**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff and resident interviews, the facility failed to honor residents' preference for eating in the dining room for 9 days due to a COVID-19 outbreak when one employee tested positive on 8/2/25 for 3 of 5 residents reviewed for choices (Residents #20, #63, and #110).Review of the facility's policy COVID-19 Response Program last revised August 2025 revealed that the term outbreak was not defined and there was not any instruction for dining activity during an outbreak. The policy did state for the facility to notify the health department of any suspected or confirmed cases. During an observation of the dining room on 8/11/25 at 12:20 PM, there were not any residents eating lunch in the dining room. An interview with the Administrator on 8/11/25 at 12:45 PM revealed the facility was currently in outbreak status and the dining room had been closed since 8/2/25 when one employee tested positive. He stated he was instructed by someone from the county health department to temporarily cease all group interactions, including dining. a. Resident # 20 was readmitted to the facility on [DATE]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #20 was cognitively intact, had adequate vision/hearing, had clear speech, and understood/understands. She was independent with eating. During an interview with Resident #20 on 8/11/25 at 1:45 PM, she revealed that she often ate lunch and dinner in the dining room. She stated it upset her that the facility closed the dining room all last week (8/2/25 - 8/11/25) due to a COVID-19 outbreak. b. Resident #63 was admitted to the facility on [DATE]. Review of the comprehensive MDS assessment dated [DATE] revealed that Resident #63 was cognitively intact, had adequate vision/hearing, had clear speech, and understood/understands. She was independent with eating. Resident #63 was interviewed on 8/11/25 at 1:47 PM. She revealed that she enjoyed eating lunch and dinner in the dining room every day. She stated that she was unhappy because the facility closed the dining room since 8/2/25 due to a COVID-19 outbreak. c. Resident #110 was readmitted to the facility on [DATE]. Review of the comprehensive MDS assessment dated [DATE] revealed that Resident #110 was moderately cognitively intact, had adequate vision/hearing, had clear speech, and understood/understands. She was independent with eating. An interview was conducted with Resident #110 on 8/11/25 at 1:53 PM. She revealed that she was upset the dining room was closed since 8/2/25 due to a COVID-19 outbreak. She ate lunch and dinner in the dining room daily. The Director of Nursing (DON) was interviewed on 8/14/25 at 9:50 AM. She revealed that according to the facility's policy titled, COVID-19 Response Program last revised August 2025, one positive COVID-19 case was considered an outbreak and would remain in outbreak status until 14 days without a positive test result. The DON stated that the health department told her to suspend all group dining, and one positive result was considered an outbreak. She indicated that there were not any residents that complained to her about being upset with the dining room being closed for the last 9 days. Review of an email sent by the Communicable Disease Nurse to the Staff Development Coordinator on 8/4/25 revealed that guidance was provided about source control. However, there was not a suggestion to temporarily cease dining activities for residents with one positive case of COVID-19 in the building. During an interview with the Communicable Disease Nurse for the county on 8/15/25 at 9:09 AM, she revealed that she never spoke to anyone from the facility about the outbreak that started on 8/2/25. She indicated that she only received a voicemail from the facility notifying her that one employee tested positive for COVID-19 on 8/2/25. She explained if only one employee tested positive for COVID-19, then that would cause the facility to be under surveillance and should have conducted contact tracing and testing. The Communicable Disease Nurse for the county stated she would never give the facility advice to temporarily cease group dining, since an outbreak was considered 2 or more cases within a 14-day period. An interview was conducted with the Public Health Nursing Supervisor over Communicable Disease on 8/14/25 at 11:37 AM. She revealed that 2 or more cases of COVID-19 would be considered an outbreak. If there was only one positive case, the facility would be under observation, and the public health department would not suggest that group activities be ceased temporarily. The Administrator was interviewed on 8/14/25 at 11:56 AM. He stated that someone (unknown name) from the health department told him to temporarily cease all group dining for 14 days. The Administrator indicated that he did what he was asked to do. He stated that he was taking precautionary measures, and he expressed understanding that one positive case of COVID-19 was not considered an outbreak.

Based on observations, record review, and resident council member and staff interviews, the facility failed to conduct resident council meetings in a private area for 6 of the 6 resident council meetings reviewed in the last 6 months (2/19/25, 3/19/25, 4/16/25, 5/21/25, 6/18/25, and 7/23/25).The findings included:Review of the resident council minutes reviewed from 02/19/25 through 07/23/25 revealed resident council meetings had been held in the dining area.A resident council meeting was held on 08/12/25 at 3:00 PM with resident council members (Resident #2, Resident #20, Resident #22, Resident #30, Resident #33, Resident #61, Resident #63, Resident #99, Resident #110, Resident #113, and Resident #124.) The resident council members revealed they had their meetings in the lounge area next to the dining room. It was further revealed staff and visitors often disrupted the meeting due to not having any walls or doors. The resident council members stated they were unable to meet privately, and it was often frustrating.An observation of the lounge area next to the dining room on 08/12/25 at 4:15 PM revealed the room to be one open area with no privacy. It addition, the entrance hallway from the front door of the facility is adjacent to the lounge with no divider or wall separating them. Staff and visitors in the hallway can hear conversations in the lounge and there is no privacy between the lounge, dining room and hallway. An interview conducted with the activity's director on 08/12/25 at 10:30 AM revealed resident council meetings were held in the dining area. It was further revealed she did not have an activity room or private area to hold meetings. The activity director indicated she tried to keep meetings private, but sometimes visitors and staff were not aware of the meeting and would disrupt. An interview conducted with the Administrator on 08/14/25 at 3:05 PM revealed he was not aware that resident council meetings needed to be held in a private area and was not aware residents had complained. The Administrator indicated he did not have a meeting place that was private for resident council meetings but would work on getting one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete a baseline care plan that addressed the resident's immediate needs within 48 hours of admission for 2 of 30 sampled residents (Residents #51 and #106).The findings included: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, and end stage chronic kidney disease. The nursing admission data collection assessment initiated and completed on 5/19/25 and revealed Resident #51 was on dialysis and also received antidepressant and diuretic medications. Review of Resident #51's electronic medical record on 8/13/25 revealed no evidence a baseline care plan that addressed her immediate needs was completed within 48 hours of her admission to the facility on 5/19/25. During an interview with the Minimum Data Set (MDS) Coordinator on 08/13/2025 at 3:10 PM, he stated the baseline care plans included the resident's standing orders, new medication orders, and their admitting diagnoses. He explained they were usually completed within 72 hours at the interdisciplinary care conference. The MDS Coordinator also stated that if a resident was admitted on a Thursday, the baseline care plan would be completed on the following Monday. During an interview with the Director of Nursing (DON) on 8/14/2025 at 9:44 AM, she stated the baseline care plan should be started immediately after admission and would include goals and interventions regarding the care of the resident. The DON reported that the baseline care plan should be completed within 72 hours of admission to the facility. During an interview with the Corporate Nurse Consultant on 8/14/25 at 3:37 PM she stated that the baseline care plans should be completed within 48 hours of a resident's admission. She stated the baseline care plan should contain pertinent information that addressed a resident's immediate care needs for staff until the comprehensive care plans were developed. 