he was unable to void. A urine culture was ordered by urology and an antibiotic initiated on 9/13/22. The resident ' s medical record indicated an indwelling catheter was placed on 9/14/22. An initial observation was made on 9/26/22 at 10:00 AM as Resident #27 was lying in bed. A urinary catheter bag was observed to be hanging from the bed frame with approximately 4 inches of the bag lying on the floor. On 9/26/22 at 12:59 PM, Resident #27 was observed to be lying in bed. His urinary catheter bag was hanging from the bed frame with approximately one-half of the bag lying on the floor at the time of the observation. An observation made on 9/26/22 at 1:42 PM revealed approximately one-half of Resident #27 ' s urinary catheter bag continued to be lying on the floor as the resident laid in his bed. An interview was conducted 9/26/22 at 1:55 PM with Nurse #4. Nurse #4 was the 1st shift nurse assigned to care for Resident #27. During the interview, the nurse was asked what her thoughts were about the placement of Resident #27's urinary catheter bag. Nurse #4 was observed as she entered the resident ' s room and repositioned the catheter bag so it was no longer touching the floor. After she exited the room, the nurse reported the urinary catheter bag should not have been on the floor. An interview was conducted on 9/29/22 at 12:04 PM with the facility ' s Assistant Director of Nursing (ADON). During the interview, the observations of Resident #27 ' s urinary catheter bag touching the floor were discussed. When asked, the ADON reported she would expect a catheter bag to be positioned off the floor.

Based on observations, staff interviews and record reviews, the facility failed to discard expired medications stored in 1 of 4 medication carts observed (A100 Hall Medication Cart). The findings included: 1. An observation was conducted on 9/28/22 at 12:10 PM of the A100 Hall Medication (Med) Cart in the presence of Med Aide #1 and Nurse #3. The observation revealed one - 10 milliliter (ml) opened vial of Humalog insulin dispensed from the pharmacy for Resident #94 was stored on the med cart. A yellow auxiliary sticker placed on the clear plastic box containing this vial of insulin read: Store using directions provided. Throw away any medicine that remains 28 days after first use. A hand-written notation on the box containing the insulin indicated the vial had been opened on 8/27/22 (32 days before the date of the observation). Upon inquiry, Nurse #3 reported the vial of insulin was expired and needed to be discarded. A review of Resident #94 ' s medication orders revealed he had a current order for Humalog insulin. According to Lexi-comp (a comprehensive electronic medication database), once punctured (in use), vials of Humalog insulin may be stored under refrigeration or at room temperature; use within 28 days. An interview was conducted on 9/28/22 at 2:55 PM with the facility's Assistant Director of Nursing (ADON) to discuss the findings of the medication storage observations. During the interview, the ADON stated she would expect that we follow the guidelines on the dates expired. 2. An observation was conducted on 9/28/22 at 12:10 PM of the A100 Hall Medication (Med) Cart in the presence of Med Aide #1 and Nurse #3. The observation revealed one - 10 milliliter (ml) opened vial of Lantus insulin dispensed from the pharmacy for Resident #99 was stored on the med cart. A yellow auxiliary sticker placed on the clear plastic box containing this vial of insulin read: Store using directions provided. Throw away any medicine that remains 28 days after first use. A hand-written notation on the box containing the insulin indicated the vial had been opened on 8/27/22 (32 days before the observation). Upon inquiry, Nurse #3 reported the vial of insulin was expired and needed to be discarded. A review of Resident #99 ' s medication orders revealed she had a current order for Lantus insulin. According to Lexi-comp (a comprehensive electronic medication database), once punctured (in use), vials of Lantus insulin may be stored under refrigeration or at room temperature; use within 28 days. An interview was conducted on 9/28/22 at 2:55 PM with the facility's Assistant Director of Nursing (ADON) to discuss the findings of the medication storage observations. During the interview, the ADON stated she would expect that we follow the guidelines on the dates expired. 