**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide information regarding residents' right to formulate an Advanced Directive for 5 of 24 sampled residents (Resident #1, #15, #22, #34, and #39) reviewed for Advanced Directives. The findings include: 1. Review of the facility's policy titled, Advance Directives, Appointment of Healthcare Agent or Surrogate, POST Form, revised 1/8/2024, revealed, .Purpose .To provide guidance to support and facilitate a resident's right to .formulate an advance directive .Residents will be informed, and written information provide, during the admission process, regarding the right to accept or refuse medical or surgical treatment. The facility will honor the Advance Directive as the resident's wishes for future care and treatment .The facility recognizes the resident has the right to formulate an Advance Directive .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnosis of Calculus of Kidney, Diabetes, Gastrostomy Status, and Heart Failure. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was severely cognitively impaired. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 3. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Hypertension, Depression, Insomnia, and Chronic Obstructive Pulmonary Disease. Review of the annual Minimum Data Set, dated [DATE], revealed Resident #15 had a BIMS score of 8, which indicated the resident was moderately cognitively impaired. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 4. Review of the medical record revealed Resident #22 was admitted to facility on 5/27/2021, with diagnoses of Hemiplegia and Hemiparesis, Paranoid Schizophrenia, Impulse Disorder, Cerebral Infarction, and Aphasia. Review of the annual Minimum Data Set, dated [DATE], revealed Resident #22 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 5. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses of Aphasia, Hemiplegia, Hemiplegia, Osteoarthritis, Lack of Coordination, Liver Disease, and Chronic Pain. Review of the quarterly MDS dated [DATE], revealed Resident #34 had a BIMS score of 00, which indicated the resident is severely cognitively impaired. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 6. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnosis of Surgical Amputation, End Stage Renal Disease, Peripheral Vascular Disease, Chronic Kidney Disease, and Diabetes. Review of the significant change MDS dated [DATE] revealed Resident #39 had BIMS score of 15, which indicated the resident is cognitively intact. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. During an interview on 6/4/2024 at 10:16 AM, the SSD confirmed that all residents should have an opportunity to formulate an advance directive when they are admitted to the facility. The SSD confirmed that the facility failed to have documentation that Resident #1, #15, #22, #34, and #39 and/or their legal representative was informed, offered, or provided written documentation regarding their right to formulate an Advance Directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 6 of 6 sampled residents (#4, #42, #51, #66, #78 and #134) reviewed for enhanced barrier precautions and for 1 of 9 Certified Nursing Assistant (CNA) F failed to remove a urinal filled with urine from Resident #63's overbed table during dining. The findings include: 1. Review of the facility's policy titled, Transmission Based Precautions, revised date 4/1/2024 revealed, .To provide guidance on taking appropriate precautions to prevent transmission of infectious agents .Initiation of Enhanced Barrier Precautions .An order for enhanced barrier precautions shall be obtained for residents with any of the following .pressure ulcers .indwelling medical devices .feeding tubes, tracheostomy .even if the resident is not infected .Make gowns and gloves available which may include near or outside of the resident's room .face protection may also be needed if performing activity with risk of splash or spray .tracheostomy care .PPE [Personal Protective Equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact resident care activities include .feeding tubes, tracheostomy .wound care .any skin opening requiring a dressing .Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . Review of the facility's policy titled, Resident Rights and Resident Responsibilities dated 11/20/2023 revealed .The resident has a right to be treated with respect and dignity .The right to reside and receive services in the facility with reasonable accommodation of the resident needs and preferences .The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving but not limited receiving treatment and supports for daily living safely . 2. Review of the medical record revealed Resident #4 was admitted on [DATE], with diagnoses of Paralytic Syndrome, Dysphagia, Traumatic Brain Injury, Gastro-esophageal Reflux Disease, and Gastrostomy. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed had a BIMS score of 00, which indicated Resident #4 was severely cognitively impaired and was coded for a feeding tube. Review of the May 2024 Physician Orders revealed, .Jevity 1.5 .Enteral Tube [a tube that allows liquid food to enter your stomach or intestine through a tube] . Observation during medication administration in the resident's room on 6/4/2024 at 3:00 PM, revealed Licensed Practical Nurse (LPN) D failed to wear Personal protective equipment (PPE) while administering medications via (by way of) gastrostomy tube. There was no enhanced barrier precaution signage on the resident's door. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Hemiplegia, Gastrostomy, Depression, Heart Failure, Dementia, and Dysphagia. Review of the May 2024 Physician Orders revealed, . Jevity 1.5 Cal .G [Gastrostomy] -tube . Observations in Resident #42's room on 6/4/2024 at 3:18 PM, 6/5/2024 at 8:10 AM and on 6/6/2024 at 9:14 AM, revealed there was no enhanced barrier precaution signage on the resident's door. 4. Review of the medical record revealed Resident #51 was admitted on [DATE], with diagnoses of Hypertension, Diabetes, Peripheral Vascular Disease, Anxiety, Depression and Lymphedema. Review of the May 2024 Physician Orders revealed, a wound, .Left Posterior Thigh . Observations in Resident #51's room on 6/3/2024 at 4:06 PM, 6/5/2024 at 8:16 AM and on 6/6/2024 at 8:48 AM, revealed there was no enhanced barrier precaution signage on the resident's door. 5. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Dementia, Muscle Weakness, and Psychological Disturbances. Review of the May 2024 Physician Orders revealed, .Coccyx: Clean area with Normal saline .One Time Daily . Every .Day . Observations in Resident #66's room on 6/5/2024 at 9:54 AM, revealed there was no enhanced barrier precaution signage on the resident's door. 7. Review of the medical record review revealed Resident #78 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and hemiparesis following Cerebral Infarction, Diabetes, Parkinson's disease, Alzheimer's disease, Gastrostomy, and Dysphagia. Review of the May 2024 Physician Orders revealed, .Glucerna 1.5 Cal . continuous .G-tube . Observations in Resident #78's room on 6/3/2024 at 10:17 AM, 6/4/2024 at 3:24 PM, 6/5/2024 at 8:14 AM and 6/6/2024 at 9:19 AM revealed there was no signage for enhanced barriers precautions on the resident's door. 8. Review of the medical record revealed Resident #134 was admitted to the facility on [DATE], with diagnoses of Diabetes, Hydrocephalus, Nontraumatic subarachnoid hemorrhage, Tracheostomy, Dysphagia and Gastrostomy. Review of the May 2024 Physician Orders revealed, .Jevity 1.5 .Enteral .Continuous .G-Tube Site Care .One Time Daily .Tracheostomy cannula care .Change Disposable inner cannula .Every .Day . Observation in Resident #134's room on 6/5/2024 at 10:49 AM, revealed LPN E performed medication administration via peg tube on Resident #134, and failed to wear proper PPE. There was no enhanced barrier signage noted on the resident's door, and the only PPE worn by LPN E was gloves. Observation on 6/5/2024 at 2:59 PM, revealed LPN E performed trach care on Resident #134 and failed to wear proper PPE. There was no enhanced barrier signage noted on the resident's door, and the only PPE worn by LPN E was gloves. During an interview on 6/6/2024 at 11:32 AM, the Director of Nursing (DON) was asked does the facility have anyone in isolation, or enhanced barriers precautions. The DON stated, .we do enhance barrier on our .wounds .trachs [tracheostomy] .foley . The DON confirmed staff should wear gloves and gowns when providing wound and trach care. The DON was asked how the staff know if a resident is on enhanced barriers precautions. The DON stated, . there will be enhanced barriers signs up . The DON confirmed Resident's #4, #42, #51, #66, #78 and #134 did not have enhanced barrier precautions signage on their door. 9. Review of the medical record revealed that Resident #63 was admitted to the facility on [DATE], with diagnoses Malnutrition, Acute Kidney Failure, Hypertension, Cerebral Infarction, and Rheumatoid Arthritis. Review of the Care Plan dated 2/21/2024, revealed .has self-care deficits R/T [related to] eating, hygiene .will be assisted with ADL's .Toileting .Provide assistance as needed .Provide hygiene after voiding .Allow resident to keep urinal on overbed table for resident's convenience and safety . Observation in the resident's room on 6/3/2024 at 12:01 PM, CNA F entered the resident's room to deliver his plate of lunch. Resident #6 asked CNA #F to empty his urinal that was sitting on his overbed table. CNA F informed resident that he would have to wait until all residents were served lunch. CNA F placed the resident's plate of food on the overbed table next to the urinal with 300 milliliters of urine. Observation in the resident's room on 6/3/2024 at 12:19 PM, revealed Resident #63's urinal containing urine was noted on the overbed table as resident was eating his lunch. During an interview on 6/6/2024 at 10:56 AM, the DON was asked what a staff should do when a resident requests them to empty a urinal when a plate is being delivered during dining. The DON confirmed that the staff should place the plate in a clean location, empty the urinal, and perform hand hygiene.

Based on facility orientation and competency assessment review, facility employee file review, medical record review, and interview, the facility failed to ensure the licensed nurses had the competencies and skill sets necessary to document assessments and administer intravenous medications for 1 of 3 Licensed Practical Nurses (LPN #2) for 1 of 1 sampled resident (Resident #1) receiving antibiotic therapy via peripherally inserted central catheter. The findings include: 1.Review of the Orientation and Competency Assessment Nursing-LPN revealed .PEER LEADER: As skills/competencies are reviewed with the employee or return demonstration is satisfactorily completed by the employee, place date and Peer Leader Initials in columns 4 or 5 to the appropriate skill/competency . 2. Review of the employee personnel file of Licensed Practical Nurse [LPN] #2 revealed the employee had not been evaluated to ensure the knowledge and skill sets were competent to document assessments and care for the facility's residents receiving intravenous therapy. 3. Review of the medical record of Resident #1, revealed the resident had no nursing assessment completed on 2/4/2023 when a significant change in condition occurred. Record review revealed a physician's order dated 2/4/2023 for Vancomycin 1000 milligrams (mg) intravenous (IV) injection daily for 7 days, Zosyn 3.375 grams IV solution every 6 hours for 7 days, both to be administered via a Peripherally Inserted Central Catheter (PICC) line. Record review revealed LPN #2 documented the administration of the central line IV Vancomycin IV on 2/4/2023 at 2:00 PM, and on 2/5/2023 at 2:00 PM; and the Zosyn on 2/5/2023 at 11:00 AM and 5:00 PM. During a telephone interview on 10/31/2023 at 2:01 PM, LPN #2 was asked if a competency evaluation to determine her knowledge and skills had been completed, LPN #2 stated, No ma'am, I'm not IV certified .I felt like I was running an Intensive Care Unit that day. I started IVs with the PICC line. I'm not an IV nurse. I wasn't supposed to do it. I didn't feel comfortable . When LPN #2 was asked if she completed an assessment on 2/4/2023 when Resident #1 had a change in condition, LPN #2 stated, .I wrote a clinical note as a late entry the next day. I didn't do a complete assessment. The facility was asked during the survey for a Competency checkoff/Skills check off for LPN #2, the facility did not provide competency information for LPN #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, employee file review, medical record review, observation, and interview, the facility failed to provide treatment and services for 1 of 3 (Resident #5) sampled residents reviewed for behaviors. The finding include: 1. Review of the facility policy titled, Behavioral Health Services, with a revision date of 10/2/2023, revealed .It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .Highest practicable physical, mental, and psychosocial well-being .determined through the comprehensive assessment and by recognizing and competently and thoroughly addressing the physical, mental, and psychosocial needs of the individual .interventions shall be evidenced-based, culturally competent, trauma-informed, and in accordance with professional standards of practice .Behavioral health care plans shall be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition . 2. Review of Resident #5's employee file revealed he was employed at the facility as a Housekeeper on 11/20/2000 and was employed until 11/14/2003. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, Diabetes, Psychosis, Dementia, Mood Disorder, and Adult Failure to Thrive. Review of the NURSING ADMISSION/readmission FORM, dated 5/17/2023, revealed .Resident transported to facility via .law enforcement .accompanied by .jail nurse/CO [corrections officer] .Behavior .wanders .BRADEN SCALE FOR PREDICTING PRESSURE INJURY RISK .Degree of physical activity .Walks frequently .MOBILITY Ability to change and control body position .No limitations . Review of the Care Plan Report, dated 5/24/2023, revealed Resident #5 exhibited wandering behavior with interventions implemented which included to redirect when wandering, prompt activity attendance to keep resident occupied, and monitor resident's location to ensure safety. Review of the GRIEVANCE RECORD, dated 5/24/2023, revealed Resident #14's mother was .Concerned with an admission in the facility during the last week that there is a history [symbol for with] her daughter & [and] family .Result of investigation .Agreed pt [patient] was not to visit [symbol for with] resident in the past. He is a patient now .Education [symbol for with] all staff male resident to not be on 500 hall or the room of pt [Resident #14's room number]. Patient will not be room on 500 hall .Comment from person filing grievance .he [Resident #5] better not be in her [Resident #14] room . Review of the Statement of In-service Training for Employees of [named facility], dated 5/24/2023, revealed . [Named Resident #5] is not to be allowed to enter 500 hallway at any time. [Named Resident #5] is to have no interaction with [named Resident #14] at any time no matter her location whether in lobby watching television or in her room . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 03, which revealed he had severe cognitive impairment, exhibited wandering behaviors on 1 to 3 of 7 days, required only supervision for all most activities of daily living (ADLs), and received Anti-Depressant medications on 7 of 7 days. Review of the NURSE'S EVENT NOTE, dated 10/16/2023, revealed .Locations Incident Occurred .Shower Room .Inappropriate comments towards female staff member .CNA [Certified Nursing Assistant] reported .that in shower room during shower she had resident and another male resident assisting them, resident in [name Resident #5's room number] stated while undressing .It's unfair we don't get to see yall [you all] naked but yall get to see us . CNA stated to resident that she was there to assist resident with ADL care and to help him. Resident then stated .take your top off .CNA informed resident that was an inappropriate comment/conversation. Resident finished showering and left shower room without further incident .STEPS IMPLEMENTED TO PREVENT RECURRENCE .Verbal redirection from conversation when inappropriate conversation is brought up by resident. Reminded that kind of talk was not warranted with staff . Review of the Clinical Note, dated 10/16/2023, revealed Psych NP [Nurse Practitioner] made aware of resident's behavior directed toward female staff. New recommendation to start Namenda 5 mg [milligram] 1 tab [tablet] orally daily, and reevaluate .MD [Medical Doctor] aware and agrees . Review of the OCTOBER 2023 MEDICATIONS, dated 10/1/2023 through 10/31/2023, revealed Namenda 5 mg was ordered and begun on 10/16/2023. Review of the Care Plan Report, created 10/16/2023, revealed .has verbal behavioral symptom directed at others. Sexual comments towards staff and residents .Intervention in place .New psych medications . Review of the Psych Progress Note, dated 10/18/2023, .Type of Visit .Requested by Staff .follow-up this date related to new med [medication] initiation on 10/16/23 [2023] related to inappropriate comments being made toward staff .Patient does not recall comments voiced to staff .patient lacks insight into current medical and psychiatric needs and management, judgement fair to poor .Continue current medication regimen, GDR [Gradual Dose Reduction] not recommended at this time .Namenda 5 mg added on 10/16/2023 . There was no other interventions implemented for the 10/16/2023 behavior, other than Namenda, to address Resident #5's behaviors. Review of the NURSE'S EVENT NOTE, dated 10/23/2023 revealed .Location [named Resident #10's room number] .Inappropriate behavior .Reported by pt [patient] in Room [named Resident #10's room number] that pt entered her room and showed his private area. He then asked her to see her breasts and she told him no, get out of my room .Pt is now 1:1 with staff member .STEPS IMPLEMENTED TO PREVENT RECURRENCE .Resident to be placed 1:1 with staff member and made aware he is not to enter other pt rooms . Review of the Clinical Note, dated 10/23/2023, revealed At 0440 [4:40 AM] today .Per resident in room [named Resident #10's room number], she stated that after 1 pm [1:00 PM] smoke break yesterday [10/22/2023], she was in her room vomiting when [named Resident #5] entered the room and stated he had something to make her feel better. He then proceeded to pull his pants down and expose his private area. Following this, he asked to see her breasts, which she stated that she told him no and to leave her room. Per pt in [named Resident #10's room number], the pt [Resident #5] then left the room and has not spoke to her since . Review of the Clinical Note, dated 10/23/2023, revealed .Resident was transported to [named Psychiatric Hospital] by facility . Review of the [Named Hospital] Psychiatric Care Notes, assessment date 10/23/2023, revealed .Staff report that early this am [morning] another female resident reported that [named Resident #5] entered her doorway to her room and exposed his genitals to her. He then asked her to show her breasts to him. She ordered him out of her room doorway and the patient exited the area .Patient is known to provider and recently voiced a sexually inappropriate comment to staff, medication regimen was changed, however patient has now shown his genitals to a female peer .10/30/23 [2023] .Staff report that patient was sexually inappropriate the prior day with nursing staff .ACTIVE PROBLEMS .Inappropriate sexual behavior .PSYCHIATRIC HISTORY .Patient with a history of sexually inappropriate behavior per family, stating he would peep in windows and make inappropriate comments. Patient was incarcerated until early this year when he transferred to a SNF [Skilled Nursing Facility] from jail . Review of the Care Plan Report dated 10/23/2023, revealed . This resident went in another resident's room and showed his genital area to her then told her to show him her breast. Intervention .placed in 1:1 [one on one] and resident was made aware to not go in to other resident's room .Intervention in place .psych referral to eval and treat . During an interview on 10/23/2023 at 10:15 AM, Licensed Practical Nurse (LPN) #4 confirmed Resident #5 was in one on one. LPN #4 stated, [I was] Told he walked into another resident's room and exposed himself and had some inappropriate comments. LPN #4 was asked has Resident #5 had any other inappropriate behaviors prior to this incident. LPN #4 stated, .Yes .[with] just CNA's before. LPN #4 confirmed that he was told in report that morning that Resident #10 had reported the incident to staff around 4:00 AM that morning. Observation outside the resident's room on 10/23/2023 at 10:24 AM, Resident #5 stood in the doorway to his room and LPN #4 stood in front of him. Resident #5 stated to the surveyor, We're just talking. Resident #5 asked LPN #4, Did I do something? 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Diabetes, Chronic Viral Hepatitis, Post-traumatic Stress Disorder, Schizophrenia, Pancreatitis, Cocaine Dependence, Nicotine Dependence, Bipolar Disorder, Anxiety Disorder, and Borderline Personality Disorder. Review of the MDS dated [DATE] revealed Resident #10 had a BIMS of 15, which indicated Resident #10 was cognitively intact, and was independent with only staff supervision for all ADLs. Review of the NURSES'S EVENT NOTE, dated 10/23/2023, revealed .inappropriate behavior of another resident .At 0440 this morning resident approached this nurse and stated that yesterday following afternoon smoke break she was in her room puking [vomiting]. She stated that the resident from room [named Resident #5's room number] entered her room and told her he had something to make her feel better and dropped his pants exposing himself. She stated that then he asked to see her breast and she told him no, to leave her room .Resident is currently joking and laughing with staff, no psychosocial issues evident . Observation and interview on 10/23/2023 at 10:26 AM, revealed Resident #10 sat on her bed fully clothed. Resident #10 was asked had anything happened in the facility to make her feel uncomfortable. Resident #10 stated, Yes ma'am, yesterday [named Resident #5] .exposed himself to me and wanted to see my breasts. I was at the trash can getting sick, he said I have something that will make you happy and he pulled his pants down .showed me himself .he said can I see your boobies .I said you need to get out . Resident #10 confirmed Resident #5 left her room when she told him to. Resident #10 stated, No sooner than I tell them [facility staff] they started writing a report and put him in 1 on 1 . Resident #10 confirmed that was the only time Resident #5 had displayed inappropriate behaviors toward her. Resident #10 was asked did she feel safe in the facility and stated, Yes. 5. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Dysphagia, Paralytic Syndrome, Hepatitis C, Gastrostomy, and Diffuse Traumatic Brain Injury. Review of the quarterly MDS dated [DATE] revealed Resident #14 was rarely/never understood, and staff assessed her with severe cognitive impairment. 6. During a telephone interview on 10/27/2023 at 11:29 AM, CNA #7 confirmed Resident #5 had made sexually inappropriate comments to her. CNA #7 stated, I had taken him and another male resident to the shower, both are independent. I was standing there waiting and he made a few remarks that we get to see them naked, and they don't get to see us naked .I told him .that is inappropriate, and he walked over to me and kind of whispered just take off your shirt . CNA #7 confirmed she reported the incident to LPN #3. CNA #7 was asked what the facility did at that time. CNA #7 stated, I'm not sure . CNA #7 confirmed that was the only inappropriate comments Resident #5 had made to her. CNA #7 was asked was she aware that Resident #5 was not supposed to go on the 500 Hall. CNA #7 stated, No . Not that I'm aware. During an interview on 10/30/2023 at 1:45 PM, LPN #1 was asked were any residents not allowed to come to the 500 Hall. LPN #1 stated, Yeah [named Resident #5]. LPN #1 was asked why that is. LPN #1 stated, I don't know. I just think [named Administrator #2] made that rule that he was supposed to stay up front, if he did come back, it would be with a staff member. I just thought it was for roaming issues .learned when [named Administrator #2] was here you didn't ask questions . During a telephone interview on 10/30/2023 at 5:12 PM, Administrator #2 was asked why Resident #5 was not allowed on the 500 Hall. Administrator #2 stated, Yes ma'am .20 years ago right after I came in 2004, the mother [Resident #14's mother] had said something about she didn't want him .visiting [named Resident #14], he might touch her, some kind of family thing .same thing that she said with her step son [Resident #14's step brother] .contacted me and said that she didn't want him visiting [named Resident #14] .I had completely forgotten all of that, then when he was admitted [named Resident #14's mother] gave me a call and she reminded me .I said I will take care of it. My immediate plan was that he wasn't to go past the 300 Hallway .my department heads knew I filled them in . Administrator #2 was asked how she ensured all staff were notified Resident #5 was not allowed on the 500 Hall. Administrator #2 stated, I left it to the department heads to notify them. I can't tell you if they did a written in-service or not . Administrator #2 was asked how she ensured Resident #5 did not come to the 500 Hall. Administrator #2 stated, .I can tell you I never saw him in the back .it just seemed like it was some kind of family thing. Administrator #2 stated, It was 20 years ago .I just remember when she called me after he was admitted [May 2023]. Administrator #2 was asked with Resident #5's history, how were all the resident protected from him. Administrator #2 stated, They [staff] would have redirected him if he wandered into anyone's room. There was no documentation in Resident #5's care plan of any restricted boundaries in the facility. During a telephone interview on 10/31/2023 at 8:59 AM, Resident #14's mother was asked about her concern with Resident #5's admission to the facility. Resident #14's mother stated, He abuse her [Resident #14] and I jumped [named Administrator #2] about letting him come in [admitted to the facility] . [named Administrator #2] told me she couldn't stop him from coming back in . Resident #14's mother confirmed she could not remember when Resident #5 abused Resident #14 and stated, It was after he was fired out there and I told them not to let him come in her room .he came running over here telling me they was trying to accuse him of something he didn't do. I called them and they said [named Resident #5] had been there .I went down there and talked to the DON [Director of Nursing] . [named Administrator #2 and ADON #1 and DON] .said they found Vaseline on [named