Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored properly for two (#7 and #8) of two sampled residents whose medications were observed not to be stored according to company policy and procedure. The administrator identified 26 residents resided in the facility. Findings: A Storage of Medications policy, dated 01/2022, read in part, Medications and biologicals are stored safely, securely, and properly, following manufactuers' recommendations or those of the supplier. The medications supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 11/22/24 at 11:10 a.m., medication cart #1, located on the west hall, was observed to be unattended. Res #7's metformin 500 mg (diabetic medication) was observed on top of the medication cart. On 11/22/24 at 11:11 a.m., medication cart #1, located on the west hall, was observed to be unattended. Res #8's clonidine 0.1 mg (blood pressure medication) and sevelamer 800 mg (phosphate binder) was observed on top of the medication cart. On 11/22/24 at 11:12 a.m., CMA #1 reported they could not leave the medication carts unattended. On 11/22/24 at 3:20 p.m., the DON reported they were to have all medications stored properly.

Based on record review and interview the facility failed to ensure a physician was notified when a medication was held for one (#24) of five sampled residents reviewed for unnecessary medications. The administrator identified 28 residents resided in the facility. Findings: A Physician Notification of Change policy, dated 12/01/09, read in part, .The facility will .consult with the resident's physician .of the following events .A need to alter treatment significantly .commence a new form of treatment . A Medication Administration policy, dated 01/22, read in part, .If a dose of regularly scheduled medication is withheld .not available .An explanatory note is entered .If [two] consecutive doses .of a vital medication are withheld .or not available the physician is notified. Nursing documents the notification and physician response . Resident #24 had diagnoses which included muscle weakness and multiple sclerosis. A Physician Order, start date 04/06/24, documented Aubagio (pyrimidine synthesis inhibitor) 14 mg tablet give one tablet by mouth one time a day related to multiple sclerosis. It documented the medication was on hold. The April 2024 MAR documented the Aubagio was administered on the 6th, 7th, and 8th. It documented the medication was held for the rest of the month. The May 2024 MAR documented the Aubagio was held for the month. The June 2024 MAR documented the Aubagio was held for the month. The July 2024 MAR documented the Aubagio was held for the month. The August 2024 MAR documented the Aubagio was held for the month. The September 2024 MAR documented the Aubagio was held for the month. There was no documentation the facility notified Resident #24's physician prior to the medication being placed on hold. On 09/23/24 at 2:31 p.m., LPN #1 stated on April 5th there was a note written on a pharmacy note that insurance would not cover the medication because it was $120 per month. LPN #2 stated pharmacy had written a note on their end under profile. LPN #2 stated the nurse was supposed to call the doctor to change the order. LPN #2 stated they could not find any progress note of the physician being notified. On 09/23/24 at 2:33 p.m., LPN #2 stated they had called the facility pharmacy to identify this information. LPN #2 stated if a medication was not available to administer, they would notify the DON to see if they would approve the cost. They stated if the facility would not approve the cost, they would notify the physician. They stated they would then call the pharmacy back and put a note in. They stated they would also notify the family. On 09/23/24 at 2:43 p.m., the DON stated, I put the hold order on there. They stated the revision date was 04/05/24 and the start hold date was 04/06/24. On 09/23/24 at 2:45 p.m., the DON reviewed resident #24's record and stated they did not find any documentation or a nurse note for the reason the medication was on hold or if the physician was notified of the medication being on hold. On 09/24/24 at 12:20 p.m., Regional Nurse Consultant #1 provided a form from pharmacy related to Resident #24's Aubagio. They stated they did not locate any documentation of the physician being notified when the medication was put on hold. They stated the physician had signed monthly orders that documented the medication was on hold. The form from pharmacy, dated 04/05/24, documented the nurse would call the physician. It documented insurance wound not cover. There was no documentation the physician was notified of the medication not being covered by insurance.