3. An observation was conducted on 9/28/22 at 12:10 PM of the A100 Hall Medication (Med) Cart in the presence of Med Aide #1 and Nurse #3. The observation revealed one - 10 milliliter (ml) opened vial of Lantus insulin dispensed from the pharmacy for Resident #94 was stored on the med cart. A yellow auxiliary sticker placed on the clear plastic box containing this vial of insulin read: Store using directions provided. Throw away any medicine that remains 28 days after first use. A hand-written notation on the box containing the insulin indicated the vial had been opened on 8/28/22 (31 days before the date of the observation). Upon inquiry, Nurse #3 reported the vial of insulin was expired and needed to be discarded. A review of Resident #94 ' s medication orders revealed he had a current order for Lantus insulin. According to Lexi-comp (a comprehensive electronic medication database), once punctured (in use), vials of Lantus insulin may be stored under refrigeration or at room temperature; use within 28 days. An interview was conducted on 9/28/22 at 2:55 PM with the facility's Assistant Director of Nursing (ADON) to discuss the findings of the medication storage observations. During the interview, the ADON stated she would expect that we follow the guidelines on the dates expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a tour of C wing-300 hall on 9/26/22 at 10:00 AM, a dark orange colored stain approximately 24 inches long and 12 inches wide was observed under the bed of Resident #44. On 9/26/22 at 10:05 AM during an interview with the Resident #2's visitor, the visitor revealed the catheter bag for the Resident #44 had leaked on the floor one week prior and had not been cleaned up properly. There was a faint odor of urine in the room. An observation on 09/27/22 at 10:00 AM revealed the floor under the bed still a dark orange stain. On 09/27/22 at 11:24 AM the dark orange stain was still visible under Resident #44's bed. In an interview on 9/28/22 at 9:35 AM a nurse aide (NA) stated she did not know what the stain was under Resident #44's bed. She further stated she had not noticed the stain. On 9/28/22 at 9:55 AM an interview was conducted with the Housekeeping Supervisor. He stated the stain had not been reported to him. He further stated that there should not be a stain under bed 307A. He explained the resident room floors were swept and mopped daily. He further explained if the stain could not be mopped up, he would schedule for the floor to be stripped and waxed. An observation of room [ROOM NUMBER]A on 9/29/22 at 10:00 AM revealed the stain under had been removed. Resident #44 stated the housekeeping staff had mopped under the bed on 9/28/22. On 9/29/22 at 3:00 PM an interview was conducted with the assistant administrator. She stated she expected the floors to be cleaned routinely and as needed. She further stated the facility had floor projects in place to strip two rooms a week until all floors are done. 3. An observation of room [ROOM NUMBER] on 9/26/22 at 10:45 AM revealed dark colored stains on the floor tiles throughout the entire room. There were also several broken tiles underneath the resident's bed. During an interview with the resident in room [ROOM NUMBER] on 9/26/22 at 10:50 AM, she said housekeeping staff came in every day and swept and mopped the room, but the dark stains remained. She stated that sometimes they were able to get some the dark areas up but not much. She also stated that she really didn't want her family to come and visit in the room because the floor looked so bad. The resident also stated that the broken tiles didn't bother her because they were under the bed so she never rolled over them with her wheelchair. Housekeeper #1 was interviewed on 9/27/22 at 3:03 PM. She explained she cleaned resident rooms daily and swept and mopped the floors. She verified there was a lot of dirt build up on the floors in residents' rooms and halls which had been an issue throughout the entire facility since at least April 2022, when she started her employment. She thought the facility needed more floor technicians and added one went on medical leave three weeks ago. Housekeeper #1 added the floors needed to be stripped and waxed. On 9/28/22 at 3:35 PM, an observation of room [ROOM NUMBER] was completed with the Housekeeping Supervisor. During an interview on 9/28/22 at 3:38 PM, the Housekeeping Supervisor said he thought the stains on the floor were from aging floor tiles or glue. He stated the floor in room [ROOM NUMBER] was due to be stripped and waxed next week when the resident would be out of the building. He stated that will usually help but sometimes the stains would re-appear within a few weeks. He also stated that there were two floor technicians who worked at the facility, but one was out on medical leave The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the housekeeping department stripped and waxed two resident rooms per day. She added the building was older and the flooring had