Based on facility policy, record reviews and interviews, the facility failed to ensure the physician and the responsible party for Resident (R)68 were notified related to refusal of insulin on multiple occasions for 1 of 1 reviewed for notification. Review of the facility's policy titled, Change in a Resident's Condition or Status, states: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g.,changes in level of care, billing/payments, resident rights, etc.). The, Policy Interpretation and Implementation, states: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications two (2) or more consecutive times. The findings include: The facility admitted R68 on 06/03/2024 with diagnoses including, but not limited to, cerebrovascular accident, dysphagia, aphasia, lack of coordination, diabetes mellitus type 2 and cerebral edema. During an interview on 07/14/2024 at 12:50 PM with the responsible party for R68, she stated that R68 refuses insulin and no one lets her know. She stated, He will die without that insulin. She also stated that she was R68's Power of Attorney because he could not make any decisions for himself. Review of the medical record for R68 on 07/15/2024 at 11:35 AM revealed a Medication Administration Record (MAR) for June 2024 the findings are as follows: On June 5, 2024 R68 refused the scheduled dose of Glargine 40 units of insulin at 06:00 PM and Humalog 5 units at 06:00 PM, He additionally refused the blood sugar check and if any needed insulin via sliding scale at 06:00 PM. On June 14, 2024 R68 refused Glargine 40 units of insulin at 06:00 PM. On June 29, and June 30, 2024 R68 refused Glargine 40 units of insulin at 06:00 AM. Further review of the medical record for R68 revealed a MAR for July 2024 the findings are as follows: On July 3, 2024 R68 refused the scheduled dose of Glargine 40 units of insulin at 06:00 AM. On July 6, 2024 and July 12, R68 refused Lispro 5 units scheduled for 12:00 Noon. On July 12, 2024 R68 refused Glargine 40 units of scheduled insulin at 09:00 AM. On July 12, 2024 R68 refused the blood sugar check and any needed insulin via sliding scale at 12:00 Noon and at 06:00 PM. On July 13, 2024 R68 refused Lispro 5 units scheduled for 06:00 AM. No documentation could be found in the medical record for R68 to ensure the physician and the responsible party were notified of the refusal of insulin or blood sugar checks. During an interview on 07/16/2024 at 07:20 AM the Director of Nursing (DON) stated she would expect the nurse that encountered the refusal to notify the physician and the responsible party. During an interview on 07/16/2024 at 07:35 AM with the Licensed Practical Nurse, (LPN)5, Assistant Director of Nursing, it was brought to her attention that she had documented a refusal of insulin for R68 on 07/06/2024 and there was no documentation that LPN5 had notified the physician nor the responsible party. LPN5 reviewed her documentation and confirmed that she had not notified the physician nor the resident's responsible party. During an interview on 07/16/2024 at 08:22 AM with LPN1, she stated that anytime a resident refuses an medication we should notify the physician and the responsible party.

Based on the guidance for administering insulin via an Insulin Pen, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent for 4 out 25 opportunities for error. The medication administration error rate was 16 percent. Review of the guidance titled, Insulin Administration Using an Insulin Pen, states: How to Use. 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or a cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it onto the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the dose window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove any air from the needle. Repeat this step if needed until a drop appears. 12. Dial the number of units ordered. The findings include: An observation during med pass on 07/15/2024 at 08:40 AM, revealed Licensed Practical Nurse (LPN)3 held the insulin pen horizontally and did not remove the cap from the needle and dialed up 2 units and pressed the injection button, she did not confirm that the insulin was seen at the tip of the needle. LPN3 confirmed that the insulin pen was primed incorrectly. She then stated that she should have held the pen upright to ensure the air was removed and that the resident would receive the correct dose of insulin. During an observation during med pass on 07/15/2024 at 09:05 AM, LPN3 was to administer Flonase. LPN3 failed to shake the Flonase prior to administration. During an interview on 07/15/2024 at 09:11 AM with LPN3, she confirmed that she had not shaken the Flonase, and that the resident shook it and administered it to herself. The resident did not shake the Flonase prior to putting it in the edge of her nostril and with her thumb on the bottom of the bottle and her first 2 fingers on the sprayer, she administered the medication. LPN3 could not confirm that the resident received the Flonase. During an observation on 07/15/2024 at 09:30 AM, LPN1 was to administer insulin via an insulin pen. The pen was new, she applied the needle and did not attempt to prime the insulin pen. LPN1 stated at 09:40 AM that she knew to prime the pen, but did not. She could not confirm that the resident received the correct dose of insulin. During an observation on 07/16/2024 at 07:50 AM, LPN4 was to administer insulin via an insulin pen. She cleaned the rubber seal with an alcohol prep and then applied the needle. She dialed up the 2 units for priming, and held the insulin pen horizontally and pressed the injection button, she did not confirm that insulin had escaped the needle. When asked, LPN4 stated that to prime the pens you should hold the pen vertical and not horizontal and observe for insulin escaping the needle when you push the injection button. She