Based on record review and interview, the facility failed to update a care plan for smoking for one (#24) of 13 sampled residents reviewed for care plan updates. The administrator identified two residents who smoked resided in the facility. Findings: An undated Smoking List, documented two residents who smoked. Resident #24 was not on the list. 1. Resident #24 had diagnoses which included muscle weakness and multiple sclerosis. A Smoking/Vaping Supervision Checklist, dated 06/29/24, documented Resident #24's smoking privileges had been revoked due to serious safety issues to self, other elders, and the facility as a whole. A Quarterly Resident Assessment, dated 07/17/24, documented Resident #24's cognition was intact. It did not document current tobacco use. A Care Plan, revised 08/14/24, documented the resident was a smoker and was at risk for smoking related injuries and health complications. It documented a goal for the resident's safety to be maintained through the next review date. On 09/17/24 at 1:50 p.m. Resident #24 stated they were no longer allowed to smoke at the facility. On 09/19/24 at 1:17 p.m., the administrator stated Resident #24 was no longer smoking. They stated the resident was offered nicotine patches. On 09/19/24 at 2:14 p.m., the corporate MDS consultant stated they were responsible for resident care plans. They stated care plans were updated after quarterly and annual assessments and 21 days from admission. On 09/19/24 at 2:15 p.m., the corporate MDS consultant reviewed Resident #24's care plan and stated there was a care plan for the resident's smoking. They stated it did not document the resident's smoking privileges were no longer in effect. They stated since they had just now been informed the resident was no longer a smoker, they would have to update the care plan. On 09/19/24 at 2:17 p.m., the corporate MDS consultant entered the DON's office to identify when the resident's smoking privileges were no longer in effect. The DON stated 06/29/24 was the day the resident stopped being able to smoke cigarettes.

Based on observation and interview, the facility failed to ensure posted staffing information, which included the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census was updated. The administrator identified 28 residents resided in the facility. Findings: On 09/17/24 at 12:14 p.m., an observation was made of the posted staffing on the wall at the beginning of hall 200 which included the name of the facility, census of 29, and the names of each staff for each shift. It did not include the hours for each licensed staff and did not have RN hours. On 09/18/24 at 8:18 a.m., an observation of the posted staffing on the board on hall 200 still had the date of 9/17/24, census of 29, and the staff for each shift. It did not have the total hours for any discipline. On 09/19/24 at 9:52 a.m., an observation of posted staffing at the beginning of both hall 100 and 200 was made which included the name of the facility, census, date of 9/17/24, and each shift assignment. It did not include the total hours for licensed staff and had not been updated. On 9/19/24 at 9:57 a.m., the administrator stated they were aware of the posted staffing regulation. They stated it was to include who the nurse, CNA, and CMA was, and what hall they were working for each shift. They stated it was located on each hall and updated every night. On 09/19/24 at 10:26 a.m., the administrator observed the posted staffing board on hall 100 and stated the required information was not present. They stated it did not have the correct date. They stated they did not know of the requirements.