2. Resident #106 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, polyneuropathy, depression, and pressure ulcers of left and right buttocks. The nursing admission data collection assessment initiated and completed on 7/11/25 and revealed Resident #106 received antidepressant medications, would begin physical therapy as tolerated, and required daily dressing changes for wound care. Review of Resident #106's electronic medical record on 8/13/25 revealed no evidence a baseline care plan that addressed her immediate needs was completed within 48 hours of her admission to the facility on 7/11/25. During an interview with the Minimum Data Set (MDS) Coordinator on 08/13/2025 at 3:10 PM, he stated the baseline care plans included the resident's standing orders, new medication orders, and their admitting diagnoses. He explained they were usually completed within 72 hours at the interdisciplinary care conference. The MDS Coordinator also stated that if a resident was admitted on a Thursday, the baseline care plan would be completed on the following Monday. During an interview with the Director of Nursing (DON) on 8/14/2025 at 9:44 AM, she stated the baseline care plan should be started immediately after admission and would include goals and interventions regarding the care of the resident. The DON reported that the baseline care plan should be completed within 72 hours of admission to the facility. During an interview with the Corporate Nurse Consultant on 8/14/25 at 3:37 PM she stated that the baseline care plans should be completed within 48 hours of a resident's admission. She stated the baseline care plan should contain pertinent information that addressed a resident's immediate care needs for staff until the comprehensive care plans were developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and resident and staff interviews, the facility failed to apply compression wraps to Resident #87's legs as ordered. The deficient practice occurred in 1 of 1 resident reviewed for providing services to meet professional standards (Resident #87).Findings included:Resident #87 was admitted to the facility on [DATE] and had cumulative diagnoses including congestive heart failure, morbid obesity and lymphedema.Review of records revealed a physician's order dated 5/28/25 for compression wraps to bilateral (both right and left) legs every morning and to be removed every evening for lymphedema.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact.A revised care plan dated 7/21/25 revealed focus areas for congestive heart failure, lymphedema, and activities of daily living deficit. Review of Resident #87's Treatment Administration Record (TAR) for 8/13/25 revealed documentation by nursing staff that compression wraps were placed at 8:00 AM by Nurse #1. On 8/13/25 at 10:00 AM an interview with Resident #87 was conducted in conjunction with an observation. Resident #87 stated that she did not have compression wraps on her legs. Resident #87 stated she was very worried about the staff not putting the compression wraps on her legs and explained she did not want her lymphedema to get worse. Resident #87 stated historically that staff had put the wraps on in the morning and then took them off at night. Resident #87 then uncovered both of her legs which revealed no compression wraps in place to either of her legs. On 8/13/25 at 2:30 PM an interview and record review were conducted with Resident #87's primary nurse, Nurse #1. Nurse #1 reported she did not have anything to do with Resident #1's compression wraps. Nurse #1 stated she did not know how often the compression wraps should be applied or when they should be removed. Nurse #1 reviewed the TAR for 8/13/25, which had Nurse #1's initials documenting application of the compression wraps, and Nurse #1 confirmed that her initials were noted on the TAR as documenting that the compression wraps were applied on the resident by her at 08:00 AM. Nurse #1 stated she did not know how her initials got there. Nurse #1 then acknowledged that she did not place the wraps on at 08:00 AM but said that the wraps were already on, and that was what she charted on at 08:00 AM. Nurse #1 stated she did not how or when Resident #87's leg wraps were removed or who may have removed them.On 8/13/25 at 3:05PM, an interview with the Director of Nursing (DON) was conducted. The DON stated if a task was ordered by the physician, it should be carried out by nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and resident, staff and physician interviews, the facility failed to provide ordered physical therapy for a resident with history of stroke and spastic contractures in 1 of 1 resident reviewed for rehabilitation services (Resident #5).Findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident with right sided hemiparesis and hemiplegia with spasticity (weakness and paralysis with muscle spasms), type II diabetes, neuropathy, atrial fibrillation and depression.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. A revised care plan dated 6/24/25 showed focus areas for stroke, with hemiplegia/hemiparesis, contractures, falls, diabetes, atrial fibrillation, depression, activities of daily living deficits, psychotropic medication monitoring, braces for contractures and physical therapy.Review of records revealed a facility physical therapy functional maintenance program sheet dated December 2024. The functional maintenance program specified that Resident #5 was to be up in his wheelchair for three to four hours daily, was to perform wheelchair mobility exercises and to maintain proper sitting posture while in his wheelchair. The functional maintenance program sheet contained no stipulations or benchmarks to assess for decline in function or who to notify if needs arose. A Neurology physician office note dated 7/25/25 revealed Resident #5 had spastic quadriparesis following multiple strokes and during the same visit, received botox injections to various muscle groups in his left arm and his right arm due to spasticity which had adversely affected his function. The physician noted Resident #5's strokes in 2024 which rendered his left side weaker than his right side. The physical assessment noted restriction of left shoulder flexion, restriction of left elbow extension and supination as well as restriction of finger extension of the left and right hands due to spasticity. The physician then noted the in-office botox injection procedure and Resident #5's need for continued physical therapy. Review of records also revealed that on 7/25/25, the Neurology physician ordered a physical therapy referral and that Resident #5 was to wear his left elbow and left wrist brace for 4 hours every day and for four hours every night. Further review of records revealed no documentation pertaining to initiation of physical therapy services following the order on 7/25/25. In an interview with Resident #5 on 8/11/25 at 10:30 AM, Resident #5 was observed sitting up in bed. He was awake, alert, groomed and watching TV. He said that he got up to his wheelchair as often as he could. Resident #5 reported that he was very concerned that the doctor had ordered physical therapy for him a few weeks ago but I haven't had any therapy yet.On 8/13/25 at 09:30 AM, Resident #5 was observed in his room, awake, sitting up in bed, watching TV conversing with visitors at his bedside. In an interview with the Rehabilitation Manager on 8/13/25 at 10:30 AM, the Rehabilitation Manager informed that the 7/25/25 order for the Physical Therapy (PT) referral had not been completed yet. The Rehabilitation Manager stated that Resident #5 was on a wait list because there was only one physical therapist working in the building. The Rehabilitation Manager stated that when they received an order for PT, rehab services first conducted a rehab screening. Then if the screening gave indication that a referral was needed, then the referral was completed. The Rehabilitation Manager stated that only once the screening and referral deemed a resident was appropriate for PT services, would a resident be accepted for PT. The Rehabilitation Manager stated that there was no set timeframe for when an order was received and when services began and this varied based on a resident's needs. The Rehabilitation Manager further stated that specific findings that moved a resident from screening to referral, to formal physical therapy also varied based on resident's needs. The Rehabilitation Manager stated that the timeframe from 7/25/25 to 8/12/25 was longer than usual but that they were very behind schedule because there was only one therapist working on PT screenings. The Rehabilitation Manager stated that Resident #5 was last seen by PT in December 2024 and was discharged at that time with a functional maintenance program. The Rehab Manager further stated that nursing staff was to notify the physician and rehabilitation services of any need for additional therapy. On 8/13/25 at 11:00 AM, an interview with the Physical Therapist was conducted. The Physical Therapist stated that she was not contracted but was a facility staff member. The Physical Therapist confirmed that Resident #5 had received an order for a physical therapy referral on 7/25/25 and Resident #5 was on a wait list for the referral. The Physical Therapist stated that when they received an order for physical therapy, a screening was done first, then a referral, then the decision was made whether or not a resident was appropriate to picked up for formal physical therapy services. The