thinned out and thought the cement under the floor had pushed up through and caused the stains on the floor. Based on observations, resident and staff interviews, and record reviews, the facility (1) failed to maintain the floor in good repair in 1 of 7 hallways (A wing-100 hall), maintain walls and baseboard in good repair in 2 of 6 rooms on the A wing- 100 hall (rooms [ROOM NUMBERS]), maintain clean floors in 3 of 6 rooms on the A wing- 100 hall (Rooms 104, 109 and 110); (2) failed to maintain clean floors in 1 of 3 rooms on the C wing-300 hall (room [ROOM NUMBER] bed A); (3) failed to maintain the floor in good repair in 1 of 13 rooms observed (A wing-room [ROOM NUMBER]); (4) failed to provide washcloths, towels, and fitted bed sheets to residents residing on 1 of 2 resident wings of the facility (A wing) and (5) failed to maintain a clean, safe and orderly living environment for residents residing in room numbers 402, 406, 407 and 412 of the A-wing in the facility. Findings included: 1a. During a tour of A wing-100 hall on 9/27/22 at 10:01 AM, across from room [ROOM NUMBER], a six inch long hole was observed in the middle of the floor and crumbled cement was visible. Medication Aide #1 was interviewed on 9/27/22 at 10:03 AM. She shared the hole in the floor had been there for at least three weeks and said the maintenance department was aware of the hole in the floor. She added sometimes she placed a yellow caution sign over the floor tile which prevented residents, staff and visitors from walking or rolling their wheelchairs over it. In an interview with the resident who resided in room [ROOM NUMBER] on 9/27/22 at 10:10 AM, he stated the hole in the floor had been there a while and he expressed concern that someone might fall if they walked over it. On 9/29/22 at 1:56 PM, a tour of the A wing-100 hall was completed with the Maintenance Director and Assistant Maintenance Director. During the observation, the Maintenance Director measured the hole in the floor and reported it was 6.5 inches long, 2.25 inches wide and 3/8 inch deep. He described the hole in the floor as damaged tile with cement coming up. The Assistant Maintenance Director added the hole had been in the floor for about six months, but had not been repaired since he was the only maintenance employee in the building from June 2022 until earlier in the week when the Maintenance Director had started employment at the facility. The Assistant Maintenance Director explained he had been more focused on other maintenance repairs and had not gotten to the repair of the floor in the hallway. The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the hole in the hallway floor was identified on 9/23/22 and the facility had planned to cover the hole to prevent it from being a trip hazard. 1b. An observation of room [ROOM NUMBER] on 9/26/22 at 3:27 PM revealed gouges in the wall behind the resident's bed with exposed sheetrock. During an interview with the resident in room [ROOM NUMBER] on 9/26/22 at 3:30 PM, she shared the gouges in the wall had been there for almost a year. She said sometimes she asked staff to move her bed away from the wall so it wouldn't scratch up the wall. Observation of room [ROOM NUMBER] on 9/28/22 at 2:12 PM revealed gouges in the wall behind the resident's bed. On 9/29/22 at 2:06 PM, an observation of room [ROOM NUMBER] was completed with the Maintenance Director and Assistant Maintenance Director. In an interview with the Maintenance Director on 9/29/22 at 2:07 PM, he stated the gouges in the wall with exposed sheetrock were because there was no guard on the bed to prevent it from bumping up against the wall. The Assistant Maintenance Director explained there was a maintenance book at each nurse's station where staff wrote down repair requests. He had not performed routine audits of resident rooms to identify areas of concern; rather, he relied on staff to notify him of issues in the maintenance repair book. The maintenance repair book, located at the A wing nurse's station was reviewed on 9/29/22 at 2:14 PM and revealed no repair requests were located inside the book. The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the Assistant Maintenance Director had been the only maintenance employee in the facility since March 2022. The Maintenance Director had started at the facility earlier in the week and would address the repair of walls in resident rooms. 