Based on observation, record review and interview, the facility failed to ensure: a. urine in a hat was covered to prevent cross contamination when it was transported down a resident hall; and b. a container holding urine was cleaned prior to placing it back into the resident's room for one (#4) of one sampled resident whose urine was observed being transported down the hall. The ADON identified six residents who utilized urinals. The Roster Matrix, dated 09/17/24, documented one resident with a urinary catheter. Findings: Resident #4 had diagnoses which included neuromuscular dysfunction of the bladder. A Quarterly Resident Assessment, dated 08/17/24, documented Resident #4 had an indwelling catheter. On 09/19/24 at 8:40 a.m., CNA #1 was observed asking the DON about enhanced barrier precautions with Resident #4. They asked the DON if they were allowed to wear the yellow gown to dump urine down the hall. The DON stated staff were to take the gown off. The DON stated staff were ok to carry the urine out. The DON stated, Make sure it is in the bag. On 09/18/24 at 8:43 a.m., CNA #1 was observed transporting a hat that contained urine from Resident #4's room down the hall into the powder room on Hall 100. The CNA dumped the urine in the toilet, flushed the toilet, and placed the hat in a plastic bag in the resident's room. The CNA placed the bag in a cabinet in the resident's room, removed their gloves, and sanitized their hands. The CNA did not clean the hat prior to placing it back in the resident's room. The CNA did not cover the urine to transport the open hat down the hall. On 09/18/24 at 8:45 a.m., CNA #1 stated they did not use a bag to transport the urine down the hall. They stated they did place the hat in a bag when they brought it back to the room. They stated the hat was not rinsed out before placing it back in the resident's room. They stated it was the first time they had used a hat to transport urine. They stated usually they had a urinal to transport it. CNA #1 stated they were usually on the other hall and would use the hose in the whirlpool room to rinse it out. On 09/18/24 at 12:01 p.m., the DON stated when urine was transported from a resident's room to the powder room it should be in a bag. They stated the container should be placed in a plastic bag in the resident's room after use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident Council meetings were held. The administrator identified 28 residents resided in the facility. Findings: The facility Resident Rights and Family Handbook, undated, read in part, .The Resident Council is designed to give residents and family members a regular opportunity to participate in the planning of future activities and events. The Resident Council meeting also provides a forum to exchange ideas and socialize with people facing similar challenges. Resident Council meetings are scheduled monthly on the activity calendar . The September 2024 Activity Calendar documented a Resident Council meeting was scheduled on 09/18/24 at 2:00 p.m. On 09/18/24 at 8:25 a.m., the Resident Council president stated they took over a Resident Council president four weeks ago. They stated they thought there was a Resident Council meeting scheduled, but they had not heard when. On 09/18/24 at 8:26 a.m., the administrator stated they were the person responsible for Resident Council because the facility did not have an AD. They stated they had not had an activity director for about a month. On 09/18/24 at 1:58 p.m., the DON was observed searching for the Resident Council meeting book. They stated the facility did not have a social service person because they had quit two to three weeks ago. The Resident Council meeting book did not contain meeting information for July or August 2024. On 09/18/24 at 2:02 p.m., the administrator stated the facility held a Resident Council meeting in July. They stated the facility did not hold a meeting in August because they Couldn't get anyone to do the Resident Council President. The administrator stated the facility would not have held a Resident Council meeting because they didn't have a Resident Council president. They stated the new Resident Council president had agreed to the position this past Monday. They stated the previous Resident Council president left the faciity on [DATE] and the new Resident Council president admitted to the facility on [DATE]. The administrator stated they could not validate a meeting was held in July because they did not have any paperwork. They stated a meeting was not held in August 2024. On 09/18/24 at 2:14 p.m., no Resident Council meeting was observed taking place. On 09/18/24 at 2:35 p.m., a meeting was held with the Resident Council group. The Resident Council group stated they did not know when the next Resident Council meeting was scheduled and were unable to identify when the last Resident Council meeting was held. They stated it was held when the precious activity person was employed. On 09/19/24 at 12:58 p.m., the administrator stated residents were notified of the scheduled Resident Council meetings on the activity calendar that was posted in each resident room. They stated the activity director would go to each resident room notifying them of the day and time of the meeting. The administrator stated all staff were responsible for getting residents up and to the meetings. On 09/19/24 at 1:01 p.m., the administrator stated the scheduled Resident Council meeting for 09/18/24 did not occur because One we didn't have and activity director, and two I was just so busy. They stated they were trying to get people hired.