Physical Therapist stated that because she was the only physical therapist in the building, she had not yet been able to screen Resident #5, but that there were only two other residents ahead of him as of today. The Physical Therapist stated that Resident #5 had been on the physical therapy schedule before but was discharged in December 2024. When he was discharged from therapy he was placed on a functional maintenance program in order to prevent functional decline. The Physical Therapist stated that the functional maintenance programs varied based on specific needs of residents and there was no standard criteria for how or when a resident was moved through the process of screening, to referral and then to being formally accepted for physical therapy services. The Physical Therapist further stated that because Resident #5 was on a functional maintenance program, he would be a lower priority for screening in the event of long wait lists, but that she was doing her best to get to all the residents on the wait list. In a follow up interview with Resident #5 on 8/13/25 at 2:00 PM, Resident #5 was observed in his room. Resident #5 stated that he had a doctor's appointment a few weeks ago, he had been feeling worse, his arms were very stiff before that appointment. The doctor gave him some injections and that helped a lot, and his arms did not feel that stiff now. Resident #5 stated that he felt better right now because of the injections he received but that the doctor told him that he needed therapy so his arms didn't get worse again. He wanted to get his therapy so his arm would stay limber. Resident #5 said he wore his arm braces on his left elbow and left wrist every day for 4 hours like his doctor told him to. Resident #5 stated his family helped him put his braces on some of the time and that staff helped him at other times.Attempts to contact the ordering Neurology physician were unsuccessful. Attempts to interview Resident #5's assigned nurse (Nurses #1) were not successful. Attempts to interview the Director of Nursing were unsuccessful.In an interview with the Administrator on 8/14/25 10:45 AM, the Administrator stated that he did not know the expectations or expected timeframes of when a physical therapy order was placed and when the order should be implemented, but that sometimes the timeframes were different based on resident needs. The Administrator stated that the therapist does a screening, but he did not know anything else because that was out of his scope of practice. In an interview with the Medical Director on 8/14/25 at 2:30 PM, the Medical Director stated that the timeframe of when Resident #5's physical therapy referral order was placed, and the current date was too long. The Medical Director said that she would have expected that order to be carried out within one week and we dropped the ball and there was a breakdown in communication, and I will be following up on that today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and resident and staff interviews, the facility failed to provide a privacy curtain for 2 of 16 rooms on the 200-hall reviewed for privacy (Resident #27 and Resident #40). The findings included:a. Resident #27 was admitted to the facility on [DATE].The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was cognitively intact.An observation and interview conducted with Resident #27 on 08/11/25 at 10:00 AM revealed Resident #27 did not have a privacy curtain and shared a room with another resident. Resident #27's room was closest to the door and provided no privacy if the Resident's door was open. Resident #27 further revealed he had not had a privacy curtain in a while and could not recall why he did not have one.An observation conducted on 08/12/25 at 11:35 AM revealed Resident #27 did not have a privacy curtain hanging.b. Resident #40 was admitted to the facility on [DATE].The admission MDS dated [DATE] revealed Resident #40 was cognitively intact.An observation and interview conducted with Resident #40 on 08/11/25 at 10:15 AM revealed Resident #40 did not have a privacy curtain and shared a room with another resident. Resident #40's room was closest to the door and provided no privacy if the Resident's door was open. Resident #40 further revealed he had not had a privacy curtain since admission and had asked nursing staff, but they had yet to bring one. Resident #40 stated he would like a privacy curtain due to his roommate and staff constantly entering.An observation conducted on 08/12/25 at 11:10 AM revealed Resident #40 did not have a privacy curtain hanging.An observation and interview conducted with the Director of Housekeeping on 08/12/25 at 11:20 AM revealed she was not aware Resident #27 and Resident #40 did not have a privacy curtain. It was further revealed housekeeping should be checking for curtains daily and making sure they are clean and hanging.An interview conducted with the Administrator on 08/14/25 at 3:05 PM revealed he was not aware Resident #27 and Resident #40 did not have a privacy curtain. It was further revealed it was housekeeping's responsibility to make sure each resident had a privacy curtain. The Administrator stated he expected rooms to be checked daily for privacy curtains and the cleanliness of the privacy curtains.

Based on record review, observations and staff interviews, the facility dietary staff failed to demonstrate competency with monitoring the chemical sanitization level for the low temperature dish machine by not performing testing at least once per shift which could affect 111 of the 111 residents. The findings included: The program brochure for the low temperature dish machine was reviewed. It stated the minimum chemical sanitizer rinse requirements were 50 parts per million (ppm) of chlorine. An observation of the dish machine with Dietary Manager (DM) was conducted on 8/11/25 at 9:46 AM and the DM confirmed the chlorine level of the low temperature dish machine measured 0 ppm. During an interview with the Dietary Manager on 8/11/25 at 9:48 AM, the Dietary Manager stated that dietary staff were supposed to test the chemical sanitization level daily. However, the dish machine temperature log only included temperatures of the rinse/wash cycles, and not the chemical sanitization level. During a follow up interview with the DM on 8/11/25 at 12:41 PM, she revealed that the vendor had fixed the dish machine an hour earlier. The DM stated the vendor reported the nozzle to the chemical sanitization was not working properly. The DM indicated that she was able to wash and sanitize all dishes prior to lunch meal service on 8/11/25. An observation and interview were conducted with Dietary Aide #1 on 8/12/25 at 9:45 AM. The low temperature dish machine measured 272 ppm, which was in the optimal range. Dietary Aide #1 stated she had never measured the chemical sanitization level of the dish machine before, only the 3-part sanitization sink for the pots/pans. Dietary Aide #2 was interviewed on 8/13/25 at 11:56 AM. She revealed that she did not always record the temperatures of the dish machine but had never measured the chemical sanitization level. During a follow-up interview with the Dietary Manager on 8/14/25 at 8:00 AM, she revealed that she had never used a low temperature dish machine before and was not aware of the minimum chemical sanitization level. An interview was conducted with the Administrator on 8/14/25 at 12:08 PM. He revealed that the dish machine chemical sanitization level should be checked every morning and documented appropriately. If any issues were found where the level was below 50 ppm, then the vendor should have been contacted immediately.

Based on observation and staff interviews, the facility failed to 1) to maintain the minimum chemical sanitization level of the low temperature dish machine according to the manufacturer's recommendations 2) clean the convection ovens, the fryer, the toaster, steamer, stove and plate warmer for 3 of 3 observations 3) allow cooking pans and dishes to completely dry prior to assemblage and stacking for two of two observations, 4) remove cracked and dirty plates prior to meal service for 1 of 1 observation and clean 2 of 3 meal carts. These practices had the potential to affect food served to residents. 