Resident #14's] stomach .I was just sick .they told me he was fired from coming out there . Resident #14's mother confirmed this occurred many years ago and she could not remember how long it had been. Resident #14's mother confirmed that Administrator #2 and ADON #1 knew about the incident and her request for him not to visit Resident #14. During a telephone interview on 10/31/2023 at 11:15 AM, LPN #9 confirmed that she worked in the facility from 6/2022 through 10/2023. LPN #9 was asked about Resident #5's admission. LPN #9 stated, .I can tell you it was a back door admission .the process is that anybody that comes in has to go through our central intake. I was brought this paperwork by [named Administrator #2] and was told not to put it in the thread on teams, which is central intake, where they clear them and look them over for approval .She just said because he was coming from the jail, at that point I had maybe 4 or 5 training days over admissions, that side of it, so I didn't know .when she said he was coming from the jail I just thought it was because he was coming from the jail until I realized the controversary. LPN #9 was asked what the controversy was. LPN #9 stated, At the time I wasn't aware but apparently .another resident, a female resident .on the back hall . [named Resident #5] used to be an employee there and there was allegations of sexual abuse against him so that's what .I didn't know anything about that until afterwards, not a word was mentioned [by Administrator #2]. LPN #9 confirmed that she heard about the allegation from another employee but could not remember who. LPN #9 confirmed an in-service was conducted to notify staff that Resident #5 was to stay on the 200 Hall but it was not done on admission. LPN #9 stated, No, that was later .couldn't have been 2 weeks. He wasn't there long [before the in-service was conducted] . During a telephone interview on 10/31/2023 at 12:18 PM, the Director of Social Work confirmed that new admissions had to go through Central Intake. The Director of Social Work stated, I only did that [Admissions] a couple of weeks .they had to come through Central Intake. We had a TEAMS group [a video conferencing group] set up .staff reviews it [new admission referral] .if they're approved there's an admission process . The Director of Social Work was asked was she aware of any residents who were admitted without going through Central Intake. The Director of Social Work confirmed that Resident #5 was admitted without going through Central Intake and stated, From my understanding and from my memory I don't remember it [Resident #5's referral] ever coming on TEAMS. The Director of Social Work was asked would the approval for his admission have come from Administrator #2. The Director of Social Work stated, Yes ma'am. During a telephone interview on 10/31/2023 at 1:25 PM, Administrator #2 was asked did Resident #5's admission go through Central Intake. Administrator #2 stated, I can't tell if they notified Central [Intake] or not .we went back and forth with the nurse and [named Nurse Practitioner]. Administrator #2 was asked who made the ultimate decision to admit Resident #5. Administrator #2 stated, Nobody made it solely .social was involved and [named ADON #1] .BOC [Business Office] would have been involved financially . Administrator #2 was asked did she recall the time a creamy substance was reportedly found on Resident #14's abdomen, and she, ADON #1, and the DON met with Resident #14's mother about the incident. Administrator #2 stated, I do not. I just remember there was something with [named Resident #5] .I've had a lot of reportables. During a telephone interview on 11/1/2023 at 3:35 PM, the Medical Director was asked was he familiar with Resident #5. The Medical Director stated, Yeah, he's our local person here. He was in jail before he got here . The Medical Director was asked was he told Resident #5 had behaviors prior to admission. The Medical Director stated, He had some behavior .mother taking care of him .some anxiety, depression, uncooperative, don't know background of why he went to jail . The Medical Director was asked was he aware that Resident #5 made sexually inappropriate comments to a CNA on 10/16/2023 and the psych nurse practitioner ordered Namenda 5 mg daily as an intervention for his behaviors. The Medical Director stated, No, not at all. The Medical Director was asked what his thoughts on the appropriateness of Namenda were. The Medical Director stated, First of all, I am completely unaware and blinded about this incident, but I'm not sure Namenda would be appropriate for this person. This is just not appropriate he should have been sent to some psych place at this time .If they had asked me . The Medical Director was asked was he aware that Resident #5 exposed himself to a female resident in the facility on 10/22/2023. The Medical Director stated, No ma'am, not at all. The Medical Director re-iterated at this time that Resident #5 should have been sent out to a psych facility following the sexually inappropriate comments to staff on 10/16/2023. The Medical Director was asked was he aware that an in-service had been held with staff on 5/24/2023 that Resident #5 was not to be allowed on the 500 Hall. The Medical Director stated, Yes, I was told there was an in-service . [named Resident #14] been a patient for a long time .admitted in 2003 and her mother is my patient as well .she [Resident #14's mother] had some objection [to Resident #5's admission] because of something in the background .long time ago [Resident #14's mother] not really comfortable with him there .that's the reason he was instructed to stay in [his] room on 200 Hall. During an interview on 11/1/2023 at 4:10 PM, ADON #1 was asked about the Clinical Note she documented on 10/16/2023 at 4:30 PM, who was the MD notified, and who notified him. ADON #1 stated, [Named the Medical Director]. If I documented it, I did it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 2 of 2 (Treatment Nurse and Certified Nursing Assistant (CNA) #1) staff members failed to clean a treatment cart and replace contaminated oxygen tubing. The findings include: 1. Review of the facility policy titled, Infection Prevention and Control Program, with a revision date of 10/24/2022, revealed .It is the policy of this facility to establish and maintain an infection control program .designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .All staff are responsible for following all policies and procedures related to the program .The RNs [registered nurses] and LPNs [Licensed Practical Nurses] supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed . Review of the facility policy titled, Oxygen Concentrator and Oxygen Storage, with a revision date of 12/1/2022, revealed .To administer oxygen for the treatment of certain diseases or conditions in a safe manner .It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment . Cannulas .should be changed weekly and as necessary . 2. Observation on the 400 Hall on 10/23/2023 at 3:11 PM, revealed the fire alarm sounded, the Treatment Nurse pushed the Treatment Cart into Resident #11 and #12's room, exited the room, closed the door, and went to stand in front of the exit door at the end of the 400 Hall. The Treatment Cart was left in the residents' room. Observation on the 400 Hall on 10/23/2023 at 3:15 PM, revealed the fire alarm all clear was called and at 3:16 PM, the Treatment Nurse removed the Treatment Cart from Resident #11 and #12's room. The Treatment Nurse cleaned the top, flat surface of the cart with a Super Sani-wipe but did not clean any other parts of the Treatment Cart. The Treatment Nurse opened the top drawer of the cart, removed the wound care supplies, and entered Resident #12's room to complete his wound care treatment. The Treatment Cart was not thoroughly cleaned after removal from a resident's room and before use of the cart to remove wound care supplies. During an interview on 10/31/2023 at 1:06 PM, the Treatment Nurse confirmed that the Treatment Cart should have been cleaned after it was removed from a resident's room. 3. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Arial Fibrillation, Restlessness and Agitation, Diabetes, and Heart Disease. Review of the Physician's Order dated 5/18/2023 and validated 10/9/2023, revealed .Oxygen .1 liters/minute by NC [nasal cannula] . Review of the Minimum Data Set assessment dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status score of 08, which indicated moderate cognitive impairment, and was coded for oxygen therapy. Observation and interview in the resident's room on 10/24/2023 at 1:05 PM, revealed Resident #13 was in bed and her oxygen tubing was lying on the floor under the head of her bed. CNA #1 entered Resident #13's room and stated, Has she got that [oxygen] off, she pulls it off a lot. CNA #1 obtained a paper towel from the bathroom dispenser, wiped the binasal cannula portion of the oxygen tubing off with the dry paper towel, then placed the contaminated oxygen cannula into Resident #13's nares, draped the tubing around the resident's ears, then exited the resident's room. CNA #1 failed to replace the contaminated oxygen tubing. During a telephone interview on 10/27/2023 at 11:50 AM, CNA #1 was asked what would wiping the binasal cannula portion of the oxygen tubing with a dry paper towel do. CNA #1 stated, .If it had any dust or anything [on it], usually would have had an alcohol pad and wiped it off. CNA #1 was asked what she should have done with Resident #13's oxygen tubing that was lying on the floor. CNA #1 stated, Took it with an alcohol pad and wiped it off . During an interview on 11/2/2023 at 4:05 PM, Regional Nurse Manager #1 was asked what should staff do when they find a resident's binasal cannula oxygen tubing on the floor. Regional Nurse Manager #1 stated, Replace it. Regional Nurse Manager #1 confirmed Resident #13's oxygen should have been replaced after staff found it on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility Pest Control Contract, Pest Control Invoices, medical record review, and interview, the facility failed to maintain an effective pest control program and prevent parasites or possible maggots for 1 of 3 (Resident #9) residents reviewed for wounds. The findings include: 1. Review of the facility contract, Named Pest Control Company, dated 4/1/2012, revealed .[Named Pest Control Company] will provide such services as needed to effectively control .insect infestations .with the exception of flies .services shall be performed monthly or as needed based on the nature of any recurring pest problem . Review of [Named Pest Control Company] Invoice dated 4/1/2023, 5/1/2023, 6/1/203, 7/1/2023, 8/1/2023, 9/1/2023, 9/13/2023, and 10/1/2023, revealed pest elimination services were billed to the facility. 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Spinal Stenosis, Chronic Peripheral Venous Insufficiency, Non-Pressure Chronic Ulcer of Skin, Lymphedema, Chronic Kidney Disease, Morbid Obesity, and Embolism and Thrombosis Deep Vein Lower Extremity. Review of the Physician's Order dated 5/18/2023 and recertified on 8/4/2023, revealed .Monitor .daily skin audit d/t [due to] refusal of ADL [Activities of Daily Living] care often . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact, and required extensive to total staff assistance for most ADLs. Review of the ADL Verification Worksheet dated August 2023, documented Resident #9 received a bath every day in August except for 8/2, 8/3, 8/4, 8/25 and 8/26/2023. Review of the August 2023 Treatments dated 8/1/2023 through 8/31/2023, revealed skin audits were completed daily in August. Review of the comprehensive Care Plan with a revision date of 8/7/2023, revealed .Self care deficit R/T [related to] ambulation, bathing, bed mobility .hygiene .Bathing .3x [times] week/prn [as needed] as tolerated alternating days with bed baths .per resident's preference .Hygiene .Monitor for skin integrity .at risk of further skin breakdown .Monitor skin integrity daily while providing care . Review of the Clinical Note dated 8/31/2023, revealed Upon entering room, this nurse and two CNA's [Certified Nursing Assistants] began to bathe the resident. This nurse noted larvae present .Nursing management notified. During a telephone interview on 10/25/2023 at 4:42 PM, Assistant Director of Nursing (ADON) #2 confirmed she worked on 8/31/2023. ADON #2 was asked about the larvae on Resident #9. ADON #2 stated, .I was actually there that day .they [staff] went in there .