1c. An observation of room [ROOM NUMBER] on 9/26/22 at 11:17 AM revealed scuff marks on the wall across from the B bed. The baseboard at the bottom of the A bed wardrobe had peeled away from the wall. During an interview with the resident in room [ROOM NUMBER]-A on 9/26/22 at 11:20 AM, he said the baseboard had been peeled away for a month and didn't think any staff member knew about it. On 9/29/22 at 2:06 PM, an observation of room [ROOM NUMBER] was completed with the Maintenance Director and Assistant Maintenance Director. The Maintenance Director measured the peeled baseboard at 24 inches long, and the scuff marks on the wall measured 83 inches long. In an interview with the Maintenance Director on 9/29/22 at 2:09 PM, he stated the scuff marks were from a wheelchair that had scraped against the wall. The Assistant Maintenance Director explained there was a maintenance book at each nurse's station where staff wrote down repair requests. He had not performed routine audits of resident rooms to identify areas of concern; rather, he relied on staff to notify him of issues in the maintenance repair book. The maintenance repair book, located at the A wing nurse's station was reviewed on 9/29/22 at 2:14 PM and revealed no repair requests were located inside the book. The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the Assistant Maintenance Director had been the only maintenance employee in the facility since March 2022. The Maintenance Director had started at the facility earlier in the week and would address the repair of walls in resident rooms. 1d. An observation of room [ROOM NUMBER] on 9/26/22 at 3:27 PM revealed dark colored stains on the floor tiles throughout the room. During an interview with the resident in room [ROOM NUMBER] on 9/26/22 at 3:28 PM, she said housekeeping staff came in daily and swept and mopped the room, but the stains remained on the floor. Housekeeper #1 was interviewed on 9/27/22 at 3:03 PM. She explained she cleaned resident rooms daily and swept and mopped the floors. She verified there was a lot of dirt build up on the floors in residents' rooms and halls which had been an issue throughout the entire facility since at least April 2022, when she started her employment. She thought the facility needed more floor technicians and added one went on medical leave three weeks ago. Housekeeper #1 added the floors needed to be stripped and waxed. Observation of room [ROOM NUMBER] on 9/28/22 at 2:12 PM revealed dark colored stains on the floor tiles throughout the room. On 9/29/22 at 2:30 PM, an observation of room [ROOM NUMBER] was completed with the Housekeeping Supervisor. During an interview on 9/29/22 at 2:31 PM, the Housekeeping Supervisor said he thought the stains on the floor were from aging floor tiles or glue. He explained the floor in room [ROOM NUMBER] had recently been stripped and waxed which helped with removing the glue stains but typically within a few weeks the stains re-appeared. He confirmed there were two floor technicians who worked at the facility, but one was out on medical leave. The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the housekeeping department stripped and waxed two resident rooms per day. She added the building was older and the flooring had thinned out and thought the cement under the floor had pushed up through and caused the stains on the floor. 1e. An observation of room [ROOM NUMBER] on 9/26/22 at 11:40 AM revealed dark colored stains on the floor tiles throughout the room. Housekeeper #1 was interviewed on 9/27/22 at 3:03 PM. She explained she cleaned resident rooms daily and swept and mopped the floors. She verified there was a lot of dirt build up on the floors in residents' rooms and halls which had been an issue throughout the entire facility since at least April 2022, when she started her employment. She thought the facility needed more floor technicians and added one went on medical leave three weeks ago. Housekeeper #1 added the floors needed to be stripped and waxed. Observation of room [ROOM NUMBER] on 9/28/22 at 2:10 PM revealed dark colored stains on the floor tiles throughout the room. On 9/29/22 at 2:32 PM, an observation of room [ROOM NUMBER] was completed with the Housekeeping Supervisor. During an interview on 9/29/22 at 2:33 PM, the Housekeeping Supervisor said he thought the stains on the floor were from aging floor tiles or glue. He confirmed there were two floor technicians who worked at the facility, but one was out on medical leave. The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the housekeeping department stripped and waxed two resident rooms per day. She added the building was older and the flooring had thinned out and thought the cement under the floor had pushed up through and caused the stains on the floor. 