1. The manufacturer program brochure for the low temperature dish machine was reviewed and specified the minimum chemical sanitizer rinse requirements were 50 parts per million (ppm) of chlorine. An observation and interview with the Dietary Manager (DM) were conducted on 8/11/25 at 9:46 AM. During dish service, the chlorine level of the low temperature dish machine measured 0 ppm. The DM stated that she needed to contact the Maintenance Director. During an interview with the Maintenance Director on 8/11/25 at 9:47 AM, he revealed that the chemical sanitization was serviced by the vendor. During a follow up interview with the DM on 8/11/25 at 9:48 AM, she revealed that the vendor last came to service the low temperature dish machine about 3 weeks ago. She stated they were supposed to test the chemical sanitization level daily. However, the dish machine temperature log only included temperatures of the rinse/wash cycles, and not the chemical sanitization level. During a follow up interview with the DM on 8/11/25 at 9:57 AM, she revealed that all breakfast dishes would be rewashed and sanitized in the 3-part sink that measured within the desirable range chemical sanitization level. The DM stated she planned to purchase paper goods to serve at lunch, so the sanitized dishes could air dry prior to dinner service. During a second follow up interview with the DM on 8/11/25 at 12:41 PM, she revealed that the vendor had fixed the dish machine an hour earlier. The DM stated the vendor reported the nozzle to the chemical sanitization was not working properly. The DM indicated that she was able to wash and sanitize all dishes prior to lunch meal service on 8/11/25.During an additional follow up interview with the DM on 8/14/25 at 8:00 AM, she revealed that she had never used a low temperature dish machine before and was not aware of the minimum chemical sanitization level. An interview was conducted with the Administrator on 8/14/25 at 12:08 PM. He revealed that the dish machine chemical sanitization level should be checked every morning and documented appropriately. If any issues were found where the level was below 50 ppm, then the vendor should have been contacted immediately. 2. An observation of the kitchen and interview with [NAME] #1 was conducted on 8/11/25 at 9:51 AM. The doors of the two convection ovens were coated with a light brown substance, and a darker brown substance was seen on the inside of both ovens. The bottom of the fryer was covered with a dark brown liquid and food crumbs. The food crumbs were also seen along all inside walls of the fryer. [NAME] #1 stated that the kitchen equipment should be cleaned weekly; however, he could not say when the ovens were cleaned last. He stated the fryer was used within the last two days, and it was cleaned sometime last week. [NAME] #1 indicated the fryer would not be used today.An observation of the kitchen and interview with [NAME] #2 was conducted on 8/12/25 at 9:38 AM. The doors of the two convection ovens were coated with a light brown substance, and a darker brown substance was seen on the inside of both ovens. The bottom of the fryer was covered with a dark brown liquid and food crumbs. The food crumbs were also seen along all inside walls of the fryer. A white residue covered the outer surfaces of the steamer and the stove. [NAME] #2 stated the kitchen equipment was cleaned every 3 weeks and was due to be cleaned tomorrow (8/13/25). An interview was conducted with the Dietary Manager on 8/12/25 at 9:39 AM. She stated the kitchen equipment should be cleaned daily, but only she and [NAME] #2 were the staff willing to do so. The DM stated the last time the kitchen equipment was cleaned was two weeks ago. An observation of the kitchen and interview with Dietary Aide #1 was conducted on 8/13/25 at 7:07 AM. The plate warmer was noted to have white residue covering the entire top of the equipment, and a stiff, yellow piece of food and other brown pieces of food were seen near one of the plate openings. Dietary Aide #1 stated the evening staff on 8/12/25 were supposed to clean it. During a follow up appointment with the Dietary Manager on 8/14/25 at 8:02 AM, she revealed that she expected dietary staff to clean the kitchen equipment daily and after use. The Dietary Manager indicated that dietary staff had been very resistant to any instructions they were given. She stated she had been working on building a better team in the kitchen since she was hired at the facility five weeks ago. The Administrator was interviewed on 8/14/25 at 12:14 PM. He revealed that the cooks should follow the Dietary Manager's expectations of kitchen equipment cleaned daily and deep cleaned weekly. The Administrator stated that the Dietary Manager was new to the facility, and it would take time to improve the kitchen.3. An observation of the kitchen and interview with the Dietary Manager were conducted on 8/11/25 at 9:55 AM. Observed on the cooks' clean rack were two large silver pans approximately 4 inches deep, and two smaller silver pans approximately 4 inches deep, were seen with wet nesting. The Dietary Manager apologized and went to rewash them. She stated the cooks were responsible for cleaning the pans they used.During a follow up interview with [NAME] #1 on 8/11/25 at 9:56 AM, he stated he normally let the pans air dry on the rack in the dish room prior to storage. However, he must not have let the pans air dry fully prior to placing them ready for use. An observation of the kitchen and interview with [NAME] #1 was conducted on 8/11/25 at 10:01 AM. Sixteen cereal bowls and eighteen small plates had wet nesting next to the tray line. [NAME] #1 confirmed the dishes were wet and brought them back to the dish machine area. During a follow up interview with the Dietary Manager on 8/14/25 at 8:05 AM, she revealed that dietary staff should air dry all pots, pans, and dishes prior to storage for use. She stated she did not have enough time during dishwashing to air dry because the nursing staff did not bring the dirty dishes to the kitchen in a timely manner. The Dietary Manager indicated that the staff from the kitchen had to stop what they were doing daily to retrieve the meal trays and meal carts from each hall after service. An observation of the kitchen and interview with the Dietary Manager was conducted on 8/12/25 at 9:41 AM. Six silver pans approximately 4 inches deep, and three smaller silver pans approximately 4 inches deep, were seen with wet nesting on the clean rack in the cooks' area. The Dietary Manager stated she had educated the cooks numerous times about letting the pans air dry, but they have not complied. She further stated that she would rewash the pans that were wet.The Administrator was interviewed on 8/14/25 at 12:07 PM. He revealed that all dishes and pots/pans should not have wet nesting and be air dried prior to use. The Administrator indicated that the Dietary Manager was new to the facility, and it would take time for her to improve the dietary department.4. An observation of the kitchen and interview with Dietary Aide #1 on 8/13/25 at 7:04 AM. Thirteen plate holders had food residue on them, and twenty-seven dinner plates had cracks. She stated that the Dietary Manager told her to throw them away, but if she did that then they would not have any plates for meal service. During a follow up interview with the Dietary Manager on 8/13/25 at 7:08 AM, she revealed that she had new dinner plates available in storage and went to go wash them. During a follow up interview with the Dietary Manager on 8/13/25 at 7:15 AM, she revealed that she educated all dietary staff about cracked dishes and proper cleaning of the dishes. An observation of the 100 hall and interview with the Dietary Manager was conducted on 8/13/25 at 8:29 AM. The meal cart had white residue marks all over the inside and outside. The Dietary Manager stated that she told Dietary Aide #3 to clean all meal carts yesterday. An observation of the 200 hall and interview with Dietary Aide #3 was conducted on 8/13/25 at 8:31 AM. The meal cart had marks of white residue that covered the inside and outside. Dietary Aide #3 stated he was supposed to clean all meal carts yesterday but forgot. During a follow-up interview with the Dietary Manager on 8/14/25 at 8:08 AM, she revealed that she expected that the meal carts would be cleaned daily and deep cleaned on the weekends. The Administrator was interviewed on 8/14/25 at 12:12 PM. He revealed that if plates were chipped, they should not be used during meal service and should have been replaced. The Administrator indicated that all dishware should be clean before use, including meal carts.

Based on observation and staff interviews, the facility failed to ensure debris was removed from behind the dumpsters for 3 of 3 dumpsters observed. This practice had the potential to attract pests and rodents. An observation of the dumpster area was conducted on 8/11/25 at 10:04 AM. Behind all 3 dumpsters, used debris items such as straws, cup lids, empty chip bags, and empty milk cartons were observed. An interview was conducted with the Maintenance Director on 8/11/25 at 10:07 AM. He stated that he normally picked up debris items in the parking lot, but the dietary department was responsible for the dumpster area. He stated he would grab a shovel and pick up the debris behind the dumpsters. During an interview with the Dietary Manager on 8/12/25 at 9:52 AM, she revealed that the Maintenance Director was responsible for cleaning the dumpster area. The Maintenance Director told her that when the garbage truck emptied the dumpsters, debris would often get left behind the dumpsters. During a follow up interview with the Maintenance Director on 8/14/25 at 9:42 AM, he revealed that he was unsure of who was assigned to clean behind the dumpsters, but it was most likely him. However, he requested clarification by the Administrator. The Administrator was interviewed on 8/14/25 at 12:05 PM. He revealed that the dietary department was responsible for cleaning the dumpster area. However, maintenance and housekeeping currently cared for the dumpster area. The Administrator stated that the debris should not be left behind the dumpsters even after the dumpsters were emptied. Managing the dumpster area should be a daily cleaning task.