could not confirm that the resident received the correct dose of insulin. During interviews on 07/15/2024 and 07/16/2024, with the Director of Nursing (DON), the nurse check off sheets for demonstration, related to administering insulin via a flex pen were requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy, observations and interviews the facility failed to ensure outdated medications and biologicals were removed from storage with other medications and biologicals in use for residents in 3 of 4 medication carts and 2 of 2 treatment carts. Review of the facility policy titled, Storage of Medications, states, The facility stores all drugs and biologicals in a safe, secure and orderly manner. The Policy Interpretation and Implementation, states: 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The findings include: An observation on [DATE] at 07:10 AM of the Hall B2 medication cart revealed 1 bottle of UTI-Stat Cranberry, Lot #B-23092 was expired on [DATE]. The expired bottle of UTI-Stat was verified by Licensed Practical Nurse (LPN)1 and removed from the medication cart. Review on [DATE] at 10:14 AM of the Hall B Treatment Cart revealed the following: 1 Bottle of Cleansing Body Lotion, Manufactured by Medline-Remedy, 8 fluid ounces, 236 milliliters with Lot #16H1221 was expired on 08/2018. 1 Skintegrity - Hydrogel Impregnated Gauze, Manufactured by Medline, 4 x 4 square, 2 pack with Lot #000192 was expired on 05/2023. 1 Hydrogel - Simpurity 4 x 5 wound dressing, with Lot #18090905, Mfg. [DATE] was expired on [DATE]. The expired biologicals were confirmed by LPN8 and removed from the cart. Review [DATE] at 10:30 AM of Medication Cart Hall B1 revealed the following: 1 Aspart Flex Pen Lot #FZF9J11- in use with no open date and no expiration date. 1 Lantus Flex Pen Lot #4F9583A - in use with no open date and no expiration date. 1 Lispro Flex Pen - Lilly - Lot #D707064A - in use with no open date and no expiration date. 1 Box Goodsense - Hemorrhoidal Suppositories Lot #2G5585, 10 Suppositories expired. 1 Bottle of Guardian Fiber Powder Lot #4037575, expired [DATE]. The above medications were confirmed by LPN9, and removed from the medication cart. Review on [DATE] at 11:06 AM of Medication Cart Hall A 1 revealed the following: 1 box of Evencare Controls for glucometers, Manufactured by Medline with Lot #108211221031203 was expired on [DATE]. The box the control solution was confirmed by LPN7 and removed from storage. Review on [DATE] at 11:20 AM of Hall A Treatment Cart revealed the following: 1 Foam Dressing 2 x 2, Item #B-NM5050F, Lot #18111105 was expired on [DATE]. 1 Can of Safe-N-Simple Odor Eliminator - Clear Lubricant with Lot #191004, expired on [DATE]. 1 Bottle of Adapt Stoma Powder with Lot #8K012, expired on 11/2023. 2 Suture Removal Trays, Manufactured by Medline with Lot #(10)21CB0461, expired on [DATE]. 14 Medihoney - Hydrogel dressings 2.4 x 2.4 ( 6cm x 6cm) with Lot#043620, expired on 08/2023. 4 Medihoney - Hydrogel dressings 4.3 x 4.3 (11cm x 11cm) with Lot #042820, expired on 06/2023. 2 Simpurity - Hydrogel wound dressings 4 x 5 with Lot #18090905, expired on [DATE]. 1 Tender Wet Active dressing, 2.2 (5.5 cm) round, with Lot #7153716/1, expired on 04/2020. The expired biologicals were confirmed by LPN8, and removed from the treatment cart.

Based on review of the facility policies observations, record reviews and interviews the facility failed to ensure Resident (R)125 was free of significant medication errors when he received a blood pressure medication outside the ordered parameter. R125 received the blood pressure medication multiple times in error for 1 of 5 residents reviewed for unnecessary medications. The facility further failed to ensure insulin via a flex pen was administered correctly by nurses for 3 out of 3 residents observed during medication administration. Review of the facility policy titled, Administering Medications. states, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. If a dosage is believed to be inappropriate or excessive for a resident, a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, and right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. Review of guidance titled, Insulin Administration Using an Insulin Pen, states: How to Use. 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or a cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it onto the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the dose window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove any air from the needle. Repeat this step if needed until a drop appears. 12. Dial the number of units ordered. The findings include: An observation during med pass on 07/15/2024 at 08:40 AM, revealed Licensed Practical Nurse (LPN)3 held the insulin pen horizontally and not remove the cap from the needle and dialed up 2 units and pressed the injection button, she did not confirm that the insulin was seen at the tip of the needle. LPN3 confirmed that the insulin pen was primed incorrectly. She then stated that she should have held the pen upright to ensure the air was removed and that the resident would receive the correct dose of insulin. During an observation on 07/15/2024 at 09:30 AM, LPN1 was to administer insulin via an insulin pen. The pen was new, she applied the needle and did not attempt to prime the insulin pen. LPN1 stated at 09:40 AM that she knew to prime the pen, but did not. She could not confirm that the resident received the correct dose of insulin. During an observation on 07/16/2024 at 07:50 AM, LPN4, cleaned the rubber seal with an alcohol prep and then applied the needle. She dialed up the 2 units for priming, and held the insulin pen horizontally and pressed the injection button, she did not confirm that insulin had escaped the needle. When asked, she stated that to prime the pens you should