1f. An observation of room [ROOM NUMBER] on 9/26/22 at 11:17 AM revealed dark colored stains on the floor tiles throughout the room. During an interview with the resident in room [ROOM NUMBER] on 9/26/22 at 11:18 AM, he said housekeeping staff came in every other day and swept and mopped the room, but didn't always mop the entire floor. Housekeeper #1 was interviewed on 9/27/22 at 3:03 PM. She explained she cleaned resident rooms daily and swept and mopped the floors. She verified there was a lot of dirt build up on the floors in residents' rooms and halls which had been an issue throughout the entire facility since at least April 2022, when she started her employment. She thought the facility needed more floor technicians and added one went on medical leave three weeks ago. Housekeeper #1 added the floors needed to be stripped and waxed. On 9/29/22 at 2:35 PM, an observation of room [ROOM NUMBER] was completed with the Housekeeping Supervisor. During an interview on 9/29/22 at 2:36 PM, the Housekeeping Supervisor said he thought the stains on the floor were from aging floor tiles or glue. He explained the floor in room [ROOM NUMBER] had recently been stripped and waxed which helped with removing the glue stains but typically within a few weeks the stains re-appeared. He confirmed there were two floor technicians who worked at the facility, but one was out on medical leave. The Assistant Administrator was interviewed on 9/29/22 at 2:57 PM. She said the housekeeping department stripped and waxed two resident rooms per day. She added the building was older and the flooring had thinned out and thought the cement under the floor had pushed up through and caused the stains on the floor. 4a. During an interview on 9/26/22 at 10:45 a.m., Resident #14 who was cognitively intact indicated there were no washcloths and towels available for the nursing assistant to use when providing his care. He stated the nursing assistant (unable to recall name) used a pillowcase to wash him. The resident indicated this occurred a few days prior to this interview. He also stated there were no fitted sheets available for his bed. An observation revealed a flat/top sheet was used as the bottom sheet of the resident's bed. 4b. An interview was conducted on 9/26/22 at 11:15 a.m. with Resident #82 who was cognitively intact. He stated he usually bathed himself but had been unable to bathe due to a lack of washcloths and towels. He revealed the facility had not provided washcloths and towels for at least 2-3 weeks. He also revealed there were no fitted bottom bed sheets available. Observation of the raised head of the resident's bed revealed a flat bed sheet that had loosened from the mattress. On 9/27/22 at 10:23 a.m. an observation of the linen cart on the A-200 hall revealed several hospital gowns, 1-blanket, several flat bedsheets. There were no washcloths and towels stored in the cart. On 9/27/22 at 10:48 a.m. the linen cart on the A-400 hall contained several top sheets, several bed pads, 1-blanket, and 7-towels. There were no washcloths in the cart. The observation on 9/27/22 at 3:42 p.m. of the linen closet on the A-100 hall revealed multiple hospital gowns, multiple flat bed sheets, 1-fitted sheet; 1-pillow; 1-tub of assorted socks, and 2-tan blankets. There were no towels or washcloths in the closet. On 9/27/22 at 4:26 p.m. the linen cart on the A-400 hall consisted of a pack of wipes, 1-bottle of perineal/body cleanser, 2-boxes of latex gloves on the top shelf, the second shelf was empty. The bottom shelf with multiple bags of adult diapers, 1-pack of wipes and a washbasin containing various items. There were no towels, washcloths or bed linen on the cart. During an interview on 9/28/22 at 3:26 p.m., NA#3 stated in the past 2-weeks there were not enough washcloths, towels and fitted sheets. She recalled when the laundry staff put the clean linen on the hall carts and in the linen closet, there were only 6-washcloths available for residents on three of the halls in the A-wing of the facility. An interview with the Environmental Director on 9/29/22 at 1:32 p.m. revealed he was first notified by Laundry Staff when there was a shortage of towels and washcloths in the facility. He stated the facility had a shortage of washcloths, towels, and fitted bedsheets for approximately two weeks. He also stated dirty fitted sheets were coming into the laundry department ripped at the seams. An order was placed for more linen one and a half weeks ago. Until the delivery of the new linen, the Laundry Staff was required to check the dirty linen closets every thirty minutes instead of every one hour and thereby wash linen more frequently due to the shortage. During an interview on 9/29/22 at 2:05 p.m., the Laundry Staff stated there had been a shortage on washcloths, towels, and fitted sheets since the prior month. He stated he put in an order request in August 2022 but had not received any of the items as of the time of this interview. He revealed the nursing assistants would horde clean linen in residents' rooms, put soiled linen in the same bag as trash, and/or throw away washcloths that have fecal material. The Laundry Staff also revealed that the day before this interview 1-large bag of washcloths, 1-large bag of towels, 1-large bag of fitted sheets, and 2-cases of bedpads were delivered from the facility's sister facility. 