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours. This was for 1 of 3 Federal Fiscal Year quarters reviewed for sufficient nurse staffing (Quarter 2: January 1-March 31, 2025).Findings included:The PBJ report for the Federal Fiscal Year Quarter 2 2025 (January 1 through March 31, 2024) revealed there were no Registered Nurse (RN) hours for 2/22/25, 2/23/25, 3/10/25, and 3/16/25. The nursing staff time detail reports for 2/22/25, 2/23/25, 3/10/25, and 3/16/25 revealed there was not a RN onsite for at least 8 hours a day. The daily staff schedules for 2/22/25, 2/23/25, 3/10/25, and 3/16/25 revealed there was a RN onsite for at least 8 hours a day. During an interview on 8/14/25 at 2:27 PM with the Scheduling Coordinator, she provided documentation of an agency RN on 2/22/25, 2/23/25, 3/10/25, and 3/16/25. The Scheduling Coordinator explained that sometimes the agency nurses don't clock in when they arrive at the facility for work. She further stated that when they fail to clock in, that information doesn't get transcribed into the PBJ report. During an interview on 8/14/25 at 4:25 PM with the Administrator, he stated he was unaware that some agency nurses were not clocking in at the facility and it resulted in inaccurate data being submitted to the PBJ. He stated that all staff, regardless of agency status, should be documenting their time in the facility timecard system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and resident interviews, the facility failed to invite the resident to participate in the care planning process for 1 of 23 residents whose care plans were reviewed (Resident # 78). Findings Included: Resident #78 was originally admitted on [DATE]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact. During an interview on 7/21/24 at 10:45 am, Resident #78 stated he had not been invited to attend a care plan meeting for a long time and that he wanted to be asked to attend his care plan meetings. An interview was conducted with the facility Social Worker on 7/23/24 at 12:22 pm. She indicated Resident #78 had not attended a care plan meeting since August 2022 and was not able to confirm if he had been invited to attend any of his care plan meetings after August 2022. She further revealed the [NAME] Office Manager was responsible for sending out care plan invitations. An interview was conducted on 7/23/24 at 2:16 pm with the [NAME] Office Manager. She revealed that she had not invited Resident #78 to his care plan meetings because Resident #78 always seemed to want to run things by his friend. She further revealed that she should have provided Resident #78 with an invitation to attend his care plan meetings and sent out an invitation to his friend as well. An interview was conducted on 7/24/24 at 12:12 pm with the facility Administrator. He indicated that residents should be invited to attend their care plan meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to provide incontinent care in a safe manner which caused a fall (Resident #29). This was for 1 of 3 residents reviewed for accidents. The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia and Hemiparesis (paralysis of one side of the body) affecting right side of body. Record review revealed Resident #29's care plan last reviewed 2/23/24, showed she required two person staff assistance to re-position and turn in bed. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #29 was severely cognitively impaired. She had range of motion (ROM) limitations and impairment to the one side of her body-upper and lower extremity. She required substantial/maximum assistance personal hygiene and bed mobility. Review of incident report dated 2/28/24 revealed Resident #29 rolled off the bed to the floor during morning care while turned on her left side. The bed was in a high position at the time. The report stated the Nurse Practitioner (NP) and Nurse #8 were called to the room. Resident #29 was assessed and found to have a bump forming on her left forehead. Resident was lifted back to bed using mechanical lift. Orders given by NP to send resident out for evaluation and treatment. emergency room notes dated 2/28/24 revealed Resident #29 had developed a hematoma (bruise) on the left side of her forehead described to be approximately an inch in diameter. A computerized tomography (CT) scan of the head and spine was negative for fracture or intracranial hemorrhage. She also received x-rays for her pelvis and upper/lower extremities which were also negative for fracture. No other treatments were provided, and Resident #29 returned to the facility the same day. During an interview with Nurse Aide (NA) #5 on 7/22/24 at 11:38 am, she stated she was on the adjacent hall when she heard NA #4 call out for help. She stated she arrived at Resident #29's room and saw her on the floor. She stated NA #4 told her she was performing incontinent care and had rolled the resident onto her side. She stated she was trying to pull the under pad back toward the center of the bed when Resident #29 rolled off the other side. NA#5 stated the bed was in high position when she walked into the room. NA #5 stated the NP and Nurse #8 were down the hall when the incident occurred. She stated both came and assessed the resident. NA #5 stated she and NA #4 assisted Resident #29 back to bed using the mechanical lift. NA #5 also stated she had not worked with Resident #29 much but she did state she was available to assist NA #4 and did not know why she didn't ask for help. NA#4 was not employed by the facility at the time of survey. Multiple attempts to reach her were unsuccessful. Nurse #8 was not employed by the facility at the time of survey. Multiple attempts to reach her were unsuccessful. During an interview with the Nurse Practitioner (NP) on 7/24/24 at 11:00 am, she stated she was present in the facility when the resident fell. She stated she responded to the room along with Nurse #8 and assessed the resident from head to toe. The bed was in high position when she arrived to the room. She stated Resident #29 had a hematoma that was starting to form on her left forehead. The NP stated the resident's vitals were fine and she had no other complaints. She stated she decided to send her out for evaluation anyway because of the hematoma/head injury. During an interview with the Nurse Consultant, the Administrator, and the Director of Nursing (DON) on 7/24/24 at 2:38 pm, the Administrator stated that he had been made aware of the incident as soon as it occurred and began a plan of correction on 2/29/24. The current DON was not employed at the facility during the incident, but she stated she did continue the monthly audits through May. The Nurse Consultant stated the individual care guide for each resident is available for all staff members for review and all staff members, including agency staff, are expected to follow the care guides when providing care to the residents for their safety. The administrator stated fall prevention is still a part of their monthly quality improvement meetings. The facility provided the following Corrective Action Plan with a completion date of 3/7/24: On 2/28/24, Resident #29 was receiving care by only one aide who attempted to turn Resident #29 in her bed by herself resulting in a fall. The bed was in a high position at the time. The report stated the Nurse Practitioner and Nurse #8 were called to the room. Resident #29 was assessed and found to have a bump forming on her left forehead. Resident was lifted back to bed using mechanical lift. The Nurse Practitioner gave orders to send resident out to the hospital for further evaluation. On 2/29/24, the DON completed an audit of all current residents who required two staff members to assist with bed mobility. On 2/29/24 the DON in-serviced all nursing staff, including agency, on the falls prevention policy and included using the care guides for bed mobility. The DON or designee will ensure that any staff who does not complete the in-service training by 3/4/24 will not be allowed to work. The facility made the decision to discuss the deficiency, the plan of correction including monitoring, and when to begin discussing it in their weekly QA meetings on 3/7/24. Beginning 3/8/24, the DON or designee will monitor staff weekly for 2 weeks, every other week x 2 months, and then monthly using the bed mobility monitoring tool to ensure staff members were following the care guides when providing incontinent care to residents and using two staff members for bed mobility as care planned. Reports will be presented to the weekly QA committee beginning 3/11/24 by the Administrator or DON to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meetings. Allegation of Compliance Date: 3/7/24 Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on how to care for residents requiring two-person assistance for bed mobility and using the mechanical lift for transfers. The training also included where to locate information on residents who required two-person assistance for bed mobility and those who required the mechanical lift for transfers. Staff rosters were provided by the facility and showed most of the training occurred on 2/29/24 with additional staff completing the training on 3/1/24. Any staff member who did not completed the training by 3/1/24 would not be allowed to work. All new agency staff and new hires completed the training during orientation. The survey team did multiple observations during the week of residents who required two staff members for bed mobility. Staff members were observed providing incontinent care and bed baths using two staff members as needed based on the resident's care guide. Staff interviewed all verbalized they had been observed performing incontinent care and bed baths by the DON or designee and were able to verbalize where to locate the care guide for each individual resident. Review of the monitoring tool showed audits were performed weekly x 2 weeks, every other week x 1 month and then monthly for an additional 2 months. No further falls related to care have occurred. The Corrective Action plan was validated on 7/24/24 and concluded the facility had implemented an acceptable corrective action plan on 3/7/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to secure the urostomy (an opening in the urinary system) tubing per the physician order on 1 of 4 residents observed for urinary catheters (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE]. Resident 48's diagnoses included urinary bladder cancer with urine retention. His admission Minimum Data Set (MDS) assessment, dated 6/12/24, revealed the resident was moderately cognitively impaired. He required extensive assistance with activities of daily living, including incontinent care, had a urostomy and was always incontinent of bowel. Review of Resident 48's plan of care, dated 7/22/24, revealed a urostomy, related to urinary bladder cancer, with interventions including anchoring (through use of the leg band) the catheter (tubing) to prevent excess tension. Review of the physician's s order for Resident #48, dated 6/6/24, revealed an order for urostomy catheter care every shift and as needed. Ensure the leg band is in place. On 7/23/24 at 8:05 AM, during the observation of incontinent care for Resident #48, provided by Nurse Aide #3, the urostomy tubing was observed to be unsecured to the resident's leg. There was no anchoring device present on the resident's legs. On 7/23/24 at 8:20 AM, during an interview, Resident #48 indicated he was not sure about securing the urostomy catheter tubing and could not recall the anchoring device on his legs. On 7/23/24 at 8:55 AM, during an interview, Nurse Aide #3 indicated that she did not know that Resident #48 had his urostomy catheter tubing unsecured at the beginning of her shift. She continued it was the responsibility of the nurses to apply the anchors to secure the urinary catheter tubing to the resident's leg. She did not observe the anchoring device on resident's legs. On 7/23/24 at 10:05 AM, during an interview, Nurse #8 