Based on observation, record review and interview, the facility failed to ensure scheduled activities were held. The administrator identified 28 residents resided in the facility. Findings: An undated facility Resident Rights and Family Handbook, read in part, .We have a full program of social, intellectual, recreational, creative and religious activities available to residents at our Center. The variety of activities offers something of interest to everyone. A calendar of monthly events is posted in a convenient location . The September 2024 Activity Calendar documented on 09/18/24 the facility was to have exercise at 9:00 a.m. and cup pong at 10:00 a.m. 1. Resident #24 had diagnoses which included muscle weakness and multiple sclerosis. An admission Resident Assessment, dated 04/16/24, documented it was very important for Resident #24 to do things with groups of people and it was very important for them to do their favorite activities. A Quarterly Resident Assessment, dated 07/17/24, documented Resident #24's cognition was intact. On 09/17/24 at 1:50 p.m., Resident #24 stated they used to participate in activities when the previous staff member was employed and doing activities. They stated now they just stayed confined to their room. They stated the activities person left around a couple months ago. 2. Resident #20 had diagnoses which included acute kidney failure and type two diabetes mellitus. An admission Resident Assessment, dated 07/01/24, documented Resident #20's cognition was moderately impaired. It documented it was very important for Resident #20 to do things with groups of people and it was very important for them to do their favorite activities. On 09/17/24 at 12:08 p.m., Resident #20 stated they used to participate in the activity program, but the facility did not have an activity director now. They stated it had been close to a month since they had an activity director. 3. Resident #22 had diagnoses which included major depressive disorder, anxiety, and left hemiparesis following cerebral infarct. An admission MDS Assessment, dated 9/21/23, documented activity preferences as somewhat important for having reading material, music, and favorite activities. It documented activity preferences as very important for animals, news, being around groups of people, going outside when the weather was good, and religious services. A Quarterly MDS Assessment, dated 6/19/24, documented the resident was cognitively intact with a BIMS score of 15. On 09/17/24 at 1:57 p.m., the September 2024 activities calendar was observed on the wall in Resident #22's room. On 09/17/24 at 2:36 p.m., Resident #22 stated they do not do activities at all. They stated the activities person had been gone for about a month. They stated they had some activities when they were there. They stated since they had been gone no one else did the activities. They stated they would like to go outside and smoke because they were tired of just looking at the walls all the time. On 09/18/24 at 8:26 a.m., the administrator stated they had not had an activity director for about a month. On 09/18/24 at 9:20 a.m., there were no scheduled activities observed taking place in the facility. There were three residents sitting in the front sitting area by the front doors watching television. Behind the residents were four corporate staff members and the pharmacist sitting at tables. There were no observations the 9:00 a.m. scheduled exercise activity took place. On 09/18/24 at 10:42 a.m., there had been no observations the 10:00 a.m. scheduled cup pong activity took place. On 09/18/24 at 2:35 p.m., a meeting was held with the Resident Council group. They stated they used to have an activity program at the facility. They stated now they didn't necessarily have activities. They stated the activity person left about three weeks ago, and ever since, they had not had activities. On 09/19/24 at 12:41 p.m., CNA #1 stated when they first came to the facility they had a great activity program. CNA #1 stated they had not seen any scheduled activities taking place this week. They stated there was not a scheduled person in that department right now. They stated even when the facility had an activity director, they would often times get pulled to do other things. They stated the facility needed an activity program to Keep the residents living and lively. On 09/19/24 at 1:00 p.m., the administrator stated normally the activity program had a monthly calendar they passed out to the residents. They stated the facility would announce scheduled activities, and staff would go around and notify the residents, and bring them to the activity when they wanted to participate. The administrator stated they were responsible for ensuring activities took place. On 09/19/24 at 1:01 p.m., the administrator stated the scheduled activities for 09/18/24 did not occur because One we didn't have and activity director, and two I was just so busy. They stated they were trying to get people hired.

Based on observation, record review and interview, the facility failed to ensure: a. expired foods were removed from circulation; b. the kitchen was kept clean and in good repair; and c. leftover reheated soup reached an internal temperature of 165 degrees Fahrenheit. The administrator identified 28 residents resided in the facility. Findings: An undated Weekly Cleaning Schedule, documented the refrigerator, and the wall behind the back and front door to the kitchen were to be cleaned weekly to include the bottom of the refrigerators and freezers. On 09/17/24 at 10:54 a.m., the initial tour of the kitchen was conducted with the CDM. On 09/17/24 at 11:03 a.m., a carton of nectar thickened tea in the refrigerator was dated 08/23/23 with a best used by date of 12/28/23. The CDM stated the policy for food storage was to label, date, and rotate. On 09/17/24 at 11:05 a.m., the CDM stated the thickener was expired. On 09/17/24 at 11:13 a.m., the dry storage area had five more cartons of the same thickener with the same best used by date of 12/28/23. The CDM stated they must have gotten lost as they do not use thickener much. They stated there was a whole case that was expired since they were the same date and they came in a box of six. On 09/17/24 at 11:16 a.m., the freezer next to the desk in the office had dark areas and debris on the bottom floor of the freezer. On 09/17/24 at 11:18 a.m., the CDM stated the freezer was wiped down a few weeks ago. They stated they had a schedule and the freezer needed to be cleaned. On 09/18/24 at 9:57 a.m., a second tour of the kitchen conducted and observations were made. On 09/18/24 at 10:13 a.m., the window seal located behind the clean side of the dishwasher had a large amount of brown dust and debris. The window blinds were broken. On 09/18/24 at 10:16 a.m., the CDM stated the window seal was not clean. On 09/18/24 at 11:24 a.m., the CDM was observed to microwave a bowl of soup that had a date of 9/17. They then placed it on the hall tray cart. On 09/18/24 at 11:27 a.m., the hall tray cart left the kitchen. The CDM was asked what temperature did they reheat the leftover soup to. They stated they forgot to temp it. The CDM went to get the tray off the cart and took a temperature. They temperature was 127 degrees Fahrenheit.