5. During an observation of room [ROOM NUMBER] on A-wing of the facility on 9/26/22 at 10:26 a.m. and on 9/29/22 at 12:34 p.m., the surfaces of 2-overbed tables were peeling, exposing rough edges. On 9/26/22 at 11:15 a.m. there were dirty, dried yellow and brown stains on floor, near the headboard of the bed and in the bathroom in room [ROOM NUMBER]a on A-wing. Also, there was torn drywall on the wall in the bathroom. A follow-up observation of room [ROOM NUMBER]a on 9/27/22 at 9:33 a.m. and 9/29/22 at 1:10 p.m. revealed the floor surrounding the bed remained dirty with the brown, yellow stains. On 9/27/22 at 10:33 a.m., 9/28/22 at 2:15 p.m. and 9/29/22 at 12:44 p.m., there was a dirty fall mat stained with white/gray residue and multiple brown particles on the floor next to the bed in room [ROOM NUMBER]b on A-wing. The frontal vents of the air conditioning/heating unit in the room were covered in thick, dark gray lint. Also, the drywall on the lower wall, near the head of the bed of 407a was scratched/torn. During an interview on 9/27/22 at 3:03 p.m., Housekeeper #1 indicated there was a lot of dirty build-up on floors in the residents' rooms and hallways and the floors were in this condition since April 2022. She stated the floors need to be stripped and waxed. The housekeeper stated there were not enough floor and housekeeping staff. She revealed there were no housekeepers on duty at the facility after 3:00 p.m. During an interview on 9/28/22 at 9:55 a.m., the Environmental Director revealed housekeeping department was responsible for deep cleaning one room on each hall per day and as needed. Also, when a resident was discharged from the facility housekeeping would deep clean the vacated room. He stated there should not be stains on the floors in the facility. On 9/28/22 at 2:17 p.m. and on 9/29/22 at 12:54 p.m. during an observation of room [ROOM NUMBER], the privacy curtain pulled between the residents' beds was stained with several large brown/tan blotches visible from the open doorway of the room. On 9/29/22 at 12:59 p.m., there was a large hole in the lower wall at the workstation located on the 400 hall of A-Wing in the facility. An interview on 9/29/22 at 1:16 p.m. with the Assistant Maintenance Director revealed he was aware of the hole in the wall at the workstation on the 400 hall of the A-Wing. He indicated he had been the only maintenance worker at the facility for one and a half years until two days prior to this interview. As a result, work orders were prioritized based on urgency with residents' requests as first priority. He stated he was unaware of the peeling overbed tables and would replace them, immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview 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 the recertification survey completed on 6/14/21. This was for 3 deficiencies that were cited in the areas of Safe/Clean/Comfortable/Homelike Environment (F584), Accuracy of Assessments (F641), and Bowel/Bladder Incontinence, Catheters (F690) on 6/14/21 and recited on the current recertification and complaint survey of 9/29/22. 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 5/10/19. This was evident for 3 deficiencies in the area of Safe/Clean/Comfortable/Homelike Environment (F584), Accuracy of Assessments (F641), and Label/Store Drugs and Biologicals (F761) originally cited on the recertification and complaint survey on 5/10/19 and recited on the current recertification and complaint survey of 9/29/22. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the complaint survey of 1/20/22. This was evident for 1 deficiency in the area of Free of Hazards/Supervision/Devices/Accidents (F689) that was originally cited during a complaint investigation on 1/20/22 and recited on the current recertification and complaint survey of 9/29/22 which resulted in two residents who sustained hip fractures and one required surgical repair. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The finding included: This citation is cross referred to: F584: During the recertification of 09/29/22 the facility (1) failed to maintain the floor in good repair in 1 of 7 hallways (A wing-100 hall), maintain walls and baseboard in good repair in 2 of 6 rooms on the A wing- 100 hall (rooms [ROOM NUMBERS]), maintain clean floors in 3 of 6 rooms on the A wing- 100 hall (Rooms 104, 109 and 110); (2) failed to maintain clean floors in 1 of 3 rooms on the C wing-300 hall (room [ROOM NUMBER] bed A); (3) failed to maintain the floor in good repair in 1 of 13 rooms observed (A wing-room [ROOM NUMBER]); (4) failed to provide washcloths, towels, and fitted bed sheets to residents residing on 1 of 2 resident wings of the facility (A wing) and (5) failed to maintain a clean, safe and orderly living environment for residents residing in room numbers 402, 406, 407 and 412 of the A-wing in the facility. During the recertification investigation on 6/14/21, the facility failed to unpack a resident ' s belongings stored in cardboard boxes for 1 of 32 residents sampled. During the recertification investigation on 5/10/19, the facility failed to maintain the walls in 4 resident rooms (Room C212A, C211B, C207B, and A303) and failed to maintain a tray table and nightstand in good repair in 1 resident room (Room C207B). F641: During the recertification on 09/29/22 the facility failed to accurately complete Minimum Data Set (MDS) assessments to reflect a gradual dose reduction of an antipsychotic medication for 1 of 5 residents (Resident #7) reviewed for unnecessary medications and the behaviors for 1 of 1 resident (Resident #116) reviewed for behaviors. During the recertification investigation on 6/14/21, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of catheters, medications, and hospice. During the recertification investigation on 5/10/19, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect dialysis, the Preadmission Screening and Resident Review (PASRR) Level status, and services provided by the facility's restorative nursing program. F689: During the recertification on 09/29/22, the facility failed to provide care in a safe manner and/or implement fall safety interventions developed and care planned by its interdisciplinary team (IDT) for 4 of 5 residents (Residents #2, #335, #7 and #132) reviewed for falls. Resident #2 sustained a fall from his bed that resulted in a fracture of the left femur neck requiring open reduction and internal fixation (surgical intervention). Resident #335 sustained a fall from his bed that resulted in a non-displaced fracture to his right femur that was conservatively managed (no surgical intervention). During a complaint investigation on 1/20/22, the facility failed to ensure 1 of 2 residents requiring extensive assistance with bed mobility and bathing was provided care safely to prevent injury. F690: During the recertification on 09/29/22, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 5 residents (Resident #27) reviewed with indwelling urinary catheters. During the recertification investigation on 6/14/21, the facility failed to change a urinary catheter as ordered for a resident. F761: During the recertification on 09/29/22, the facility failed to discard expired medications stored in 1 of 4 medication carts observed (A100 Hall Medication Cart). During a complaint investigation on 11/5/20, the facility failed to keep medications secured in a locked medication cart for 2 of 2 medication carts observed. During the recertification investigation on 5/10/19, the facility: 1) Failed to remove expired medications from 4 of 5 medication carts (Unit C-200 Hall, Unit C-100 Hall, Unit C-400, and Unit A-400 Hall med carts) observed; 2) Failed to store medications as specified by the manufacturer in 1 of 5 medication carts (Unit A-400 Hall med cart) observed; and, 3) Failed to label medications with the minimum required information (including the resident ' s name) in 2 of 5 medication carts (Unit C-200 Hall and Unit C-100 Hall med carts) observed. The Assistant Administrator (AA) was interviewed on 9/29/22 at 2:40 pm. The AA stated the QA members were made up of Administrator, the Assistant Administrator (AA), the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Supervisor and the Medical Director were always invited to attend. The AA stated that the QA committee usually meets quarterly but they have met monthly this year due to new staff. She stated that both her and the Administrator were new to the building, and this was their first recertification and she (the AA) had only been working in her position for a few months. She stated she did know there was a lot of turnover, and the facility was having to utilize a lot agency staff these last few months. She stated she was aware there were issues to address but was unaware to what extent. She stated they facility has a whole will meet to discuss these issues and how to achieve compliance. The facility administrator was unavailable for interview.