indicated she was not aware Resident #48 did not have his urostomy tubing secured to the leg, nor did he have the stabilization device (leg band) on his leg. Nurse #8 confirmed that it was the nurses' responsibility to secure the urinary catheter tubing to the resident's leg. Nurse #8 did not check the urinary catheter tubing status at the beginning of her shift today. The nurse aides did not report absences of tubing anchor for Resident #48. On 7/23/24 at 1:15 PM, during an interview, the Director of Nursing (DON) expected the nursing staff to have secured the urinary catheters tubing to prevent injury to the resident and to maintain the urine flow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and resident interviews the facility failed to provide resolution of Resident Council Meeting grievances for 3 of 3 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding water cups were not filled timely and snacks were not available (2/19/24, 3/18/24, 4/15/24). Findings included: On 2/19/24 the Resident Council Meeting Minutes noted a nursing concern that residents water cups were not filled timely, and snacks were not available. The Resident Council Follow-Up form attached to the 2/29/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the resident council. On 3/18/24 the Resident Council Meeting Minutes noted a nursing concern that residents water cups were not filled timely, and snacks were not available. The Resident Council Follow-Up form attached to the 3/18/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the resident council. On 4/15/24 the Resident Council Meeting Minutes noted a nursing concern that residents water cups were not filled timely, and snacks were not available. The Resident Council Follow-Up form attached to the 2/29/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the resident council. a.Resident # 65 was admitted to the facility on [DATE]. Resident #65's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact and had no behaviors. On 7/22/24 at 2:00pm during the Resident council Meeting Resident #65 stated that snacks were not always available to residents and that water cups were not filled timely. She further revealed that these grievances had been an issue, and the facility has not addressed their concerns. b. Resident #15 was admitted to the facility on [DATE]. Resident #15's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact and had no behaviors. On 7/22/24 at 2:00pm during the Resident council Meeting Resident #15 stated that the residents in the meeting had made the facility aware that their water cups were not filled timely, and snacks were not always available to residents, and that the facility staff had not followed up with the committee on the status of their complaints. A review of the grievance logs for 2/1/24-4/30/24 revealed no group resident council grievances. An interview was conducted with the Activities Director on 7/23/24 at 10:58 am. She revealed that during the months of February, March, and April 2024 the process was for her to take minutes and note any grievances voiced during the meeting on the minutes and then to either report them to the facility social worker or the designated department head to address their departmental concerns. She further revealed that the follow-up was completed on the follow-up form by the department head and then she would review that information at the next meeting. An interview was conducted with the Director of Nursing on 7/24/24 at 11:56 am. She indicated that she should have addressed the concerns voiced during 2/16/24, 3/18/24, and 4/15/24 Resident Council Meetings and noted a synopsis of all efforts used to address their grievances. An interview was conducted with the Administrator on 7/23/24 at 2:06 pm and he indicated that grievances voiced during resident council meetings should be addressed and residents should have received follow up to their stated grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to assist a resident in obtaining dentures. This occurred for 1 of 3 residents reviewed for dental services. The findings included: Resident # 2 was admitted [DATE] with diagnosis that included hemiplegia. A review of the annual comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively impaired and had no rejection of care. The MDS indicated Resident #2 had obvious or likely cavity or broken natural teeth, no difficulty swallowing or chewing and had weight loss. A review of the care plan revised 1/10/24 included a focused area that was initiated 5/19/22, that read, Resident #2 is at risk for weight fluctuations secondary to hemodialysis. A review of Resident #2's orders revealed a mechanically altered diet. A review of the dental provider #1's documentation for Resident #2 revealed: 1) 4/3/23 Patient had dentures would like new dentures. 2) 10/23/23 Patient requests upper denture. Waiting for approval for lower partial. An interview was conducted with Resident #2 on 7/21/24 at 10:53 am. Resident #2 revealed he had dentures at one time due to missing teeth but could not recall when the last time he had dentures. Resident #2 indicated he had requested new dentures from the facility dentist but had not received any dentures to date. Resident #2 indicated he was able to eat with current diet but when he had dentures, he was able to eat a regular consistency diet and enjoyed eating his food more. A telephone interview was conducted with the dental provider #1 on 7/23/24 at 11:48 am. She revealed Resident #2 was treated last at the facility on 10/23/23 and upper dentures had been approved by Medicaid and the provider was waiting on Medicaid approval for the lower partial. She further revealed the facility terminated their contract before the new dentures could be made. A telephone interview was conducted with dental provider #2 on 7/23/24 at 5:10 pm and she indicated that she worked with the facility to assist in the transition process. She further revealed the dental provider had met with the social worker on 1/30/24 as part of the transition process. The dental provider counseled the social worker on the process of transitioning over residents to their services and provided the new consent forms so the social worker could contact residents or resident representatives to offer services and have consents signed for those who were interested. Dental provider #2 indicated the facility did not provide any referral information to the provider for Resident #2 and was not a current patient of record. An observation was conducted of Resident #2 on 7/23/24 at 3:00 pm eating a chicken snack provided by his responsible party. Resident #2 was able to eat the chicken without difficulty. An interview was conducted with the responsible party on 7/23/24 at 3:04 pm. She indicated that she was not sure why Resident #2 had not received dentures yet and should have had them by now. She further revealed that she had not been contacted by the facility or any dental providers regarding the status of the requested dentures. An interview was conducted with the social worker on 7/24/24 at 8:58 am. She confirmed that she received the new consent forms from dental provider #2 in January of 2024 but did not reach out to Resident #2 or his responsible party to offer dental services because she got busy. An interview was conducted with the Administrator on 7/24/24 at 12:06 pm. He indicated dental services should be provided to residents in a timely manner and the facility social worker should have offered Resident #2's responsible party the opportunity to transition Resident #2 to the new dental provider for services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities, resulting in a medication error rate of 7.14% for 1 of 3 residents (Resident #354) observed during the medication administration observation. The findings included: 1. Resident #354 was admitted to the facility on [DATE]. His cumulative diagnosis included Parkinson's disease. On 9/12/23 at 9:06 A.M., Nurse #3 was observed as she prepared and administered medication to Resident #354. The administered medications included one tablet of Azilect 1 milligram (mg). (Azilect is used to treat the symptoms of Parkinson's disease). Record review of Resident #354's physician orders included a current medication order for Azilect 0.5mg, give one tablet by mouth in the morning. An interview was conducted on 9/12/23 at 9:43 A.M. with Nurse #3. During the interview the packaged bubble sheet for Azilect, sent from the pharmacy and stored on the medication cart, was reviewed with Nurse #3. The package for Azilect showed 1 tablet of Azilect 1 mg sealed in each bubble slot. The label on the Azilect package was compared with the physician orders. Nurse #3 confirmed the physician order read administer Azilect 0.5mg each morning and she had administered Azilect 1mg to Resident #354. Nurse #3 stated she had only verified Resident #354's name and the name of the medication on the pharmacy package during the Resident #354's morning administration pass on 9/12/23. Nurse #3 further stated she was responsible for also verifying the medication dose prior to administration. During the interview, Nurse #3 explained on 9/12/23 she had not verified the dose of the medication because she had previously administered Resident #354 his medications from the same packaging and she thought the medication was the right dose. An interview was conducted on 9/13/23 at 4:14 P.M. with the Director of Nursing (DON). During the interview the DON stated the nurse administering medications should identify discrepancies in medication dosing between the medications on the medication cart and physician orders prior to administering the medication to residents. The DON further explained when the physician order did not match the medication on the medication cart, Nurse #3 was responsible for verifying the dose of Resident #354's Azilect with the pharmacist and/or the physician prior to administering Resident #354 his medication on 9/12/23. The DON was unsure why this had not occurred for Resident #354. 2. On 9/12/23 at 9:06 A.M., Nurse #3 was observed as she prepared and administered medication to Resident #354. The administered medications included one tablet of folic acid 1,000 micrograms (mcg). The medication was obtained from a house stock bottle stored on the medication cart. Resident #354's physician orders included a current medication order for folic acid tablet 800 mcg, give 1 tablet by mouth in the morning for supplement. An interview was conducted on 9/12/23 at 9:43 A.M. with Nurse #3. During the interview with Nurse #3, the stock bottle of folic acid was reviewed and compared with physician orders. Nurse #3 confirmed the physician's order read administer one tablet folic acid 800 mcg each morning and she had administered folic acid 1,000 mcg to Resident #354. Nurse #3 stated folic acid was a stock item on the medication cart and she had not verified the dose of folic acid on the medication bottle with Resident #354's physician order prior to administering Resident #354 his medications. She explained it was her responsibility to check the folic acid dose on the physician order against the folic acid stock medications on her cart with each medication administration. During the interview, Nurse #3 stated she thought the stock item of folic acid on her medication cart was the same dose as the folic acid ordered by the physician when she had prepared Resident #354's medications for his morning medication administration. An interview was conducted on 9/13/23 at 4:14 P.M. with the Director of Nursing (DON). During the interview the DON stated the nurse administering medications should identify discrepancies in medication dosing between the medications on the medication cart and physician orders prior to administering the medication to residents. The DON further explained Nurse #3 was responsible for verifying the dose of Resident #354's folic acid prior to administering Resident #354 his medication on 9/12/23. The DON was unsure why this had not occurred for Resident #354.