Based on record review and interview, the facility failed to provide baths for three (#1, 2, and #3) of three sampled residents reviewed for ADL assistance. The DON identified 29 residents who required assistance with ADLs resided in the facility. Findings: 1. Resident #1 had diagnoses which included hemiplegia and fibromyalgia. Resident #1's quarterly assessment, dated 05/23/24, documented Resident #1's cognition was intact. Resident #1's care plan for ADL's revised on 02/06/24, documented, a. bathing required transfer assist of one staff. b. scheduled bath days - Monday, Wednesday, and Friday on the day shift on the 6 a.m. to 2 p.m. shift. On 06/12/24 at 12:31 p.m., Resident #1 stated they hadn't received a bath since last week. A review of Resident #1's bathing task documented the resident had not received a bath, five out of 13 opportunities. No bath was documented on 05/15/24, 05/17/24, 05/20/24, 05/22/24, and 05/24/24. 2. Resident #2 had diagnosis which included, hemiplegia and hemiparesis following cerebral infarction. Resident #2's quarterly assessment, dated 03/19/24, documented Resident #2's cognition was intact. Resident #2's care plan for ADL's revised on 10/02/23, documented bathing required assist of one staff participation. On 06/12/24 at 12:15 p.m., Resident #2 stated sometimes we get baths. A review of Resident #2's bathing task documented the resident had not received a bath seven out of 13 opportunities. No bath was documented on 05/21/24, 05/23/24, 05/25/24, 05/28/24, 05/30/24, 06/04/24, and 06/11/24. 3. Resident #3 had diagnoses which included acute and chronic diastolic (congestive) heart failure and chronic kidney disease. Resident #3's quarterly assessment, dated 05/14/24, documented Resident #3's cognition was intact. Resident #3's care plan for ADL's revised on 09/20/22, documented bathing required supervision. On 06/12/24 at 11:13 a.m., Resident #3 stated their baths were scheduled two times a week on Tuesday and Saturday. They stated they often didn't get that schedule. They stated it could be up to 10 days between baths. On 06/13/24 at 10:40 a.m., the DON stated all bathing documentation was done in the EHR, there was no longer any paper documentation. On 06/13/24 at 11:43 a.m., the DON stated they had no documentation of baths for the dates listed above.

Based on record review and interview, the facility failed to complete a nurse aide performance review once every 12 months for one (CMA #1) of five employee files reviewed. The DON identified 31 residents resided in the facility. Findings: An employee list documented 23 staff members for the facility. Findings: CMA #1 had a hire date of 01/30/04. There was no CNA annual competency reviewed located in the employees file. On 06/13/24 at 1:58 p.m., the BOM stated there was no annual competency for CMA #1.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM was certified no later than one year after hire. The Residents Census and Conditions of Residents report, dated 07/19/22, documented 30 residents resided in the facility, and two residents received tube feeding. Findings: An active employee COVID-19 vaccine status report documented the DM started employment at the facility on 02/18/15. There was no documentation the DM was certified as a dietary manager. On 07/19/22 at 7:29 a.m., the DM was asked how long they had been in their current position. They stated about two years. They were asked if they were certified as a DM. They stated they had taken classes, but had not tested. On 07/20/22 at 7:24 a.m., the administrator stated the DM was hired in their current position on 06/01/20, but started out as a PRN cook on 02/18/15.

Based on observation and interview, the facility failed to ensure food service equipment and the building was maintained clean and in good repair. The Residents Census and Conditions of Residents report, dated 07/19/22, documented 30 residents resided in the facility, and two residents received tube feeding. Findings: On 07/19/22 at 7:29 a.m., a tour of the kitchen was conducted. The following observations were made: a. there were brown and yellow stains on the ceiling tiles, b. there was an accumulation of black residue on the floor and the walls below the dish machine, c. there was an accumulation of brown residue/rust under the three compartment sink and dish machine, d. there was an accumulation of lint on the oven hood filters, e. the wood around the serve out window was unfinished/not sealed, the baseboard was loose from the wall, f. the wood on the cabinet below the hand sink was not sealed, the wood was bare, and g. there was brown residue in the wells on the steam table in the serving area. On 07/19/22 at 1:48 p.m., the DM was asked what was policy for cleaning and maintaining food service equipment and the building. They stated they cleaned daily and also had a weekly cleaning schedule. They stated they logged any maintenance issues into the computer for repairs or called the service company. The DM was made aware of the above findings.