hold the pen vertical and not horizontal and observe for insulin escaping the needle when you push the injection button. She could not confirm that the resident received the correct dose of insulin. During an interview on 07/15/2024 and 07/16/2024 with the Director of Nursing (DON), the nurse check off sheets for demonstration, related to administering insulin via a flex pen were requested but not provided. The facility admitted R125 on 06/25/2024 with diagnoses including, but not limited to, anxiety, depression and mood disorder and hypotension. Review on 07/15/2024 at 3:09 PM of the Medication Administration Record (MAR) for R125 dated June 2024 revealed a physician's order for Midodrine HCI Oral Tablet 5 milligrams. Give 1 tablet by mouth three times a day for hypotension. If SBP (systolic blood pressure) is greater than 120 DO NOT GIVE medication. The Midodrine was given on 06/27/2024 at 09:00 AM for a blood pressure of 125/60. The Midodrine was given on 06/28/2024 at 09:00 AM for a blood pressure of 135/70. It was also given on 06/28/2024 at 12:00 Noon for a blood pressure of 135/70 and at 05:00 PM for a blood pressure of 133/79. The Midodrine was given on 06/29/2024 at 09:00 AM for a blood pressure of 133/79. At 12:00 Noon on 06/29/2024 the medication was given for a blood pressure of 134/78 and again at 5:00 PM for a blood pressure of 134/78. The Midodrine was given on 06/30/2024 at 09:00 AM for a blood sugar of 127/69. Review of the MAR for R125 on 07/15/2024 at 03:15 PM revealed a blood pressure on 07/04/2024 of 126/78 at 05:00 PM and R125 received the 5 milligrams of the blood pressure medication. The Midodrine 5 milligrams was given on 07/05/2024 at 09:00 AM for a blood pressure of 131/64. On 07/07/2024 at 09:00 AM the Midodrine was given for a blood pressure of 122/58, it was given on 07/07/2024 at 12 noon for a blood pressure of 131/71 and again at 05:00 PM for a blood pressure of 131/71. On 07/09/2024, R125 received the Midodrine for a blood pressure of 124/70 at 09:00 AM and again at 05:00 PM for a blood pressure of 130/68. On 07/11/2024 at 09:00 AM R125 received Midodrine for a blood pressure of 154/76, and at 12 noon for a blood pressure of 154/74 and again on 07/11/2024 at 05:00 PM R125 received the medication again for a blood pressure of 148/72. On 07/12/2024 R125 received Midodrine 5 milligrams at 09:00 AM for a blood pressure of 136/77 and again at 12 noon for a blood pressure of 136/77 and again at 05:00 PM for a blood pressure of 136/77. R125 should not have received the Midodrine for the days listed, due to the blood pressure falling outside the parameters of the systolic blood pressure remaining higher than 120, with orders not to give if greater than 120. During an interview on 07/15/2024 at 12:45 PM with LPN1, this surveyor brought to her attention the days she gave the medication Midodrine and the blood systolic blood pressure was greater that 120 and there is a order to which states, DO NOT GIVE according to the parameters per the physician's orders. LPN1 verbalized that she sees the parameters and agreed that she should not have given the Midodrine. During an interview on 07/15/2024 at 12:55 PM with LPN2, Unit Manager, this surveyor brought it to her attention that it is documented by her that she gave R125 the Midodrine, even though the blood pressure was out of the parameters and the phsyician's order to give the medication. She verbalized that she gave the medication. During an interview on 01:00 PM with LPN3, it was brought to her attention that she too had given the Midodrine to R125 even though the blood pressure was outside the parameters to give the medications. She looked at the documentation and stated she did not give the medication, but the Unit Manager showed her that she too had given the Midodrine and should have held if for a systolic blood pressure greater than 120.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was below 5%. Observations of medication administration at the facility on 09/07/22 and 09/08/22 with two nurses on two hallways revealed there were 29 opportunities for error with 3 errors leading to a medication error rate of 10.34%. Findings include: A review of the facility policy titled, Administering Medications, dated April 2019, revealed medications were to be administered in accordance with prescriber orders, including the required time frame, and the correct dose. The following errors were determined based on the medication reconciliation following the observation of medication administration: - A review of physician's orders for Resident (R)47 revealed an order to receive vitamin D3 6000 milligrams (mg) daily. During observation of medication administration on 09/07/22 at 8:20 AM, Licensed Practical Nurse (LPN) #2 gave Resident #47 two vitamin C tablets totaling 5500 mg. - A review of the physician's orders for R220 revealed an order to receive ferrous fumerate 324 mg daily. During observation of medication administration for R220 on 09/08/22 at 8:05 AM, LPN1 was not observed to administer the medication to R220. - A review of the physician's orders for R220 revealed an order to receive vitamin B-12 500 micrograms (mcg) daily. During observation of medication administration for R220 on 09/08/22 at 8:05 AM, LPN1 was not observed to administer the medication to R220. During an interview on 09/08/22 at 10:58 AM, LPN2 stated she did not realize she did not have the correct dose of vitamin D for R47. LPN2 re-checked her medication cart and confirmed she did not have the accurate dose of the medication. LPN2 stated the incorrect dose was written on the cap of the bottle, and she did not check the label. During an interview on 09/08/22 at 11:04 AM, LPN1 stated she had accidentally marked on the medication administration record (MAR) that she had administered ferrous fumerate and vitamin