Based on observations and staff interview, the facility failed to properly discard three expired vaccines, Prevnar 20 (Pneumococcal 20-valent Conjugate Vaccine) that were available for use in 1 of 3 medication rooms (100 hall nurse's station). The findings included: An observation on 9/15/23 at 3:04 PM of the refrigerator in the medication room on the 100-hall revealed three unused, single dose syringes of Prevnar 20 (Pneumococcal 20-valent Conjugate Vaccine) that had an expiration date of 8/28/23. An interview on 9/15/23 at 3:10 PM with the Director of Nursing (DON) revealed the last resident to receive a Prevnar 20 vaccine was over a month ago. The DON explained there was not a specific nurse that oversees stocking medications in the refrigerator and checking expiration dates. She stated the nursing staff were responsible for making sure there were no expired medications or vaccines in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, the facility failed to maintain the pull cord of a bathroom call light for 2 of 2 front hall public restrooms. Findings included: On 9/11/23 at 10:00 AM an observation of the front lobby public restrooms revealed the emergency call light cords were in the activated/reset position. In each restroom the emergency pull cord was fully extended, and the reset button was in the out position. There were no call lights mounted outside the restrooms. On 9/13/23 at 3:30 PM an observation was made of an alert and oriented resident, Resident # 94, using one the front lobby restrooms. Resident #94's quarterly MDS (Minimum Data Set) dated 8/26/23 revealed he was admitted on [DATE] and he was cognitively intact. On 9/13/23 at 2:35 PM an observation of the front lobby public restrooms revealed the emergency call lights were in the activated/reset position with the cords hanging down to the floor. An interview with the receptionist on 9/15/23 at 1:13 PM revealed that the lobby restrooms were for staff and visitors, but residents used them as well. She stated she tried to redirect residents to their rooms when she observed them entering the lobby restrooms. During an interview with the Maintenance Director on 9/15/23 at 1:15 PM he stated he had been in the position of Maintenance Director for almost two years. He further stated that to his knowledge the emergency call lights in the lobby restrooms had not been in working order when he took over the position and they were not connected to the facility call system. He said he believed it had been an oversight when the front lobby and restrooms were renovated. He stated he expected the safety cords to be connected to the emergency call lights and all be in good working order. An interview conducted on 9/15/23 at 1:25 PM with Nurse Aide #1 revealed that Resident # 94 was able to transfer to the toilet with the aid of a slide board he kept on the back of his wheelchair. During an interview on 9/15/23 at 3:45 PM, Resident # 94 stated he used the front lobby restroom when he came back into the facility from outside visits or appointments because his room was on the hall farthest from the lobby. During an interview with the Corporate Nurse Consultant on 9/15/23 at 4:00 PM, she stated all emergency call lights should always be in working condition.

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours a day for 7 out of 72 days reviewed for staffing. The failure to have RN coverage for the facility had a high likelihood of impacting every resident in the facility. The facility also failed to prevent the Director of Nursing (DON) from serving as a charge nurse with a facility census of greater than 60 residents for two days, 8/20/23 and 7/30/23. The findings included: Review of the Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets, and RN timecard reports revealed there was no RN coverage for eight consecutive hours for 9/10/23, 9/3/23, 8/12/23, 8/6/23, 8/5/23, 7/23/23, 7/2/23. Further review of the Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets and RN timecard reports for the same period revealed the DON served as the charge nurse on 8/20/23 with a facility census of 103 and on 7/30/23 with a facility census of 104. An interview was conducted on 9/13/23 at 3:09 PM with the DON. She stated she did not have an RN on 9/10/23, 9/3/23, 8/12/23, 8/6/23, 8/5/23, 7/23/23, 7/2/23. She further stated the agency did not have an RN available at that time. She stated she has had a hard time finding an RN to hire. The DON also stated that the facility currently has only 3 Registered Nurses on staff. She stated she was not aware that she could not be listed as the only RN on duty for the day if the facility census was greater than 60. An interview was conducted on 9/13/13 and 9/15/23 at 1:35 PM with the facility Nurse Consultant who stated she was unaware of the RN staffing issues at the facility. She did state that she is aware of the regulation that stated the facility had to provide RN coverage for at least 8 consecutive hours a day and that the DON can't serve as a charge nurse with a facility census greater than 60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Medical Director, Nurse Practitioner, and Pharmacist interviews, the facility failed to prevent a significant medication error by failing to administer a prescribed medication for Parkinson's disease at the dose ordered by a physician for 11 of 11 doses administered for 1 of 1 resident (Resident #354) reviewed for medication errors. Findings Included: Resident #354 was admitted to the facility on [DATE]. His cumulative diagnosis included Parkinson's disease (a disease of the central nervous system that affects movements, often including tremors). Physician order dated 8/29/23 read Azilect (a medication used to treat the symptoms of Parkinson's disease) oral tablet 0.5 milligrams (mg) give one tablet by mouth in the morning for Parkinson's disease. The start date was 8/30/23 at 9:00 A.M. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #354 was cognitively intact. Review of the Medication Administration Record (MAR) for 8/30/23 through 9/12/23 revealed Azilect was documented as follows. - 8/30/23 at 9:00 A.M. not administered by Nurse #3; medication was unavailable - 8/31/23 at 9:00 A.M. administered by Nurse #3 - 9/1/23 at 9:00 A.M. not administered by Nurse #3; resident had nausea/vomiting - 9/2/23 at 9:00 A.M. administered by Nurse #6 - 9/3/23 at 9:00 A.M. administered by Nurse #7 - 9/4/23 at 9:00 A.M. administered by Nurse #3 - 9/5/23 at 9:00 A.M. administered by Nurse #8 - 9/6/23 at 9:00 A.M. administered by Nurse #3 - 9/7/23 at 9:00 A.M. not administered by Nurse #3; resident out of the facility. - 9/8/23 at 9:00 A.M. administered by Nurse #3 - 9/9/23 at 9:00 A.M. administered by Nurse #9 - 9/10/23 at 9:00 A.M. administered by Nurse #10 - 9/11/23 at 9:00 A.M. administered by Nurse #3 - 9/12/23 at 9:00 A.M. administered by Nurse #3 An interview was attempted with Resident #354 on 9/15/23 at 7:40 A.M, 9/15/23 at 10:40 A.M., and 9/15/23 at 11:35 A.M. The interview was unsuccessful. On 9/12/23 at 9:06 A.M., Nurse #3 was observed as she prepared and administered medication to Resident #354. The administered medications included one tablet of Azilect 1 mg. An interview was conducted on 9/12/23 at 9:43 A.M. with Nurse #3. During the interview the packaged bubble sheet for Resident #354's Azilect was reviewed with Nurse #3. The packaged bubble sheet for Azilect showed 1 tablet of Azilect 1 mg sealed in each bubble slot. The label read in part Take 1 tablet by mouth every morning. The label on the Azilect package was compared with the physician orders. Nurse #3 confirmed the physician order read administer Azilect 0.5mg each morning and on 9/12/23 during Resident #354's 9:00 A.M. medication pass, she had administered Azilect 1mg to Resident #354. Nurse #3 stated she had only verified Resident #354's name and the name of the medication on the pharmacy package. During the interview, Nurse #3 stated the nurse who administered medication to residents were responsible for verifying the medication dispensed from the bubble sheet matched the resident's name, the medication name, and the dosage ordered by the physician. During the interview, Nurse #3 stated she had not verified the dose of Azilect removed from the bubble sheet matched the physician order because she had previously administered Resident #354 his medications from the same packaging and she thought the