[larvae] in the folds of her legs .they were more on the left side .the girls actually took a flashlights to make sure they got them all out of the folds of her leg . ADON #2 was asked if the larvae should have been identified on the daily skin audits that were documented. ADON #2 stated, If they were there . During an interview on 10/31/2023 at 1:18 PM, the Maintenance Supervisor was asked if the facility had an issue with flies in August 2023. The Maintenance Supervisor nodded yes and stated, We had the wind curtains on the most used doors .on a fly situation the bug guy is limited . The Maintenance Supervisor was asked did they have issues with flies in any specific rooms in the facility. The Maintenance Supervisor stated, We had a few in [named the room where Resident #9 resided]. The Maintenance Supervisor confirmed they hung fly strips in Resident #9's room and the fly strips remained in the room for roughly a week. The Maintenance Supervisor confirmed flies were on the strips when they were removed from Resident #9's room. During an interview on 10/31/2023 at 3:52 PM, Regional Nurse Manager #4 was asked did the facility identify an issue with flies in Resident #9's room. Regional Nurse Manager #4 stated, There were noted some flies in the room. It wasn't a tremendous amount, just a few .I believe we placed fans in the rooms, a fly trap that was elevated up on the ceiling to capture any [flies], I believe we had pest control in . think that's it. Regional Nurse Manager #4 was asked what was determined to be the root cause of the larvae in Resident #9's skin folds. Regional Nurse Manager #4 stated, Obviously, the fly in the room . During a telephone interview on 11/1/2023 at 1:17 PM, CNA #8 confirmed she worked for a staffing agency and was in Resident #9's room on 8/31/2023 when the larvae were discovered in her skin folds. CNA #8 stated, She was one of my residents that day .the tech [other CNA ] she was sent from hospice the nurse that day was a male nurse .it was the 3 of us and we had went in there because she actually needed her wounds dressed .he [nurse] was trying to take care of her wounds .that's when I noticed the larvae moving on her .would have been her left leg we were holding, had her turned on her right side. CNA #8 was asked were there a lot of larvae present. CNA #8 stated, I would say it was a lot .I said stop .she has maggots crawling on her . [named LPN #10] and the other tech freaked out. He [LPN #10] said you're kidding me .he said I got to go out here and tell someone .I know the Administration people that work in the office were still there they all had met me in the hall asking me questions about did we give her a bed bath . CNA #8 stated, .I remember after it happened I kind of took a break from going [to the facility].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to revise care plans for 10 of 17 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #14 and #17) residents reviewed for advanced directives, behaviors, and wounds. The findings include: 1. Review of the facility policy titled, Comprehensive Careplan, with a revision date of 10/24/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan shall describe, at a minimum .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Resident specific interventions that reflect the resident's needs and preferences . Review of the facility policy titled, Advanced Directives, with a revision date of 10/18/2021, revealed .The facility will honor the Advanced Directive as the resident wishes for future care and treatment .An Advance Directive is a written instruction given by the patient that either appoints another person to make health decisions for the resident or states the resident's health care preferences, or both .Any decision making will be documented in the resident's medical record and communicated to the interdisciplinary team . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Unspecified Intellectual Disability, Peripheral Vascular Disease, Type 2 Diabetes, Acute Embolism and Thrombosis of Deep Veins, Cellulitis, Urinary Tract Infection, Dementia, Schizoaffective Disorder, Bipolar Disorder, Dementia, Chronic Kidney Disease, Epilepsy, and Adult Failure to Thrive. Review of the Care Plan Report, with an effective date of 11/13/2022, revealed .Advance Directive .Honor [named Resident #1's] wishes during stay .Resident wishes will be honored . Review of a Physician's Orders for Scope of Treatment (POST) form dated 11/13/2022 revealed an order Do Not Attempt Resuscitation and Limited Additional Interventions. Resident #1's Care Plan did not reflect her actual Code status. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Gastroenteritis and Colitis, Urinary Tract Infection, Polyneuropathy, Adult Failure to Thrive, and Repeated Falls. Review of a POST form dated 8/8/2023 revealed an order Do Not Attempt Resuscitation and Comfort Measures Only. Resident #2's Care Plan did not reflect her actual Code status. 4. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Incomplete Quadriplegia, Disorder of Adult Personality and Behaviors, Chronic Pain Syndrome, Adjustment Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and Chronic Obstructive Pulmonary Disease. Review of the Care Plan Report, with an effective date of 11/23/2022, revealed .Advance Directive .Honor [named Resident #3's] wishes during stay .Resident wishes will be honored . Resident #3's Care Plan did not reflect his actual Code status. 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, Diabetes, Psychosis, Dementia, Mood Disorder, and Adult Failure to Thrive. Review of the Care Plan Report, dated 5/18/2023 and with a revision dated of 5/24/2023, revealed .Resident #5 exhibited wandering behavior with interventions implemented which included to redirect when wandering, prompt activity attendance to keep resident occupied, and monitor resident's location to ensure safety .Advance Directive .Honor [named Resident #5's] wishes during stay .Resident wishes will be honored . Resident #5's Care Plan did not reflect the intervention that he was not allowed on the 500 Hall without a staff escort and did not reflect his actual Code status Review of the GRIEVANCE RECORD, dated 5/24/2023, revealed Resident #14's mother was .Concerned with an admission in the facility during the last week that there is a history [symbol for with] her daughter & [and] family .Result of investigation .Agreed pt [patient] was not to visit [symbol for with] resident in the past. He is a patient now .Education [symbol for with] all staff male resident to not be on 500 hall or the room of pt [Resident #14's room number]. Patient will not be room on 500 hall .Comment from person filing grievance .he [Resident #5] better not be in her [Resident #14] room . Review of the Statement of In-service Training for Employees of [named facility], dated 5/24/2023, revealed . [Named Resident #5] is not to be allowed to enter 500 hallway at any time. [Named Resident #5] is to have no interaction with [named Resident #14] at any time no matter her location whether in lobby watching television or in her room . During an interview on 10/27/2023 at 11:29 AM, Certified Nursing Assistant (CNA) #7 confirmed that she was not aware that Resident #5 was not supposed to be on the 500 Hall without a staff member present. During an interview on 10/30/2023 at 11:48 AM, CNA #6 confirmed she usually worked the 500 Hall. CNA #6 was asked were there any residents who were not allowed on the 500 Hall. CNA #6 stated, I don't think so . During an interview on 10/30/2023 at 4:25 PM, ADON #1 confirmed Resident #5's Care Plan did not reflect that he was not allowed on the 500 Hall. ADON #1 was asked should that intervention be on his Care Plan. ADON #1 stated, I would think so. Observation and interview on 11/1/2023 at 1:55 PM, ADON #1, the Nurse Consultant, and the Surveyor reviewed the Resident Care Summary Assessment on the back of Resident #5's closet door. The intervention to escort the resident if he attempted to ambulate toward back lobby, halls, and dining room was not present on the Resident Care Summary Assessment. 6. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Chronic Respiratory Failure, Type 2 Diabetes, Hypertension, and Repeated Falls. Review of the Care Plan Report, with an effective date of 3/30/2023, revealed .Advance Directive .Honor [named Resident #7's] wishes during stay .Resident wishes will be honored . Resident #7's Care Plan did not reflect his actual Code status. 7. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Congestive Heart Failure, Acute Respiratory Failure, Anxiety, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of a POST form dated 2/22/2023 revealed an order Do Not Attempt Resuscitation and Comfort Measures Only. Resident #8's Care Plan did not reflect her actual Code status. 8. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Spinal Stenosis, Chronic Peripheral Venous Insufficiency, Chronic Ulcer of Skin, Chronic Kidney Disease, Atrial Fibrillation, Asthma, Anxiety Disorder, Morbid Obesity, and Embolism and Thrombosis Deep Vein Lower Extremity. Review of the Care Plan Report, with a revision date of 8/7/2023, revealed .Self care deficit R/T [related to] .bathing .hygiene .Bathing .per resident's preference .Hygiene .Monitor for skin integrity .at risk of further skin breakdown .Monitor skin integrity daily while providing care .Advance Directive .Honor [named Resident #9's] wishes during stay .Resident wishes will be honored . Resident #9's Care Plan was not revised to reflect maggots in her skin folds and did not reflect her actual Code status. Review of the POST form dated 8/14/2023, revealed an order for Do Not Attempt Resuscitation and Comfort Measures Only. Resident #9's Care Plan did not reflect her actual Code status. Review of the Clinical Note, dated 8/31/2023, revealed staff were bathing Resident #9 and observed larvae present on her skin. During a telephone interview on 11/1/2023 at 1:17 PM, CNA #8 stated, She [Resident #9] was one of my residents that day .the tech [other CNA ] she was sent from hospice the nurse that day was a male nurse .it was the 3 or us and we had went in there because she actually needed her wounds dressed .he [nurse] was trying to take care of her wounds .that's when I noticed the larvae moving on her .would have been her left leg we were holding, had her turned on her right side. CNA #8 was asked were there a lot of larvae present. CNA #8 stated, I would say it was a lot .I said stop .she has maggots crawling on her .He [LPN #10] said you're kidding me .he said I got to go out here and tell someone .I know the Administration people that work in the office were still there they all had met me in the hall asking me questions about did we give her a bed bath . During an interview on 11/2/2023 at 4:05 PM, Regional Nurse Manager #1 was asked was Resident #9's Care Plan revised to reflect the maggots in her skin folds. Regional Nurse Manager #1 reviewed Resident #9's Care Plan and stated, No ma'am, it's not on there. Regional Nurse Manager #1 confirmed Resident #9's Care Plan should have been revised to reflect there were maggots in her skin folds. 9. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Diabetes, Chronic Viral Hepatitis, Post Traumatic Stress Disorder, Schizophrenia, Pancreatitis, Cocaine Dependence, Nicotine Dependence, Bipolar Disorder, and Anxiety Disorder. Review of the Care Plan Report, dated 10/23/2023, revealed .Advance Directive .Honor [named Resident #10's] wishes during stay .Resident wishes will be honored . Resident #10's Care Plan did not reflect her actual Code status. 10. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Dysphagia, Paralytic Syndrome, Hepatitis C, Gastrostomy, and Diffuse Traumatic Brain Injury. Review of the Care Plan Report, with an effective dated of 3/22/2023 - Present, revealed .Advance Directive .Honor [named Resident #14's] wishes during stay .Resident wishes will be honored . Resident #14's Care Plan did not reflect her actual Code status. 11. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Nicotine Dependence, Diabetes, and Paranoid Schizophrenia. Review of the Care Plan Report, dated 5/17/2023, revealed .Advance Directive .Honor [named Resident #17's] wishes during stay .Resident wishes will be honored . Resident #17's Care Plan did not include interventions and did not reflect his actual Code status 12. During an interview on 11/15/2023 at 11:03 AM, the Director of Nursing (DON) was asked who is responsible for the Care Plans. The DON stated, Our whole IDT [Interdisciplinary Team] . [named the MDS Coordinator and myself] several of us enter information as it's needed .we review what's happened in the building and try to update it there with all of our team members . The DON was shown Resident #17's Care Plan and asked does his Care Plan reflect whether the resident is a full code or Do Not Resuscitate. The DON stated, On his Care Plan it will say we are following his wishes .have Care Plan books, actually our POST book, at each Nurses' Station and has everybody's POST form .on each hall. The DON confirmed the residents' care plan should reflect their current status. The DON was asked does the resident's care plans actually reflect their Code status. The DON stated, No, it just says that we will honor his wishes . During an interview on 11/15/2023 at 11:18 AM, when asked if the Comprehensive Care Plan included Resident #17's advance directive choices, the Risk Management Director reviewed the current Care Plan and stated, It don't say. I guess it means Full Code. Resident #17's advance directive choice was Do Not Attempt Resuscitation and Limited Additional Interventions. The DON confirmed the comprehensive Care Plan should reflect the residents' current status. The DON was asked did the Care Plan actually reflect the residents' code status. The DON stated, No, it just says that we will honor his wishes . During an interview on 11/15/2023 at 11:18 AM, when asked if the Comprehensive Care Plan included Resident #1's advance directive choices, Registered Nurse #1 reviewed the current Care Plan and stated, You can't tell by the Care Plan. You would have to look somewhere else. Does it mean Full Code? Resident #1's advance directive choice was Do Not Attempt Resuscitation and Limited Additional Interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment as evidenced by the odor of urine in the 500 Hall hallway and rusty and dirty over bed tables in 1 of 5 hallways (Hallway 500) observed. The findings include: 1. Review of the facility's policy, titled Residents Rights and Resident Responsibilities, with a revision date of 10/22/2022, revealed, . The resident has a right to a safe clean comfortable and home like environment . Based on review of the facility's undated Housekeeping Department Overview .Clean .areas that have odors .clean .over bed-tables .deep clean beds . Housekeeping Duties review .Clean and disinfect bedside tables , Housekeeping Outline (Job Responsibilities) review . Housekeepers should then begin cleaning their zone .doing a complete job . specific areas to be clean .patient room furniture . Before end of shift, all areas should be rechecked . Review of a Housekeeping/Laundry Supervisor job description dated on 11/23/2011 revealed, .implement, evaluate and direct the Housekeeping and Laundry Departments .Assist in housekeeping .Report all incidents .conditions or equipment to Administrator .Make routine rounds .monitor equipment . Review of an undated Maintenance Supervisor job description, .Conduct regular rounds of the facility to check all maintenance zones to ensure the quality control .and correct or report .damage to the Administrator . 