B-12 to R220. LPN1 further stated she had not had the ferrous fumerate all week and the vitamin B12 was not on her medication cart that day. LPN1 stated she did not know why she did not have the medications. LPN1 stated that by not receiving the ordered medications to treat anemia, it could have a negative impact on R220's hemoglobin level (red blood cell count). During an interview on 09/09/22 at 4:49 PM with the Administrator and Director of Nursing (DON), the medication omissions were discussed, and the DON stated it was the facility's expectation for the nursing staff to administer medications as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure each resident room was near a toilet and bathing facilities for 1 of 3 hallways on the A Unit. Interview with Resident (R)66, who lived on the A Unit, revealed they did not have access to a sink or toilet on their hallway, and observations and interviews with staff revealed the plumbing on the hallway was broken, leaving residents without near access to bathing or toilet facilities. Findings include: A review of an admission Record for R66 revealed the facility admitted the resident on 09/07/21 with diagnoses including polyneuropathy, anxiety disorder, and anemia. A review of R66's annual Minimum Data Set (MDS) assessment, dated 08/12/22, revealed the resident required supervision with bed mobility, transfers, locomotion on the unit, dressing, eating, and toilet use. The assessment further noted the resident required limited assistance with personal hygiene and physical help with bathing. R66's Brief Interview for Mental Status (BIMS) score was not assessed. A review of an admission MDS dated [DATE] revealed the resident's BIMS score was 11, indicating moderately impaired cognition. During an initial tour on 09/06/22 at 11:58 AM, R66 was observed seated in a wheelchair beside the bed. A bedside commode was beside the resident. R66's roommate was also observed to be in the room, and a second bedside commode was beside the roommate. There was no sink or bathroom observed in the room. R66 stated during the observation that there was nowhere for the resident to use the bathroom or wash their hands on the hallway. The resident stated they had to use a bedside commode. The resident had cleansing wipes, but stated he/she really wanted to be able to wash their hands. An observation of the hallway where R66 resided revealed there were two resident rooms that had a bathroom and a sink. One room, located at the end of the hallway, was locked, and identified as the bathroom for staff. A second room, located midway down the hallway, contained a sink in an alcove. The sink was covered by a large piece of cardboard that had Do Not Use written across it. There were two doors beside the sink, one containing a toilet and the second containing a large sink used to empty bedpans and urinals. There was not enough room for a wheelchair to pass between the sink and enter the room with the toilet. Further observation of R66 on 09/07/22 at 8:30 AM revealed R66 was observed in their room, seated in a wheelchair, and eating breakfast. The bedside commode was beside the resident while the resident ate. Another observation on 09/07/22 at 9:50 AM revealed the resident was in the room, seated in a wheelchair. The bedside commode was positioned beside the resident and a plastic bag was observed inside the commode containing a dark substance. There was a urinal observed on top of the commode containing a yellow-tinted liquid. On 09/08/22 at 1:50 PM, R66 was observed in their room. R66 stated they were upset about not having access to water or a place to wash their hands or brush their teeth. R66 stated that to get water, they had to get a nurse or certified nursing assistant (CNA) to bring them a basin of water. R66 stated they had to wait, and it was not acceptable. During an interview on 09/08/22 at 1:50 PM, CNA1 stated R66 used a bedside commode, noting it had been there as long as she could remember. CNA1 stated she did not know how the resident washed their hands. An observation by the surveyor at the time of the interview revealed there was a hand sanitizer dispenser on the wall. During an interview on 09/08/22 at 2:26 PM, Licensed Practical Nurse (LPN)6 stated she was unaware there was no running water available on R66's hallway. LPN6 further stated R66 had a bedside commode and used a urinal. She stated she did not know how the resident washed his/her hands. During an interview on 09/09/22 at 10:10 AM, the Maintenance Director (MTD) stated everything on the A-Unit (location of R66's room) was old. The MTD stated there were plumbing concerns on the A-Unit. Per the MTD, the piping was old and difficult to replace, and the current restroom had been out of commission since prior to 2019. The MTD noted the plan was to eventually get the sink that was currently not working repaired soon. The MTD stated residents on the affected hallway could go to a shower room on the other side of the unit to wash their hands or to one of the bathrooms on the other hallway. During an interview on 09/09/22 at 11:11 AM, CNA7 stated he had worked at the facility for almost 21 years. CNA7 stated he took care of R66, and usually when the resident asked for water, he would get it for them to wash their face and brush their teeth. CNA7 stated the residents should have ready access to water. CNA7 stated people needed water, but the plumbing was not working, the restroom kept breaking down, and there had been plumbing problems for years. CNA7 stated the residents had not said anything to him about the situation. During an interview on 09/09/22 at 4:49 PM, the Administrator, with the Director of Nursing (DON), stated the facility was in the process of replacing piping for the plumbing, and they had been trying to work towards making the A-Unit more homelike, noting the expectation was for the residents to live in a homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations of R33 on 09/06/22 at 2:31 PM in the resident's room revealed a long triangle-shaped crack in the window glass that went from the bottom of the frame to the top. The broken piece of glass was visibly loose, the wooden window frame was also cracked, and the paint was peeling. A review of R33's admission Minimum Data Set (MDS), dated [DATE], revealed the resident was admitted on [DATE]. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. During an interview with Resident #33 on 09/06/22 at 2:31 PM, they stated the facility painted the room before they moved in. They stated the kid did not do a good job and he missed an entire part of the wall next to the door. Resident #33 stated they would like their window fixed and no staff had noticed the concerns with the window. They stated they were afraid to open their window or touch it in case it broke. They stated they had not told any staff about the window, and it was that way when they moved into the room. 3. Observations of R43's room on 09/06/22 at 1:48 PM revealed water damage along the ceiling and drywall damage behind the resident's bed. A review of R43's annual MDS, dated [DATE], revealed the resident was admitted on [DATE]. The MDS revealed the resident had a BIMS score of 10, indicating moderate cognitive impairment. During an interview with R43 on 09/06/22 at 1:48 PM, they stated the water damage was so bad the ceiling would leak when it rained really bad, and the ceiling leaked at the intersection of the two curtain tracks. They stated the drywall damage was present in the room when they moved in. They stated no staff had come to look at the issues or to fix them. They stated they did not like the drywall all messed up and it did not feel like home. During an interview with the Maintenance Director (MTD) on 09/09/22 at 10:11 AM, he stated he prioritized projects on Unit A and there was a lot to do as the unit was very old. He stated his assistant did most of the painting and had designated painting days but would get pulled to other projects. He stated most of the issues were with the toilets and the windowsills on Unit A. He stated he tried to emphasize to floor staff to keep the beds away from the wall to protect the drywall, but the beds would eventually end up back against the walls, causing further damage. He stated most of the rooms on Unit A had drywall damage. He stated since most of the residents on the unit preferred to stay in bed, it was difficult to address some of the maintenance issues. He stated work to the rooms was done when the rooms were unoccupied. He stated his plan to fix the drywall issues was to put up a poly-board (plastic board) on the wall behind resident beds to protect the drywall. He stated the drywall dust from exposed drywall could be hazardous to residents, depending on the issues they had. He stated he planned to put poly-board up in all the rooms on Unit A. During an environmental walk-through with the MTD on 09/09/22 at 2:23 PM, he acknowledged the damaged areas were not homelike and stated visual checks were done of the rooms during daily rounds. He stated checks of the outside of the building were completed as well. He stated work orders were put into the Tells system in the electronic health record (EHR). The MTD stated he did not know about the broken glass and window frame in R33's room. He stated the damage to the wall behind the resident's bed was caused by the bed being lifted too far and catching on the mounted box on the wall, ripping it out. He stated the paint had not been touched up after the mounted box had been repaired. He stated the broken window glass and frame was a safety hazard and would be replaced with a new pane of glass as soon as it was found/purchased. During an interview with the Administrator and Director of Nursing on 09/09/22 at 4:41 PM, they stated they expected paint to be in good order, vents to be clean, no water damage present, broken things fixed, and safety issues addressed. They stated the facility was bought by a new management company in December 2021, and renovations were planned. Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident (R)42, R33, and R43) of 24 residents who resided on A Unit. Observations revealed the residents' rooms had areas of disrepair. Findings include: An interview with the Maintenance Director on 09/09/22 at 10:10 AM revealed the facility had no policy regarding a homelike environment. 1. During the initial tour, conducted on 09/06/22 between 9:00 AM and 10:00 AM, observations in R42's room revealed on the right outside wall corner, the ceiling had flaking paint that was hanging off the wall. Below the ceiling on the wall, the plaster/paint/drywall had broken away from the wall, creating a hole. The resident's head of bed was directly beneath the area of damage. Further observations in the room revealed on the left wall, beside the resident's bed, the wood trim around the wall above the level of the bed was splintered, with large gashes revealing splintered raw wood. Behind the head of the bed and beneath a window, a metal vent cover was observed to be broken inwards, exposing sharp metal edges and the ceiling vent covers were observed to contain a coating of a rust-colored substance on the vents. During an interview on 09/08/22 at 2:40 PM, the Maintenance Assistant stated his role was to fix anything and everything that needed to be fixed. He further stated the nursing and housekeeping departments would put in a work order by sending an email or a written order placed in a maintenance box that he checked every day. The Maintenance Assistant further stated he checked the requests daily, and the repairs were mostly related to beds, wheelchairs, and toilets and sinks, and