medication was the right dose. During the interview, Nurse #3 stated Resident #354 had not voiced any concerns to her of not feeling well on 9/12/23 and to the best of her knowledge Resident #354 had no complaints of not feeling well since his admission. During a follow-up interview conducted on 9/15/23 at 11:44 A.M. with Nurse #3, she stated she notified the Nurse Practitioner (NP)of the error on Resident #354's Azilect's label from the pharmacy on 9/12/23 at about 10:30 A.M. Nurse #3 explained the NP told her to not use the medication in the bubble package until it had been corrected and the NP advised her to contact the pharmacy to have a new bubble package of Azilect sent with the dose of 0.5mg. An interview was attempted with Nurse #6 who was assigned to Resident #354 on 9/2/23 during the 9:00 A.M. medication administration pass was unsuccessful. An interview was attempted with Nurse #7 who was assigned to Resident #354 on 9/3/23 during the 9:00 A.M. medication administration pass was unsuccessful. An interview was conducted with Nurse #8, who was assigned to Resident #354 on 9/5/23 during the 9:00 A.M. medication administration pass. During the interview, Nurse #8 stated she works throughout the facility, and she does not specifically recall Resident #354's medication administration pass on 9/5/23 at 9:00 A.M. During the interview, Nurse #8 stated when she administered medication, she checked the name and dosage of medication on the packaged bubble sheet and compared the information with the physician order. Nurse #8 explained if she had identified the dose did not match, she would have cut the Azilect in half and administered only half the tablet to equal the correct dose. Nurse # 8 was unable to recall if the Azilect tablet had been cut in half. An interview was attempted with Nurse #9 who was assigned to Resident #354 on 9/9/23 during the 9:00 A.M. medication administration pass was unsuccessful. An interview was conducted on 9/15/23 at 11:50 A.M. with Nurse #10 who was assigned to Resident #354 on 9/10/23 during the 9.00 A.M. medication administration pass. During the interview, Nurse #11 stated she does not recall Resident #354 or administering him his medications on 9/10/23. Nurse #11 explained when the pharmacy sent bubble packages with the resident's medications, each bubble contained the correct dosage of medication for each medication administration. Nurse #11 stated she would have pushed the tablet out of one sealed bubble and administered the medication to the resident. During the interview, Nurse #11 stated she had never cut medication in half when she removed the medication from the bubble and explained if half a pill was needed the pharmacy would have sent a half a pill in each bubble. Nurse #11 stated she does not recall Resident #354 having any concerns of not feeling well when she was assigned to his care on 9/10/23. An interview was conducted on 9/14/23 at 11:03 A.M. with the Pharmacist. During the interview, the Pharmacist stated they received an order for Resident #354's Azilect 0.5mg on 8/29/23. The order was filled incorrectly by the pharmacy when the numeric code used to identify the medication by manufacturer and strength was incorrect, and a packaged bubble sheet of Azilect 1mg was sent to the facility on 8/30/23. The Pharmacist explained Azilect was not a medication the facility had on hand in a backup pharmacy at the facility and the order had to be filled and delivered by the pharmacy staff. The Pharmacists reviewed Resident #354's record and stated there were no phone calls logged from the staff at the facility on the dosing of Resident #354's Azilect being inaccurate until 9/12/23. She explained at this time the pharmacy sent a new bubble sheet for Resident #354 which contained Azilect 0.5mg. The Pharmacist explained Resident #354 would not have been affected by the higher dose of Azilect because Resident #354's record showed he did not have a diagnosis of liver damage. An interview was completed on 9/14/23 at 4:22 P.M. with the Nurse Practitioner (NP). During the interview, the NP stated on 9/12/23 she was in the building working when Nurse #3 showed her Resident #354's medication bubble sheet for Azilect and explained the dosage did not match the physician order. The NP stated she reviewed the physician order for Resident #354's Azilect and saw the order read Azilect 0.5mg every morning and the bubble sheet read Azilect 1mg every morning. The NP advised Nurse #3 to call the pharmacy and make them aware of the discrepancy. The NP further stated when she worked on 9/12/23, no concerns were brought to her about Resident #354 not feeling well. The NP further stated there would have been no negative outcome for Resident #354 had he taken 1mg of Azilect instead of 0.5mg of Azilect. An interview was conducted on 9/13/23 at 4:14 P.M. with the Director of Nursing (DON). During the interview the DON stated during each medication administration pass, the nurse who administered medications was responsible for verifying the dosage of dispensed medication with the physician order prior to administering the medication to residents. The DON further explained when the physician order did not match Resident #354's dispensed dose of Azilect on the medication cart, the assigned nurse was responsible for verifying the dose of Resident #354's Azilect with the pharmacist and/or the physician prior to administering Resident #354 his medication. The DON was unsure why this had not occurred for Resident #354's Azilect. An interview was completed on 9/13/23 at 12:55 P.M. with the Medical Director. During the interview, the Medical Director stated when staff did not have the correct dose of medication to administer to a resident, the staff were responsible for contacting either herself or the Nurse Practitioner and making them aware so additional orders could be given as needed. The Medical Director stated Azilect was used to control tremors in patients with Parkinson's disease and she explained Resident #354 would not have been harmed when he received a 1 mg dose instead of a 0.5mg dose of Azilect.

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, complaint, and infection control surveys completed on 7/23/21 and 9/24/21. This was for 2 deficiencies that were cited in the areas of Label/Store Drugs and Biologicals (761) which was cited on 7/23/21 and recited on the current recertification and complaint survey of 9/15/23; and Residents are Free of Significant Medication Errors (760) which was cited on 9/24/21 and recited on the current recertification and complaint survey of 9/15/23. 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 (QAA). The findings included: This citation is cross-referenced to: F760: Based on record review and staff, Medical Director, Nurse Practitioner, and Pharmacist interviews, the facility failed to prevent a significant medication error by failing to administer a prescribed medication for Parkinson's disease at the dose ordered by a physician for 11 of 11 doses administered for 1 of 1 resident (Resident #354) reviewed for medication errors. During the complaint investigation survey on 9/24/21, the facility failed to initiate the administration of two intravenous antibiotics after receipt of a physician's order for 1 of 1 resident reviewed who required treatment with an intravenous antibiotic medication. F761: Based on observations and staff interview, the facility failed to properly discard three expired vaccines, Prevnar 20 (Pneumococcal 20-valent Conjugate Vaccine) that were available for use in 1 of 3 medication rooms (100 hall nurse's station). During the recertification, complaint investigation, and infection control survey on 7/23/21, the facility failed to discard expired medications stored in 3 of 3 medication carts (200 Hall Med Cart, 500 Hall Med Cart, and 400 Hall Med Cart) and in 1 of 2 medication rooms (200/300 Hall Med Room) observed. During an interview on 9/15/23 at 2:30 PM, the Administrator revealed the QAA committee meets monthly and whenever needed. He stated negative trends were brought to the QAA committee's attention via staff, residents, families, and/or other members. The Administrator stated that during each monthly QAA meeting, a non-QAA staff from one of the departments is invited to attend monthly meetings to teach them the QAPI process including the education, audit and monitoring process as quality control/plan of care.