Based on observation, record review and interview, the facility failed to maintain a homelike environment for one (#21) of 16 sampled residents. Findings: A Maintenance Policy, dated 06/27/06, read in parts .The facility shall provide a safe, functional .and comfortable environment for residents, staff and public .In the event that an item is in need of repair, the defect should be reported to the maintenance department on form ., and the maintenance department will repair them promptly. If the skill to repair is beyond the ability of the facility staff, an outside vendor will be called in the case of emergency, or [company name] will be called for repair . 1. Resident #21 had diagnoses which included unspecified visual loss, history of falling, and Epilepsy. On 12/05/23 at 8:58 a.m., multiple broken/cracked tiles were observed on Resident #21's floor in their room. On 12/06/23 at 1:01 p.m., the regional consultant was asked to observe the tiles in Resident #21's room. They were asked how long the tiles had been that way. They were unsure. On 12/06/23 at 1:03 p.m., CNA #2 was asked how long had the tiles been broken. They stated A long time. On 12/06/23 at 1:09 p.m., the assistant administrator was asked to observe the tiles. They stated there had been a leak in the floor, it was repaired and they had to wait on the concrete to settle. The assistant administrator asked maintenance why the tiles had not been replaced. They stated that corporate office needed to come out and level the concrete before they could lay more tiles. On 12/07/23 at 10:03 a.m., maintenance #1 was asked how long the request had been made to corporate office. They stated the request was made about a year ago and they were instructed by corporate their staff plumbers would make the repair. On 12/07/23 at 10:09 a.m., the administrator was asked when corporate had been notified regarding the floor. They stated, maintenance should have a copy of an email. No documentation was provided for correspondence from the facility to corporate regarding the repair of the tiles.

Based on record review and interview, the facility failed to follow the care plan to monitor for side effects from the use of an anticoagulant (Xarelto) medication for one (#28) of six residents reviewed for unnecessary medications. The DON identified four residents had physician orders to be administered an anticoagulant medication. The Resident Census and Conditions of Residents report, dated 01/04/23, documented the census to be 29 residents Resident #28 had diagnoses to include hypertension and hyperlipidemia. A Physician Order, dated 08/04/22, documented Resident #28 was to be administered Xarelto 10 mg daily for hypertension. A Quarterly Assessment, dated 12/15/22, documented Resident #28 was cognitively intact for decision making, and had been administered an anticoagulant seven of seven days during the assessment. A Care Plan, dated 12/27/22, read in parts, .skin .During daily ADL care, observe skin for .bruises .is on Anticoagulant therapy .administer Xarelto .Monitor/document/report to MD .anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s . The clinical record contained no documentation Resident #28 had been monitored for side effects from the use of an anticoagulant medication. On 01/04/23 at 10:24 a.m., Resident #28 was asked if they had experienced any skin changes or concerns. Resident #28 stated, I did have a big bruise on my leg, but I don't remember what happened. On 01/05/23 at 4:20 p.m., the DON was asked if the facility had monitored Resident #28 for side effects from the use of an anticoagulant medication. The DON stated the facility does not monitor for side effects of all anticoagulants. The DON was shown Resident #28's care plan and was asked if the facility followed the resident's care plan to monitor for side effects of an anticoagulant medication. The DON stated they had not.

Based on record review, observations, and interview, the facility failed to ensure an assessment had been completed monthly to ensure the continued need for a lap belt restraint for one (#14) of two sampled residents with lap belt restraints. The Resident Census and Conditions of Residents form, dated 01/04/23, documented two residents had restraints. Findings: A Restraint and Non-Restraint devices policy, dated 05/15/01, read in parts: .provide an environment .discourages the use of restraints, or when required, the least restrictive device in the least restrictive manner .A Monthly Restraint .Assessment .will be completed .determine the continued need for the use of the restraint .document recommendations for changes . Resident #14 had diagnoses to include dementia with Lewy bodies, paranoid personality, and a history of falling. A Physician Order, dated 08/05/21, read in parts, .Waist Restraint/Non-Self Releasing Belt, while up in w/c . The resident's clinical record did not contain a monthly restraint assessment for the Months of July through December 2022, to ensure the continued need for a non-self releasing lab belt. A Quarterly Assessment, dated 10/29/22, documented Resident #14 had moderate impaired cognition, and required extensive assistance for transfers. The assessment documented a trunk restraint was used daily while in the chair and out of the bed. A Care Plan, dated 11/20/22, read in parts, .potential risk for falls .NSRB while up in wheelchair .needs opportunities for restraint-free time and physical activity .Evaluate/record continuing risks/benefits .alternatives to restraint, need for ongoing use and reason for restraint use .Monitor/document/report to PCP .changes regarding effectiveness of restraint, less restrictive device . On 01/04/23 at 10:38 a.m., Resident #14 was seated in a wheelchair in the common area. A non-releasing lap belt was across her lap, criss-crossed behind the wheelchair and secured on the lower bars of the wheel chair. The ends of the lap belt were out of the resident's reach. On 01/06/23 at 9:23 a.m., CNA #1 was asked if Resident #14 tries to get up if the restraint is not in place. The CNA stated Resident #14 does not usually try to get up but reaches for things out of reach, and leans too far. CNA #1 stated Resident #14 will try to stand up if it is a day she has a lot of energy. CNA #1 stated Resident #14 required staff to assist to a stand position. On 01/06/23 at 9:29 a.m., the DON was asked if a monthly assessment had been completed to evaluate the need for a lap belt restraint, after 06/06/22, for Resident #14. The DON reviewed the record and stated, There is not, but should be. The DON was asked if the facility followed their policy regarding the assessment and evaluation that a lap belt restraint continued to be appropriate, was the least restrictive choice, and utilized in the least amount of time. The DON stated, If there is nothing since June, then we haven't.