other than that there really was not anything. The Maintenance Director was shown the areas of concern but stated that he was not aware of the areas of concern. During an interview on 09/09//22 at 10:10 AM, the Maintenance Director stated there was a worksheet at each nurse's station to write down what needed to be repaired, and the Maintenance Director prioritized the work that needed to be done. The Maintenance Director stated that most of the work requests occurred on the A Unit, which he identified as the old side of the building. During a tour on 09/09/22 at 2:30 PM, the Maintenance Director was asked about the areas of concern. The Maintenance Director stated he was not aware of the disrepair in R42's room. The Maintenance Director stated he had been working on the roof right above R42's room that morning and thought the damage to the ceiling and the wall was related to a leak, and he hoped he had fixed it. During an interview on 09/09/22 at 4:49 PM, the Administrator stated the facility was trying to work toward making the old part of the building more homelike. Per the Administrator, the expectation was to ensure the residents lived in a homelike environment. The Administrator further stated the new ownership company was committed to investing money into the building to make the necessary repairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and the Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe and sanitary environment to help prevent the possible development and transmission of Coronavirus (COVID-19) as well as other communicable diseases and infections. Specifically, the facility failed to: 1. Ensure unvaccinated/or partially vaccinated newly admitted residents were quarantined to their rooms for two (Resident (R)223 and R230) of 5 residents reviewed for transmission-based precautions. 2. Ensure that during medication administration observations nursing staff wore the appropriate personal protective equipment (PPE) when they went in rooms with residents who were on quarantine for one of three units, Unit B. Further observations during medication administration revealed nursing staff touched medications with their bare hands without performing hand hygiene between residents and preparation of the medications. 3. Ensure staff observed in resident care areas wore their masks fully covering their nose and mouth and ensure staff taking care of residents in quarantine wore the appropriate PPE when delivering meal trays. This deficient practice had the potential to affect several residents of the facility and occurred when the facility was in a community with high COVID-19 transmission rate. Findings included: According to the CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 02/02/22 and retrieved on 09/09/22 from https:// www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who are newly admitted to the facility and for residents who have had close contact with someone with SARS-CoV-2 infection if they are not up to date with all recommended COVID-19 vaccine doses. In general, quarantine is not needed for asymptomatic residents who are up to date with all COVID-19 vaccine doses or who have recovered from SARS-CoV-2 infection in the prior 90 days. The guidelines further stated for residents who are not up to date with all recommended COVID-19 vaccine doses should be cared for by HCP [health care professionals] using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. 1. According to the admission Record, dated 09/09/22, the facility readmitted Resident #230 on 08/29/22. A review of the facility's residents' vaccination list revealed R230 had not received any dose of the COVID-19 vaccines. R230's readmission date up until the survey start date on 09/06/22 put the resident on day nine of their admission at the facility. Observations conducted on the B Hall (the hall which housed R230) during the initial pool process of the survey on 09/06/22 between 9:00 AM and 11:45 AM, revealed there was no signage which advised staff and visitors of any resident who was under observation for COVID-19 or the type of PPE to wear going into such a room. According to the admission Record, dated 09/09/22, the facility admitted R223 on 09/02/22. A review of the facility's residents' vaccination list revealed R223 had only received one dose of the COVID-19 vaccine. R223's admission date up until the survey start date on 09/06/22 put the resident on day four of their admission at the facility. Although R223 did not test positive for COVID-19, observations conducted on the B Hall (the hall which housed R223) during the initial pool process of the survey on 09/06/22 between 9:00 AM and 11:45 AM, revealed there was no signage which advised staff and visitors of any resident who was under observation for COVID-19 or the type of PPE to wear going into such a room. R223 was not on quarantine or isolation. The Administrator and the Director of Nursing/Infection Control Preventionist (DON/ICP) were interviewed on 09/09/22 at 1:45 PM. The DON/ICP identified R223 as a newly admitted resident who was not fully vaccinated. She acknowledged the resident was not quarantined or isolated to their room as of 09/06/22. The DON/ICP also acknowledged R230 had not received any dose of the COVID-19 vaccine and the resident had no signage on their room door identifying the resident was on isolation, even though their admission was within the 10 day window they were supposed to be quarantined. According to the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/02/22 and retrieved on 09/09/22 from https://www.cdc.gov /coronavirus/2019-ncov/hcp/infection-control -recommendations, Implement Universal Use of Personal Protective Equipment for HCP. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE. 3. On 09/06/22 at 3:13 PM, Certified Nurse Aide (CNA)1 was observed twice wearing her face mask below her chin with her nose and mouth exposed while talking with a resident and a fellow CNA. On 09/07/22 at 11:59 AM, CNA1 was observed entering Unit A with her mask below her chin drinking a soda. She replaced her mask and walked to the nurse's station, where she again pulled her mask off and continued touching the mask and not preforming hand hygiene before going to work with residents. During an interview with CNA1 on 09/07/22 at 12:12 PM, she stated she received a PPE in-service from the facility the day prior, 09/06/22. She stated staff demonstrated to the unit manager how to don and doff PPE and that a face mask was supposed to be worn over the nose and mouth. She stated the face mask should be over her mouth and nose at all times while in resident areas, and her mask should not have been below her chin while on the floor. On 09/08/22 at 8:14 AM, CNA2 was observed as she delivered room trays to residents considered to be under investigation related to potential exposure to COVID-19 during the morning meal service. CNA2 was observed to not be wearing the appropriate PPE going into the rooms. Specifically, CNA2 only had an N95 mask on. CNA2 failed to wear gloves, goggles/face shield, or a gown when she entered Rooms #101, #102, #104, and #105. At 8:20 AM, she was observed to don gloves and gown for the first time when she entered room [ROOM NUMBER]; however, she failed to wear either goggles or a face shield. During an interview on 09/08/22 at 8:35 AM, CNA2 stated she had been educated on the need to don full PPE including a mask, goggles, gown, and gloves when she went in rooms that housed residents on isolation. CNA2 stated she forgot to don the required PPE because she was trying to quickly pass the residents' meal trays before they got cold. During an interview on 09/08/22 at 9:11 AM, the Director of Nursing (DON) stated that when nursing staff went into a resident room with signage that advised to see the nurse, the individual going into the room must wear gown, gloves, face shield/or goggles, and an N95 mask. She stated eyeglasses without side seal could not supplement goggles or face shield. On 09/08/22 at 1:00 PM, Housekeeper (HK)1 was observed wearing her N95 face mask on the top of her head in the hallway of Unit B. During an interview with HK1 on 09/08/22 at 1:00 PM, she stated she received PPE training from the housekeeping company she worked for and her past work experience as a CNA. She stated her face mask should have been down around her nose and mouth before entering the resident area and not on the top of her head. During an interview with the Administrator and Director of Nursing on 09/09/22 at 4:41 PM, they stated they expected floor staff to wear face masks covering their nose and mouth. 2. During an observation of medication administration on 09/08/22 from 8:00 AM through 8:35 AM, LPN1 was observed to administer medications in four rooms, all with signs on the door stating, STOP see the nurse before entering and personal protection equipment (PPE) carts outside of the rooms. LPN #1 was observed entering each room with an N95 mask on only. She did not don the required gown, required eye protection, or gloves. She entered each room to provide medications, and when she came out of the room, she failed to sanitize her hands. When LPN1 returned to her medication cart, she entered information on the computer at the cart, then began her medication administration process for the next resident in a quarantine room. As LPN1 prepped the medications to be administered, she touched each pill with her fingers as she dispensed them into the medication cup. LPN1 was then observed to pour water into a drinking cup, remove a straw from the paper covering, and bend the straw with her bare fingers at the point the resident would place in their mouth. LPN1 was observed to follow this process for each resident to whom she administered medications. During an interview on 09/08/22 at 8:35 AM, LPN1 stated the stop sign and isolation PPE were in front of the resident rooms because those residents were on quarantine because they were not fully vaccinated and were new admissions. LPN1 stated it was not necessary for her to don PPE because she was just giving medications and not touching the resident. LPN1 further stated she was only in there a minute. LPN1 stated she wore her reading glasses and a mask and that was enough. LPN1 stated she should have sanitized her hands in between residents and should not have touched the pills or the straws because doing so could spread germs. LPN1 stated she was aware of the COVID outbreak and that was why she wore her N95 mask and reading glasses. On 09/08/22 at 1:20 PM, the Staff Coordinator (SC) stated she had been in the position at the facility for eight days. On 09/06/22, when she realized there were more positive COVID-19 cases, she had walked around the facility and talked to all the nursing staff that were there to educate on infection control around quarantine. Part of the education was to re-enforce what was to be done for new admissions. The SC noted they needed to coordinate the PPE containers to be placed outside of the rooms affected and place signs on the room doors affected. The SC further stated that if a resident was admitted and had not received all eligible COVID vaccines, they were to be quarantined. The SC stated she had not educated LPN1 on 09/08/22, but she completed her education following her medication pass on 09/09/22. The SC did not have any plan to educate the staff that worked on off hours, night shift, or weekends. During an interview on 09/08/22 at 9:11 AM, the DON stated that when nursing staff went into a resident room with signage that advised to see the nurse, the individual going into the room must wear a gown, gloves, face shield/or goggles, and an N95 mask.