2. Observation in room [ROOM NUMBER] A revealed the following: On 5/2/2023 at 10:35 AM revealed a plate of food. On 5/4/2023 at 10:32 AM revealed the over bed table had white food particles and the legs of the over the bed table was dirty and rusty. On 5/8/2023 at 4:16 PM revealed the top of the over bed table has a shiny, thick, sticky substance on it and the leg and the base of the over bed table was rusty and had a buildup of white grime. During an observation and interview in room [ROOM NUMBER] A, on 05/11/23 at 10:13 AM, the Maintenance Supervisor confirmed the base of the resident's over bed table was rusty and the top of the over bed table was dirty from spill of liquid. During an interview on 5/11/23 at 10:20 AM, in room [ROOM NUMBER] A, the Housekeeping Supervisor was asked if the top of the over bed table was dirty. The Housekeeping Supervisor stated, Yes and it is rusty. The Housekeeping Supervisor looked at the base of the resident's over bed table and stated, looks like a buildup of spills, it needs to be cleaned. During an observation and interview 05/11/23 at 10:24 AM, Housekeeper #1 confirmed that she had cleaned room [ROOM NUMBER] but, did not clean the over bed table. 3. Observations in the 500 Hall revealed the following: On 5/1/2023 at 11:55 AM, there was a strong odor of urine. On 5/8/2023 at 9:06 AM and 10:21 AM, there was a strong odor of urine. On 5/10/2023 at 7:49 AM and 9:50 AM, there was a strong odor of urine. 4. Observations in room [ROOM NUMBER] B revealed the following: On 5/1/2023 at 11:55 am, the room had a strong odor of urine. On 5/1/2023 at 3:30 PM, the room had a strong odor of strong urine and the top of the over bed table had food crumbs and a spilled substance lined around the edges. On 5/2/2023 at 11:20 AM, the over bed table was dirty with crumbs of food. On 5/2/2023 1:37 PM, the over bed table was dirty and had a dirty bowl and a cup with a white substance in it. On 5/2/2023 at 4:03 PM, the over bed table was dirty with a sticky, shiny substance and had the same dirty bowl and in the bottom of a dirty cup was a dried up white substance, and an empty [named] restaurant bag. On 5/4/23 at 10:23 AM, the over bed table had a dirty fork, crumbs of food, and a spilled substance that had a sticky, shiny film. On 5/8/2023 AT 10:45, on the top of the refrigerator was a plate of food with a roll, mashed potatoes, carrots, and a round red stained food item. The room had a strong odor of urine. On 5/10/2023 at 7:49 AM and 9:53 AM, there was a strong odor of urine. During an interview on 5/11/2023 at 9:00 AM, the Assistant Maintenance confirmed the maintenance department is in charge of the replacement on all equipment or furniture in the residents' rooms. During an interview on 5/11/2023 at 10:08 AM, in room [ROOM NUMBER] B the Maintenance Supervisor was asked to describe the over bed table. The Maintenance Supervisor stated, a rusty over the bed table. Confirmed the top of the over bed table had a round shaped stain on it and the edges of the over bed table was covered with a substance that had dried. 5. During an observation and interview on 5/11/2023 at 10:07 AM, in room [ROOM NUMBER] A, revealed stains on the over bed table. The Maintenance Supervisor confirmed the over bed table needed to be cleaned. 6. During an interview on 05/11/23 at 10:16 AM, in room [ROOM NUMBER] B, the Housekeeping Supervisor and the Maintenance Supervisor confirmed the base of the over bed table was rusty. During an interview on 05/11/23 at 10:17, in room [ROOM NUMBER] A, the Housekeeping Supervisor confirmed the base of the over bed had a buildup of dirt and needed to be cleaned. 7. During an interview on 5/11/2023 at 9:00, the Assistant Maintenance confirmed the maintenance department is in charge of the replacement on all equipment or furniture in the residents' rooms. During an interview on 05/11/23 at 9:23 AM, the Housekeeping Supervisor confirmed the housekeepers start cleaning the residents' rooms after breakfast, stop during the times that lunch is served to the residents, and back cleaning after lunch and the housekeepers stop working at until 2:45 PM. The Housekeeper Supervisor was asked what the housekeepers duties are. The Housekeeper Supervisor stated, Get garbage, clean sinks, toilets, bedside tables, over the bed tables, the bed and bed rails and if after 3pm, the CNAs are responsible for housekeeping. During an interview on 5/30/2023 at 1:37 PM, the Administrator (ADM) was asked who responsible to make rounds in the rooms to ensure that equipment does not need to be replaced. The ADM stated, Maintenance The ADM was asked who is responsible to make rounds in the rooms to ensure the residents' rooms are clean. The ADM stated, Housekeeping Supervisor. The ADM was asked should staff clean dirty over bed tables and remove dirty plates and utensils from the residents' rooms. The ADM stated, Yes. The ADM was asked, should rusty over bed tables be replaced. The ADM stated, repaired or replaced. The ADM was asked, should there be strong smell of urine in the hallway and in residents' rooms. The ADM stated, No, not lingering odor it needs to be for a short term. The ADM was asked, what should staff do when they smell strong urine in the hallway and a resident's room. The ADM stated, investigate and eliminate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, and interview, the facility failed to prevent misappropriation of resident's medication for 1 of 1 (Resident #20) residents reviewed for misappropriation. The findings include: 1. Review of the facility's Medication Administration: Controlled Medications, policy revised 10/24/2022 revealed, .Controlled substances are stored in a separate compartment of a non-automated dispensing system or other locked storage unit with access limited to approved personnel .All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways .on cart/cabinet/refrigerator are sent with a Controlled Drug Receipt/Record/Disposition form .once received .placed in the cart or cabinet and recorded on the Narcotic Control Record .Controlled Substances are stored under double lock until administered to the resident .The Medications delivered are recorded on the Narcotic Drug Record and stored in the controlled drug storage area by the nurse accepting delivery and a licensed witness .Controlled Drug Receipt/Record/Disposition forms are placed in the narcotic record book once verified with the medications and documented as such in the appropriate area on the form .Any discrepancies which cannot be resolved must be reported immediately .The DON, charge nurse, or designee must also report any loss of controlled substances when theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators .Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies . Review of the facility's Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, policy effective 9/20/2022 revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .to ensure proper .security .All drugs and biologicals will be stored in locked compartments ( .medication carts, cabinets, drawers, refrigerators, medication rooms) under proper .controls .Only authorized personnel will have access .Schedule II drugs and back up stock of Schedule III, IV, and V medications are stored under double lock and key .Any discrepancies which cannot be resolved must be reported immediately .a thorough investigation will be conducted in the event of a discrepancy in the count .Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted . 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Acquired Absence of Leg (Left Below the Knee Amputation), Hypertension, Depression, Benign Prostatic Hyperplasia, Peripheral Vascular Disease, and Chronic Obstructive Pulmonary Disease. Review of Skilled Nursing Visit Note, Plan of Care Narrative note dated 3/23/2023, revealed .Hospice admission .3/23/2023 .Terminal diagnosis .Peripheral vascular disease . Review of a Controlled Drug Receipt/Record/Disposition form dated 6/28/2023 revealed, .Date Dispensed .6/28/2023 .[for Resident #20] .OXYCODONE-APAP 7.5-325MG .Signature of Nurse receiving medication .[signatures of LPN #6 and LPN #7] .MISSING . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #20 was assessed with a Brief Interview for Mental Status score of 14, indicating Resident #20 was cognitively intact, required extensive assistance to total assistance with Activities of Daily Living, had Range of Motion Limitation (ROM) on 1 side of the lower extremities, incontinent of both bowel and bladder, and had active diagnoses of Peripheral Vascular Disease, Acquired Absence of Left Leg Below Knee, and Benign Prostatic Hyperplasia, and was receiving Hospice Services. Review of the undated Care Plan revealed .receiving Hospice Care .medications as ordered .Administer pain relieving medications as ordered by MD (Medical Doctor) .At risk for pain related to .has diagnosis of BKA (Below Knee Amputation), pressure ulcers .Administer medications as ordered .Monitor pain .Self-care deficit . Review of a Physician Order Sheet for July 2023, revealed an order start date of 5/30/2023 for Percocet (a highly addictive pain medication with generic name of oxycodone) 7.5 milligrams (mg)/325 mg tablet, take 1 tablet by mouth every 4 hours, as needed. During an interview on 7/26/2023 at 6:52 PM, LPN #3 stated, Did they tell y'all [you all] about the narcotic card that came up missing. LPN #3 stated that a #30 count oxycodone narcotic card came up missing, that (Name of LPN #6) was the nurse assigned to the hall on the night shift when the narcotic card was discovered missing. LPN #3 stated that LPN #6 got distracted with an emergency and left the #30 count oxycodone narcotic card unlocked, unattended, and in an unlocked and unsecured room. During an interview on 7/26/2023 at 8:10 PM, the ADON was asked if she was aware of the 30 count card of oxycodone 7.5mg/325mg narcotic card that was missing. The ADON stated the missing narcotic card occurred between the night of 6/28/2023 into the morning of 6/29/2023, she (ADON) received a call from LPN #6 between 5:00-5:30 AM the morning of 6/29/2023 informing that a #30 count narcotic sheet of oxycodone was missing. The ADON stated that LPN #6 and LPN #7 reconciled the medications with pharmacy at approximately 1:00 AM on 6/29/2023. The ADON stated that LPN #6 went back to the 400 hall charting room to check in the medications, got called away on an emergency, left the medications unsecured and unattended in the charting room, when LPN #6 returned to the charting room at approximately 2:00 AM, she (LPN #6) discovered the narcotic card was missing. The ADON stated LPN #6 should have signed in the medication and locked them in the narcotic box on the medication cart or in the medication room before stepping away. The ADON stated the missing narcotics belonged to Resident #20. The ADON stated she arrived at the facility on 6/29/2023 around 6:00 AM, and told staff to remain in the facility, started searching both inside and outside the facility, started drug testing staff, asked for permission to check belongings and vehicles, and obtain staff statements. The ADON confirmed she checked all staff belongings and vehicles except for LPN #7 who left before she could be drug tested. The ADON stated that CNA #10 (agency staff) left the faciity on 6/29/2023 between 2:00 AM - 3:00 AM to search for her missing cell phone and was called back to the facility to be tested and belongings searched. The ADON confirmed the missing #30 count oxycodone narcotic card was not found. The ADON stated when physicians prescribe medications, the medications are resident specific and when medications including narcotics are delivered to the facility they are resident specific. During an interview on 7/28/2023 at 10:34 AM, the Administrator stated the charting room was not locked and was accessible to anyone at any time before 7/27/2023, when a lock was placed on the door. During an interview on 7/28/2023 at 11:31 AM, the ADON confirmed that anyone could have had access to the charting room, where the narcotic card went missing. The ADON confirmed narcotics, or any other medications should never be left unsecured and unattended. During a telephone interview on 7/28/23 1:47 PM, LPN #6 confirmed she was the nurse working the 400 hall and in charge to log the medications in when the #30 count of oxycodone 7.5mg-325mg narcotic medication card was discovered missing on 6/29/2023. LPN #6 stated after receiving the medications from the pharmacy, she returned to the 400/500 hall, entered the charting room to check in the medications, and then CNA #10 entered the charting room and said her