Based on record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours for seven days in October, November and December 2022. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 29 residents resided in the facility. Findings: The October 2022 staff schedule did not have any RN coverage scheduled for 10/22 and 10/23. A Time and Attendance Archived Detail report, dated 10/22 and 10/23 had no documentation an RN had clocked in for these days. A Time and Attendance Detail report, dated 11/19/22, documented the RN clocked in at 7:03 a.m., and clocked out at 11:35 a.m., then the RN clocked in at 1:00 p.m., and clocked out at 6:00 p.m. A Time and Attendance Detail report, dated 11/26/22, documented: a. the RN clocked in at 8:25 a.m., and clocked out at 10:47 a.m., b. the RN clocked in at 11:00 a.m., and clocked out at 3:00 p.m., and c. the RN clocked in at 5:56 P.M., and clocked out at 8:25 p.m. The December 2022 staff schedule, documented RN coverage on 12/04/22 and 12/11/22 no other weekends had an RN scheduled. On 01/06/23 at 10:46 a.m., the DON was shown the December 2022 staff schedule and was asked who had worked on the weekends. The DON identified the facility employed an RN/DON (themself) and one other RN staff nurse in the month of December 2022. The DON confirmed the other staff RN had worked on 12/04/22 and 12/11/22. The DON reviewed their personal calendar and confirmed they had worked the other weekend days in question with the exception of 12/17/22, 12/18/22 and 12/25/22. On 01/06/23 at 10:51 a.m., the Administrator was asked if the RN had clocked in on the days in December when there was no RN coverage. The Administrator stated, the assistant administrator was printing the time (time and attendance details) on these days. On 01/06/23 at 1:28 p.m., the DON was shown the Time and Attendance Detail reports dated, 12/17, 12/18 and 12/25 that had been provided by the DON. The DON was asked if they had told the surveyor they had not worked those days in December. The DON stated, I worked days in December, new information was already there, I know I didn't work those days. The DON was shown the October 2022 schedule and the Time and Attendance Archived Detail report and asked if there was eight consecutive hours RN coverage on 10/22 and 10/23. The DON stated No. On 01/06/23 at 1:44 p.m., the DON was shown the Time and Attendance Detail report , dated 11/19/22, that documented the DON clocked in at 7:03 a.m., and clocked out at 11:35 a.m., (salary pay) then returned at 1:00 p.m., and clocked out at 6:00 p.m. (coverage) and asked if there was five hours of coverage but had 1.5 hours in between was there eight consecutive RN hours. The DON stated, No. The DON was shown the Time and Attendance Detail report, dated 11/26/22 and asked where does staffing get these hours. The DON stated, I don't enter anything on these reports, something is wrong with this, I passed meds 8:30 [a.m.] to 11:00 [a.m.], then I worked this [5:56 p.m., to 8:25 p.m.] on the floor as an aide. The DON acknowledged there was not eight consecutive hours of RN coverage.

Based on record review, and interview, the facility failed to track and trend infections for six months from July 2022 through December 2022. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 29 residents resided in the facility. Findings: An Antibiotic Stewardship Policy and Procedure, effective 12/20/17, read in parts, .The Antibiotic Stewardship program will be incorporated in the overall infection control and isolation program .The clinical team will track antibiotic use .A facility floor plan will be highlighted to show tracking and trending of antibiotic use and or side effects . The Facility Infection Analysis reports, dated July 2022 through December 2022 did not document infections and antibiotic use had been tracked using the facility floor plan. On 01/05/23 at 11:34 a.m., the IP was asked to review the Antibiotic Stewardship Book (Facility Infection Analysis forms), and asked if there had been tracking and trending of infections since June 2022. They stated, No. On 01/05/22 at 12:51 p.m., the DON was asked to review the Facility Infection Analysis reports for July 2022 through December 2022. The DON was asked if there had been tracking and trending completed since June. They stated, No. There was no facility floor plan that documented tracking and trending for July 2022 through December 2022.