Based on record review and interview, the facility failed to maintain a complete and accurate medical record for Resident #129, 1 of 3 sampled residents reviewed for Urinary Tract Infection. Resident #129 was admitted with a urinary catheter and no orders related to the care of the catheter were entered until 1 week after admission: The findings included: The facility admitted Resident #129 on 6/24/21 with diagnoses including, but not limited to, Heart Failure, Diabetes, Hypertension and Urinary Tract Infection. Record review of progress notes, on 7/14/21 at 11:29 AM, revealed a note from 6/24/21 indicating the resident had been admitted to the facility with a urinary catheter. Record review of the physician's orders, on 7/14/21 at 11:14 AM, revealed no orders for catheter care, changing the catheter, or checking the catheter were entered until 7/2/21. Record review of the Treatment Administration Record (TAR), on 7/14/21 at 11:24 AM, revealed no documentation of catheter care until 7/2/21. Record review of the Certified Nursing Assistant (CNA) care guide, on 7/15/21 at 10:32 AM, revealed the CNAs were instructed to complete catheter care on admission. During interviews with CNAs #1 and #2, on 7/15/21 at 10:14 AM, the CNAs stated they began providing catheter care on admission every shift for the resident per the care guide. The CNAs stated it is policy to provide catheter care every shift for any resident with a catheter unless instructed otherwise. Review of statements from all other CNAs who had cared for the resident also indicated they had provided catcher care every shift. During an interview with the Director of Nursing (DON), on 7/15/21 at 10:32 AM, the DON stated the admission Nurse enters all orders into the record at time of admission and these orders are verified by another nurse for accuracy. The DON stated both nurses failed to realize no catheter orders were entered. If the orders are not entered, the care can't be documented as done on the TAR, per the DON. The DON also stated the orders are reviewed by the clinical team the day after admission and the clinical team also failed to realize catheter orders were not entered. The DON stated the unit manager noticed the error on 7/2/21 and the catheter orders were entered at that time. The DON stated all CNAs who cared for the resident were interviewed and s/he was confident the resident received catheter care every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to develop a baseline care plan within 48 hours of admission for Residents #78, #283, #74 and #129, 1 of 1 sampled residents reviewed for death and 3 of 3 new admissions reviewed. The findings included: Record review of Resident #78's baseline care plan, on 07/13/21 at 03:27 PM revealed the resident was admitted on [DATE]. The baseline care plan indicated the completion date was 4/21/21. There was no other documentation to indicate the baseline care plan had been developed within 48 hours. Record review of Resident #129's baseline care plan, on 07/14/21 at 11:44 AM, revealed the resident was admitted on [DATE]. The section on the care plan for documenting the completion date was blank. There was no other documentation to indicate the baseline care plan had been developed within 48 hours. Record review of Resident # 283's baseline care plan, on 07/14/21 at 11:44 AM, revealed the resident was admitted on [DATE]. The section on the care plan for documenting the completion date was blank. There was no other documentation to indicate the baseline care plan had been developed within 48 hours. Record review of Resident #74's baseline care plan, on 07/14/21 at 11:44 AM, revealed the resident was admitted on [DATE]. The section on the care plan for documenting the completion date was blank. There was no other documentation to indicate the baseline care plan had been developed within 48 hours. During an interview with the Director of Nursing (DON), on 07/13/21 at 3:42 PM, the DON stated it is facility policy to complete baseline care plans on admission. The DON also stated the baseline care plans are reviewed by the clinical team for accuracy the following morning. During an interview with the DON, on 07/15/21 at 10:32 AM, the DON confirmed there was no documentation to indicate the baseline care plans for Residents #78, #283, #74 and #129 had been developed within 48 hours. In addition, the DON could not provide documentation each baseline care plan had been reviewed by the clinical team on the day after admission, which would have indicated completion on admission. The DON stated it was the responsibility of the admission nurses to document the completion date on the baseline care plan. The DON also stated the facility had implemented a new baseline care plan on 7/1/21 that reduced the amount of spaces the baseline care plan needed to be signed. Review of the facility's Care Plans-Baseline policy revealed: To assure that the resident's immediate care needs are met and maintained, a Baseline Care Plan is developed upon admission.

Based on observations, interviews, and record review, the facility failed to conduct kitchen operations in a safe and sanitary manner affecting all residents receiving food from the facility kitchen. Kitchen staff failed to wear a mask properly in one of one kitchens observed, three of six kitchen staff were observed wearing their masks improperly. Findings include: During the initial kitchen tour on 07/12/21 at 10:55 AM the following observations were made: Dietary Aide 1 was wearing his/her mask under his/her chin. Cook 1 was wearing his/her mask under his/her chin. Cook 2 was wearing his/her mask under his/her nose. On 07/12/21 at 11:15 AM, Kitchen Manager (KM) was heard asking all staff to wear mask correctly. On 07/12/21 at 12:32 PM, [NAME] 1 was wearing her/his mask under her/his chin. On 07/12/21 at 02:20 PM, [NAME] 1 was wearing his/her mask under his/her chin and Dietary Aide 1 was wearing his/her mask under their chin. Upon surveyor entering the kitchen, [NAME] 1 and Dietary Aide 1 raised their masks to cover their nose and mouth. In an interview with [NAME] 1 on 7/12/21 at 2:34 pm, s/he said I don't know when asked why s/he was not wearing her/his mask properly. On 07/12/21 at 02:54 PM, [NAME] 1 was wearing his/her mask under his/her chin. On 07/13/21 at 10:05 PM, [NAME] 1 was wearing his/her mask under his/her chin. On 07/13/21 at 11:23 AM, [NAME] 1, Dietary Aide 1, and KM were wearing their masks under their chins. All three of the staff were observed placing mask over mouth and nose when surveyor walked in the kitchen. In an interview on 07/13/21 at 11:38 AM, the KM and Certified Dietary Manager (CDM) acknowledged the staff has not been wearing their mask properly. On 07/13/21 at 03:40 PM in an interview with the Administrator, the expectation is all staff properly, over nose and mouth, wear their masks at all times. In training documentation related to personal protective Equipment (PPE), kitchen staff are evaluated in an Infection Control Quiz, How to Properly [NAME] and Remove PPE, as well as a PPE In-Service Quiz. All current staff trainings were completed between March 2021 and May 2021. A review of the facilities policy Proper Use of PPE , it reads .in addition to proper hand hygiene .it is important for staff to use appropriate personal protective equipment (PPE) as a barrier to exposure to any body fluids .masks are used as necessary to control the spread of infections. There is no date on the provided policy and procedures documentation.