cell phone was missing. LPN #6 stated that she went to assist with CNA #10's phone search. LPN #6 stated she discovered the missing narcotic card at approximately 2:00 AM. LPN #6 confirmed the missing narcotic card belonged to Resident #20. During a telephone interview on 7/28/2023 at 4:42 PM, LPN #7 verified she was working 7p-7am on the front hall on 6/28/2023. LPN #7 stated she and LPN #6 counted medications with the pharmacy delivery driver on 6/29/2023 around 1:00 AM and then returned to their halls to put the medications into count. LPN #7 stated a short time after she went to her hall, she received a call from LPN#6 who told her she had a narcotic card missing. LPN #7 stated they immediately started looking for the missing narcotic card and the card was never found. During an interview on 7/31/2023 at 9:30 AM, Resident #20 was asked about hospice services and pain. Resident #20 confirmed he was receiving Hospice services. Resident #20 was asked if he received his pain medications as needed. Resident #20 stated he always gets his pain medications when requested. Resident #20 stated he was not informed that his Oxycodone narcotic medications was missing on 6/29/2023. During an interview on 7/31/2023 at 10:05 AM, the Medical Director stated the facility failed to inform him of the missing #30 count of oxycodone narcotic card and should have been informed of the missing narcotics on 6/29/2023. The Medical Director stated that when medication is ordered it is meant for the resident. The Medical Director was asked if this incident was considered theft misappropriation of a resident's property. The Medical Director stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure the Activities of Daily Living (ADL) for incontinent care, nail care, and bathing were provided for 2 of 20 sampled residents (Resident #57 and #266) reviewed for ADL care. The findings included: 1. Review of the facility's policy titled, Incontinence Skin Care Policy dated 9/13/2022, revealed .Residents who are incontinent will receive appropriate treatment and services . Review of the facility's policy titled, Activities of Daily Living (ADL) dated 3/9/2023, revealed A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good .hygiene . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes, Morbid (Severe) Obesity, and Weakness. Review of the quarterly assessment dated [DATE], revealed Resident #57 was cognitively intact, required 2 plus staff members for ADL care, required extensive assistance from staff for bed mobility, for personal hygiene, and for toileting, and was always incontinent of bowel and bladder. Review of the Care Plan dated 7/4/2022, revealed Resident #57 had .Self-care deficit R/T [Related To] .hygiene .with intervention .assist .incontinence .with intervention .clean and dry skin if soiled and wet . a. Observations in the Resident #57's room on 5/2/2023 at 1:37 PM and 3:30 PM, on 5/2/2023 at 11:20 AM, 1:37 PM, and 4:03 PM, on 5/8/2023 at 9:10 AM, 10:24 AM, and 4:10 PM, revealed Resident #57's fingernails had a buildup of a black substance under them. During an interview on 5/8/2023 at 10:57 AM, in the resident's room, the Director of Nursing (DON) confirmed Resident #57 had dirty fingernails. The DON stated, they are dirty, they need to be cleaned. b. Observations in the Resident #57's room on 5/8/2023 at 9:10 AM and 10:24 AM, revealed Resident #57 was soiled with urine and bowel. Approximately sixty percent (60%) of the resident's draw sheet (a sheet placed under the resident to assist with repositioning the resident) was soiled with a brown substance, the incontinent padding was completely soiled with urine and bowel movement, and the mattress was soiled with urine. Further observations revealed outside and inside of the resident's room was a foul odor of urine. During an interview on 5/8/2023 at 10:38 AM Licensed Practical Nurse (LPN) #2 was asked when the last time was someone looked in on Resident #57. LPN #2 stated, .at 8:00 am, after breakfast .I saw it [soiled draw sheet] at that time . LPN #2 confirmed Resident #57 was soiled with urine at 8:00 am, she asked a CNA at that time to provide incontinent care for Resident #57, and she did not return to the resident's room to ensure the incontinent care had been provided by the CNA. During an interview on 5/8/2023 at 10:39 AM in Resident #57's room, the DON was asked should Resident #57 lie soiled from lack of incontinent care for 2 hours, on a soiled incontinent brief without being cleaned. The DON stated, No, they should not let him lie wet The DON was asked what should be done if staff offer incontinent care and the resident refuses. The DON stated, they should notify the nurse and try again. c. Observations in the resident's room on 5/10/2023 at 7:49 AM and 9:53 AM, revealed Resident #57 was in bed lying on a soiled incontinent pad, soiled bed sheet and their fingernails were dirty. Further observation revealed Resident #57 was soiled from the top of their torso to the bottom of their groin and outside and inside of the resident's room was a foul odor of urine. 3. Review of the medical record revealed Resident #266 was admitted to the facility on [DATE] with diagnoses of Osteomyelitis, Congestive Heart Failure, Pleural Effusion, Cirrhosis, Atrial Fibrillation, and Chronic Kidney Disease. Review of the admission assessment dated [DATE] revealed Resident #266 had moderate cognitive impairment, required extensive assist with bed transfer, toileting, and personal hygiene. Further review revealed the resident was unable to transfer outside of room, had frequent episodes of incontinent of bowel and bladder, and received extensive assistance of staff with bathing. Review of the Care Plan dated 4/21/2023 revealed .Self-care deficit R/T [related to] ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers Bathing - Bath/Shower [Resident #266] 3 x [times] week/prn [as needed] .alternating days with bed baths . Review of the ADL Verification Worksheet dated 4/1/2023-4/30/2023, revealed there was no documentation Resident #266 received or refused baths/showers on the following dates: 4/6/2023, 4/7/2023, 4/8/2023, 4/16/2023, 4/17/2023, 4/18/2023, 4/19/2023, and 4/20/2023. During an interview on 5/17/2023 at 3:08 PM, the Assistant Director of Nursing confirmed there should be daily documentation of whether a resident received a bath or shower or refused to be bathed. During an interview on 5/17/2023 at 3:55 PM, the Administrator confirmed staff should document daily as to whether some form of bath was given or not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure a laboratory test and medication order was implemented for 2 of 5 (Resident #24 and Resident #57) sampled residents during review for unnecessary medications. The findings include: 1. Review of the facility's policy title, Lab, Radiology, and Other Diagnostic Services dated 1/1/2023, revealed .The facility shall provide or obtain radiology, lab, and other diagnostic services when ordered by a physician .The facility is responsible for timeliness of these services . Review of the facility's policy titled, Medication Administration, dated 10/24/2022, revealed .Medications shall be administered .per the Physician's Signed Order .medications shall be held for vitals outside of the physicians' prescribed parameters. The MD/NP [Medical Doctor/Nurse Practitioner] shall be notified . 2. Review of the medical record revealed Resident #24 admitted on [DATE] with diagnoses of Type 2 Diabetes Chronic Viral Hepatitis C, Post-Traumatic Stress Disorder, Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Pancreatitis, Seizures Schizoaffective, and Anxiety. Review of the quarterly assessment dated [DATE], revealed Resident #24 was cognitively intact, had Anxiety, Diabetes, Hypertension, and Seizures. Review of a Pharmacy Review dated 2/23/2023, revealed CARBAMAZEPINE [a medication to prevent and control seizures] 100 mg BID [two times per day] for seizures. Periodic monitoring of serum carbamazepine level is recommended as well as liver function tests with carbamazepine Please review and consider checking carbamazepine and LFT's [Liver Function Test] every six months . Review of Resident #24's lab results for 3/2023 and 4/2023 revealed no Carbamazepine levels and no liver function panel results. During an interview on 5/11/2023 at 1:19 PM, the Assistant Director of Nursing (ADON) stated, the nurse should have put the order in for the lab but did not until 5/2/2023. The ADON confirmed the facility's physician agreed to the recommendation of a serum carbamazepine level and a liver function test every six months on 2/28/2023. 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes Morbid (Severe) Obesity, Obstructive Sleep Apnea, Anxiety, and Weakness. Review of the quarterly assessment dated [DATE] revealed Resident #57 was cognitively intact, had diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and received Insulin 7 of 7 days. Review of the Care Plan dated 7/4/2022 revealed .Type 2 diabetes .with intervention .medications as ordered .Monitor blood sugar levels per MD order and notify MD of abnormal findings as indicated. Review of the signed Physician Order for April 2023 revealed and order dated 2/20/2023, Glucose GeL 40 % [ product is used to treat low blood sugar levels] oral gel (1 tube) GEL (GRAM) Oral Notes: If blood sugar is <70 mg/dl [milligrams per deciliter] .Repeat blood sugar check in 15 minutes and if still <70 mg/dl, Repeat Glucose 40% Gel/Orange Juice with Sugar/or Glucagon. Recheck Blood sugar in 15 mins .Notify MD/NP . Review of the April 2023, Medication Administration Record (MAR) revealed Resident #57's blood sugar level on 4/5/2023 was 30 mg/dl, the provider's order for Glucose Gel to be administered if the resident's blood sugar was less than 70 mg/dl and to notify the Physician or Nurse Practitioner was not followed. Review of the Nurses Notes revealed no documentation that the provider had been notified on 4/5/2023 of Resident #57's blood sugar level of 30. During an interview on 05/11/23 at 1:26 PM, the Assistant Director of Nursing confirmed that Resident #57's blood sugar was 30 on 4/5/2023, no glucose gel was given, the insulin should not have been given, and the provider was not notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, observations, and interview, the facility failed to ensure a safe environment, provide supervision, and oversight to prevent potential accidents and injuries for 4 cognitively impaired residents who reside on the secure unit and who were assessed for having wandering behaviors (Resident #83, #7, #71, and #94) when a white substance identified as methamphetamine (a highly addictive illegal drug) was found by facility staff in Resident #83's room on 6/24/2023 and again on 6/28/2023. On 6/24/2023 at approximately 11:00 AM, the Director of Nursing (DON) was cleaning and found a crystallized white powdery substance rolled up in a $1 dollar bill, later identified as methamphetamine, in the closet of the unoccupied side of Resident #83's room. Four (4) days later on 6/28/2023, 2 white crystallized rock formed substances, in a box labeled baking soda (later identified as methamphetamine), was found in the top of Resident #83's closet with the resident's belongings. The facility's failures placed 4 cognitively impaired residents who resided on the unit and who were assessed for wandering in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Regional Nurses were notified of the Immediate Jeopardy (IJ) for F-689, during the Revisit and complaint investigation on 7/26/2023 at 7:27 PM, in the Training Room. The facility was cited Immediate Jeopardy at, F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy began on 6/24/2023 and is ongoing. The findings include: 1. Review of the facility's Drug and Alcohol Policy revised 3/2022, revealed, .the company is committed to the elimination of unlawful drug and alcohol use and abuse in the workplace .Whenever employees are working .are present on company premises or are conducting company-related work .they are prohibited from .Using, possessing, buying, selling, manufacturing, distributing, or dispensing an illegal drug (to include possession of drug paraphernalia) .any illegal drugs or drug paraphernalia will be turned over to an appropriate law enforcement agency and may result in criminal prosecution . Review of the facility's Elopement and Wandering Patients, with an effective date of 6/21/2022, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents . 2. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE], with diagnoses of Altered Mental Status, Alzheimer's Disease, Dementia, Depression, Anxiety, Mood Disorder, and Cognitive Communication Deficit. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #83 was assessed with a Brief Interview for Mental Status score of 00, indicating the resident was severely cognitively impaired, and had an active diagnoses of Cognitive Communication Deficit and Delusional Disorder. Review of the Care Plan revised 3/6/2023, revealed .Confusion, alteration in his thought process related to .dementia . has exhibited Wandering behavior .maintain safe .environment . Observation of the 100 hall on 7/18/2023 at 3:00 PM, revealed Resident #83 ambulating up and down the hall, stopping and peering into other resident rooms and entering into room [ROOM NUMBER] and laying on the A side bed. Observation of the 100 hall on 7/21/2023 at 3:30 PM, revealed Resident #83 ambulatory in the hallway standing in the door and peering into Resident #6's room , with Resident #6 yelling for staff to come get him, Resident #83 then walks away and enters into room [ROOM NUMBER] and lays on the bed. Observation of the 100 hall on 7/24/2023 at 9:00 AM, revealed Resident #9 and #94 ambulating up and down the hallway, and Resident #83 laying on the A side bed in room [ROOM NUMBER]. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Intracranial Injury, Depression, Reduced Mobility, Dementia, Psychotic Disturbance, Epilepsy, and Dysphagia Review of the admission MDS dated [DATE], revealed Resident #7 was severely cognitively impaired and was assessed with wandering that significantly impacts and intrudes privacy or activity of others. Review of Resident #7's Care plan revealed, .exhibited Wandering behavior. Intrudes others' space/rooms, rummages thru their personal belongings. 5/24/2023 Noted wandering and getting in another resident's bed . 4. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with the diagnoses of Parkinson's Disease, Neurocognitive Disorder, Unsteadiness on Feet, Delusional Disorder, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #71 was assessed with a BIMs of 1, indicating Resident #71 was severely cognitively impaired, and with wandering behaviors that significantly intrude on the privacy or activities of others. Review of Resident #71's Care plan effective 6/2/2023, revealed, .wanders w/o (without) elopement attempts . 5. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Parkinson's Disease, Dementia, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #94 was assessed as severely cognitively impaired, short and long term memory loss, having wandering behaviors and assessed with active diagnoses of Alzheimer's, Dementia, and Anxiety. Review of the Care plan dated 1/23/2023 revealed Resident #94 was care planned with wandering behaviors with redirection and alteration in thought process related to Dementia. 6. Review of the facility's investigation dated 6/24/2023 revealed the following: a. A drug detection test (conducted by a police officer) dated 6/24/2023, confirmed the white substance found in Resident #83's room was Meth/Amphetamine. b. A handwritten statement dated 6/24/2023 and signed by the RN Supervisor at the time, revealed a small bag with a dollar bill and napkin, when opened it, a crystal-like substance fell out, contained it in a rubber glove. Called the ADON (Assistant Director of Nursing), called the police, spoke with officer, he came and took it for testing; did sweep entire building; tested all staff on hall . c. A handwritten statement dated 6/24/2023 revealed Laundry Staff #1, Housekeeping Staff #2, LPN #4, Certified Nursing Assistant (CNA) #5, CNA #6, and the Director of Nursing (DON), who was the RN Supervisor at the time, were all drug tested. d. 100 hall, 200 hall, 300 hall, 400 hall and 500 hall were all searched. 7. Review of the facility's investigation dated 6/28/2023 revealed the following: a. A drug detection test (conducted by a police officer) dated 6/28/2023, confirmed the white substance found in Resident #83's room was Meth/Amphetamine. b. An unsigned handwritten statement dated 6/28/2023, revealed, LPN#6, CNA #8, CNA #3, Housekeeper #3, LPN #11, RN #1, Dietary aide #1, and [NAME] #1 were drug tested on [DATE]. c. The DON provided an unsigned handwritten statement dated 6/28/2028, that reflected the 100 hall, 200 hall, 300 hall, 400 hall and 500 halls had all been searched. d. A unsigned separation notice for CNA #9. 8. During an interview on 7/21/2023 at 1:47 PM, Licensed Practical Nurse (LPN) #1 was asked has there ever been a report of illegal substances found in the facility. LPN #1 stated, .I heard that it occurred .I was told that a nurse was cleaning up a room .when cleaning out the closet in a resident's room, they found a small bag that they thought was methamphetamine, called police and turned over [the small bag thought to be methamphetamine] to them. LPN #1 was asked who found the substance. LPN #1 stated, [Name of RN Supervisor at the time] .it was her who found it in [room of Resident #83] . During an interview on 7/21/2023 at 2:03 PM, the DON confirmed that an illegal substance was found on the 100 hall in Resident #83's room closet on 6/24/2023. The DON confirmed that the police were called, tested the illegal substance and the substance was identified to be methamphetamine. The DON confirmed that a building sweep [search of the facility] was conducted on 6/24/2023, and only staff working on the 100 hall and staff who came onto the 100 hall, at the time the methamphetamine was found, were drug tested. The DON was asked how you know if anyone else went down that hall other than the staff you tested. The DON confirmed that the investigation was complete. The DON confirmed that no residents had been drug tested as a result of the illegal substance found on the 100 hall on 6/24/2023 and again on 6/28/2023. During an interview on 7/21/2023 at 2:08 PM, the Administrator confirmed an illegal substance had been found on the 100 hall on 6/24/2023. The Administrator confirmed that it was reported to law enforcement. The Administrator confirmed she only drug tested staff that worked that hall or staff that would have had to enter that hall on that date when the drugs were found. During an interview on 7/24/2023 at 9:00 AM, LPN#2 was asked if they were aware of an incident where an illegal substance identified as methamphetamine was found on the 100 hall. LPN #2 stated, Which time. LPN #2 was asked if finding an illegal drug in the facility had occurred more than once. LPN #2 stated, You will have to ask management about that. LPN #2 was asked what room the illegal substance was found in the second time. LPN #2 stated, .I was told it was the same room [Resident #83's room] . During an interview on 7/24/2023 at 9:00 AM, RN #1 confirmed the resident on the A side bed in room [ROOM NUMBER] was Resident #83, and Resident #83 was the only resident in the room. RN #1 confirmed Resident #83 wanders into other rooms and lay on the bed and staff has to redirect him often. RN #1 confirmed Resident #83 is confused, has severe cognitive impairment, and unable to make decisions for himself. RN #1 confirmed that Residents#7, #9, #71, and #94 are wanderers and wander into other resident's rooms. During an interview on 7/24/2023 at 9:15 AM, the Administrator confirmed no police report was available, and the facility did not drug test any residents related to the 6/24/2023 and 6/28/2023 incidents when the drugs were found in Resident #83's room. The Administrator further stated no residents were tested or assessed to ensure the residents did not come into contact with the illegal substances found on 6/24/2023 and 6/28/2023. Continued interview with the Administrator revealed only the staff assigned on the 100 hall and staff that would have gone onto the hall were drug tested. The Administrator confirmed the DON was the nurse on the 100 hall that found the illegal substance. The Administrator confirmed there were no witness statements included in the facility's investigation. The Administrator confirmed she did not notify Resident #83's family when the illegal substance was found his room. During an interview on 7/24/2023 at 10:04 AM, the ADON stated the DON called her and informed her that an illegal substance was found on Saturday 6/24/2023, before lunch time. The ADON stated on 6/24/2023, the DON (RN Supervisor at the time) was cleaning out a closet in a resident's room on the 100 hall and found a bag in a box of baking soda that she thought may have been methamphetamine. The ADON confirmed she informed the Administrator, and the Administrator informed her to instruct the nurse to call law enforcement. Continued interview with the ADON revealed on 6/24/2023, law enforcement retrieved the substance, tested it, and determined it was methamphetamine. The ADON stated on 6/24/2023, only staff who worked the 100 Hall and staff who would have been in that hall at the time of the 6/24/2023 incident were drug tested. Continued interview with the ADON revealed the ADON could not verify that all staff that entered the 100 Hall unit on 6/24/2023 had been drug tested. The ADON confirmed she was unsure if any written statements were obtained. The ADON confirmed that Residents #71, #83, and #94 have wandering behaviors and reside on the 100 Hall where the methamphetamine drugs were found. During an interview on 7/24/2023 at 11:09 AM, the Administrator stated the facility does not have a visitors log and has no means of determining who enters the building or who visits on the 100 hall but did confirm Resident #83 does not have visitors. During an interview on 7/24/2023 at 11:15 AM, the DON confirmed that the facility has no cameras and there is no way to know fully who may come onto the 100 hall. During an interview on 7/24/2023 at 11:24 AM, the Police Officer confirmed that he responded to a call at the facility on 6/24/2023 at approximately 1:09 PM, and a call on 6/28/2023 at approximately 1:20 PM, related to unknown substances that were found in a resident's closet. The Police Officer confirmed the substance had been tested by him and was identified as methamphetamine. The Police Officer confirmed that he reported the results to the DON on 6/24/2023 and called the results back to the Administrator on 6/28/2023. The Police Officer stated he was told the substance was found in the closets of the same room on both 6/24/2023 and 6/28/2023. During a telephone interview on 7/24/2023 at 12:19 PM, the Medical Director confirmed he was informed on 6/24/2023 and on 6/28/2023 when an illegal substance was found in the facility and was aware the illegal substance was methamphetamine. During an interview on 7/24/2023 at 4:17 PM, LPN #4 stated she was the nurse working 6 AM-6 PM shift on the 100 hall on 6/24/2023 when the illegal substance was found. LPN #4 stated the DON was cleaning out an empty closet in Resident #83's room, came to the 100 hall medication cart with a plastic bag containing a folded dollar bill, a crystal substance, and a crushed white substance. LPN #4 stated CNA #6 stated that looks like meth, she (LPN #4) instructed CNA #6 to go wash her hands and to put on some gloves to clean it up. LPN #4 confirmed the DON took the plastic bag off the hall and made some phone calls. LPN #4 confirmed no other staff other than the staff who came on to the 100 hall were drug tested. LPN #4 confirmed that she was told by the DON that the substance was methamphetamine. LPN #4 confirmed she was not in serviced or educated on what to do if the staff find illegal substance in the facility. LPN #4 confirmed Resident #83 wanders throughout the unit. LPN #4 confirmed she did not notify Resident #83's family of the illegal substance found in the closet in his room. LPN #4 confirmed that when working on the 100 hall and busy with residents, she is not aware of who enters the hall. LPN #4 confirmed she was unaware that the same illegal substance was found 4 days later on 6/28/2023 in the same room in a closet. During an interview on 7/24/2023 at 4:36 PM, CNA #8 confirmed residents on the 100 hall wander into other residents' room on the 100 hall. CNA #8 confirmed she worked 6 AM to 6 PM shift on 6/24/2023 and had a work assignment on the 100 hall. CNA #8 confirmed the illegal substance was found in Resident #83's room in the closet. CNA #8 confirmed the DON (RN Supervisor at the time of the 6/24/2023 incident) found it, they thought it was a dollar bill at first because it was wrapped in a dollar bill. CNA #8 confirmed she was working on the 300 hall when the found it on 6/28/2023. During an interview on 7/24/2023 at 4:56 PM, the DON confirmed an illegal substance was found on 6/24/2023 by herself (the RN Supervisor at the time) and again 4 days later on 6/28/2023 by CNA #9 and another CNA the DON was unable to confirm. The DON stated there were no in-services or education provided to the staff on bringing illegal substance onto the facility property when the illegal substance was found on 6/24/2023 or 6/28/2023. The DON confirmed the illegal substance found on 6/24/2023, was in the A side closet (unoccupied side) in Resident #83's room and the same illegal substance found on 6/28/2023, was found in the B side closet that was occupied with Resident #83's belongings. During an interview on 7/25/2023 at 9:36 AM, CNA #6 confirmed she was assigned to the 100 hall when the illegal substance was found on Saturday, 6/24/2023. CNA #6 confirmed the DON came out into the hall and stated she found a plastic bag with a dollar bill rolled up in it in a box of baking soda. CNA #6 confirmed the DON opened it and a white crystal substance fell out. CNA #6 confirmed it was found in the unoccupied A side closet of Resident #83's room. CNA #6 confirmed no in services or education was provided on what to do if the staff find what appears to be illegal substances in the facility. CNA #6 stated Resident #83 wanders on the unit, in out of other resident rooms. CNA #6 further stated the 100 hall has several wandering residents that include Resident #71 and Resident #94. CNA #6 confirmed that when staff is busy they do not always know who comes onto the hall. CNA #6 confirmed that staff come on the hall, go to the supply room for supplies, nurses are giving medications, CNAs are giving baths and taking care of residents, and sometimes there is no way to know who is coming on the hall. During an interview on 7/25/2023 at 11:44 AM, LPN #5 stated she was working the 100 hall on 6/28/2023 when the 2nd occurrence of an illegal substance was found. LPN #5 stated the illegal substance was found in Resident #83's room in the B side closet that contained the resident's belongings. LPN #5 stated CNA #3 and CNA #9 took Resident #83 to his room because he was soiled, was looking for clothes in his closet, and CNA #3 saw a box of baking soda with a tissue hanging out from the box. LPN #5 confirmed CNA #3 opened the tissue and found a hard rock like substance and immediately reported it. LPN #5 confirmed that she witnessed 2 rock like substances in the tissue, instructed CNA #3 to wash her hands, and notified the Risk Manager. LPN #5 was asked if the 100 hall had wandering residents that go in and out of rooms or go through others' belongings. LPN #5 confirmed that the presence of an illegal substance is a safety issue and a concern, the LPN stated Resident #83 is confused, not cognitively intact, and pilfers in other resident rooms. LPN #5 stated there was no increased monitoring of vital signs or change in condition was put into place for the wandering residents who may have had access to the illegal substance. LPN #5 confirmed she did not notify Resident #83's family or any other resident families residing on the 100 hall. LPN #5 confirmed that she doesn't always know when staff or visitors come onto the 100 hall if she is busy taking care of residents. During an interview on 7/25/2023 at 1:28 PM, the Director of Regional Nurses confirmed she was notified on 6/24/2023, when the illegal substance was found on the A side closet in Resident #83's room on the 100 hall. The Director of Regional Nurses stated she was notified by the Administrator on 6/24/2023, reporting a suspicious substance had been found, gave the directive to remove it, call the police, search the facility and initiate drug testing. The Director of Regional Nurses confirmed only the staff assigned to the 100 hall and staff who may have gone onto the 100 hall were drug tested. The Director of Regional Nurses confirmed the DON was the RN Supervisor at the time the illegal substance was found on 6/24/2023. The Director of Regional Nurses confirmed that the building was searched including the B side closet in Resident #83's room. The Director of Regional Nurses confirmed she was present in the facility on 6/28/2023, the 2nd time an illegal substance was found. The Director of Regional Nurses confirmed that CNA #3 and #9 were in Resident #83's closet looking for clothes when they saw a paper sticking up out of a baking soda box, immediately took it to LPN #5, and she (Director of Regional Nurses) and the Risk Manager went onto the hall, removed the paper towel and called law enforcement. The Director of Regional Nurses confirmed no residents were drug tested or assessed for the potential exposure to the illegal substance. The Director of Regional Nurses confirmed she was not aware if family members had been notified. The Director of Regional Nurses confirmed no staff from the 6p-6a or 7p-7a on 6/23/2023 or 6/27/2023 were drug tested or interviewed related to the illegal substance. The Regional Director of Nurses was asked what interventions were put into place to ensure resident safety related to illegal substance being brought into the facility. The Director of Regional Nurses stated, I think our problem was taken care of (when (CNA #9 refused to be tested) because we are making rounds and have found no more since the 28th. The Regional Director of Nurses was asked how the facility is ensuring resident safety. The Director of Regional Nurses stated, Staff know to report any suspicious substance and activity, to report those things, continue room sweeps as part of safety round we are doing. The Director of Regional Nurses confirmed that rounding was already in place as part of the Plan of Correction for the recertification survey but they added the step to look for suspicious contents to the rounding. The Director of Regional Nurses confirmed no resident monitoring was put into place on 6/24/2023 or 6/28/2023 related to the finding of the illegal substance. During an interview on 7/25/2023 at 3:20 PM, the Administrator confirmed an illegal substance determined to be methamphetamine was found in Resident #83's closet on the 100 hall in the B side closet on 6/28/2023 around lunch time. The Administrator confirmed CNA #3 and CNA #9 found a piece of tissue sticking out of a baking soda box and took it to the nurse. The Administrator confirmed that on 6/28/2023, the illegal substance was found in the same room that it was found in on 6/24/203, but in the opposite closet, on the B side. The Administrator confirmed the B side closet was occupied by Resident #83's belongings. The Administrator confirmed the facility did not notify Resident #83's family. The Administrator confirmed that only staff members that worked the 100 hall and who were known to frequent the hall were tested on both 6/24/23 and 6/28/2023. The Administrator confirmed residents were not assessed to ensure they had not come into contact with the illegal substance. The Administrator was asked to review the investigations for 6/24/2023 and 6/28/2023 and was asked if this was a complete investigation. The Administrator stated, Yes, we instructed staff to look for any suspicious items and our daily rounds are ongoing. The Administrator confirmed no education had been provided related to illegal substances on facility property regarding the 6/24/23 or 6/28/2023 incidents. The Administrator confirmed no family had been notified regarding the illegal substances found on 6/24/2023 or 6/28/2023. The Administrator confirmed there are no cameras in the facility and no visitor sign in logs to indicate who enters the facility or the 100 hall. During an interview on 7/25/2023 at 6:04 PM, CNA #3 confirmed she was working the 100 hall on 6/28/2023 when the illegal substance was found in Resident #83's closet. CNA #3 confirmed that she and CNA #9 were in the resident's closet looking for clothes when they noticed tissue sticking up from out of a box of baking soda. CNA #3 confirmed they took the tissue down to the nurse and gave it to her. CNA #3 confirmed they told LPN #5 that they found the suspicious substance in the top of Resident #83's closet while looking for his clothes. CNA #3 confirmed CNA #9 refused to be drug tested and walked out of the facility. CNA #3 confirmed she received no education or in-services on illegal substances in the facility. __________________________________________________________________________ A third onsite revisit survey was conducted on 8/14/2023 to 8/16/2023 to validated the Allegation of Compliance (AoC) IJ Removal Plan, received on 8/1/2023 with an IJ Removal date of 7/28/2023, for previous deficiency F-689 cited at a scope and severity of J on 7/31/2023. The surveyor verified the AOC Removal Plan through record review, audit reviews, review of education and sign-in sheets, observations, and interviews for the immediate corrective actions listed below: The Medical Director was notified of the immediate jeopardy citation regarding F689 on 7/26/23 by the Administrator. The Surveyor verified and validated onsite through interview with staff and the Medical Director. All residents were assessed by the Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, and Unit Manager on 7/26/23 for changes in clinical conditions related to the potential ingestion of highly addictive drug substance (illicit substances). No negative findings reported. The Surveyor verified and validated onsite through record review and interview with staff . The Drug and Alcohol Policy and Accident and Supervision Policy was reviewed on 07/26/23 by the Administrator, Regional Director of Operations, Regional Nurse Managers, Assistant [NAME] President of Clinical Services/Quality. No revisions to the policies were recommended at this time. The Surveyor verified and validated onsite through policy review and interview with staff. Signs were placed on entrance doors by the Assistant Director of Nursing, Staffing Coordinator, and Unit Manager on 7/26/23 alerting No illicit substances are permitted on the premises. The Surveyor verified and validated onsite through observation and interview with staff. Resident #83 was assessed by the Medical Director on 7/27/23 with no negative findings. The Surveyor verified and validated onsite through record review and interview with staff. All other residents in the facility were assessed by the Medical Director on 7/27/23 with no negative findings. The Surveyor verified and validated onsite through record review, interview with staff and the Medical Director. An event note for Resident #83 was completed by the Assistant Director of Nursing on 7/27/23 for the unusual event on 6/24/23 and 6/28/23. Family member was notified of the unusual event(s) on 7/27/23. The Surveyor verified and validated onsite through medical record review and interview with the ADON and Patient Representative. A search of facility premises was conducted on 7/27/23 by Director of Nursing, Assistant Director of Nursing, Risk Management Nurse, Unit Manager, Staffing Coordinator, MDS Coordinator, and Maintenance Supervisor for illicit or suspicious substances. No illicit or suspicious substances were found. The Surveyor verified and validated onsite through review of facility search sheets and interview with staff. The environmental/safety committee was revised on 7/27/23 to include: Administrator, Maintenance Supervisor, Housekeeping/Laundry Personnel, Dietary Manager, Director of Nursing or Assistant Director of Nursing, Activity Director, and Social Services. The committee will meet weekly to conduct environmental rounds to include monitoring for illicit substances. Environmental rounds, to include monitoring for illicit substances will be weekly and have assigned persons. The assigned areas are 100, 200, 300, 400 and 500 Hall resident rooms, all other areas that are not resident rooms to include, but not limited to, supply rooms, storage rooms, kitchen, food pantry, utility rooms, janitorial rooms, dining rooms, common areas, and outside grounds. Forms in attachments. Permission to search resident rooms will be obtained prior to search. The Surveyor verified and validated onsite through review of Environmental / Safety Committee weekly minutes with committee members signatures and assigned rounding sheets and interview with staff members. A visitor log was developed by the Regional Nurse Manager on 7/27/23 and placed in the front lobby. Visitors will be encouraged to sign in upon entry to the facility. The requested information requested on the log includes, date, visitor name, time in, time out and, who/where visiting. Form in attachments. The Surveyor verified and validated onsite through observation of the visitor logs and interview with staff. A Resident Council meeting is scheduled for 7/28/23 by the Social Service and Activity Director regarding: reporting unusual/suspicious substances or activities located on facility premises. The Surveyor verified and validated onsite through review of Resident Council Minutes and interview with staff and residents. A checklist was developed by the Regional Nurse Manager on 7/27/23 to aide in the implementation of interventions in regard to identification of illicit substances. The checklist will be initiated by the Charge Nurse upon discovery of illicit substance(s) and completed by Nursing Management (Director of Nursing, Assistant Director of Nursing, Risk Manager, Staffing Coordinator, Unit Manager or Administrator.) The Checklist will assist with directing the staff in investigation and effective interventions if illicit substances are identified. Form in attachments. The Surveyor verified and validated onsite through review of the checklist and interview with staff. Staff question initiated by Regional Nurse Management on 7/27/23 - Do you have any knowledge of any persons bringing suspicious/illicit substances &/or alcoholic beverages or having suspicious activity including recent former employees? No one answered in the affirmative of the above question. The Surveyor verified and validated onsite through review of the printed questionnaire, staff answers and signatures and staff interviews. General Signs & Symptoms of Impairment related to substance use in employees and Signs and symptoms of impairment related to substance use and/or exposure in residents were posted in the nurse charting rooms by the Regional Nurse Manager on 7/27/23. The Surveyor verified and validated onsite through observation and staff interviews. Education was initiated by the Director of Nursing for employees on 7/26/23 regarding the facility Drug and Alcohol policy. Education completion will be documented and verified per the Inservice Record by the Administrator, Director of Nursing and Assistant Director of Nursing. After initiation of drug and alcohol policy on 7/26/23 by inservice record, it was added to Relias on 7/27/23 and assigned to all staff for further completion. The Surveyor verified and validated onsite through review of in-services, review of Relias training roster, and interview with staff. Education was initiated in the Relias Learning System with all staff on 07/27/23 by the Administrator to employees in reference to the Drug and Alcohol Policy. Education completion will be verified per Relias course completion record by the Administrator, Director of Nursing, and Assistant Director of Nursing. Agency Staff and facility staff prior to returning to work will be educated in person or verbally via phone at the beginning of the shift by the Administrator, Director of Nursing, Assistant Director of Nursing, Risk Manager, Unit Manager, or Charge Nurse regarding the Drug and Alcohol Policy. Education completion will be documented and verified per the Inservice Record by the Administrator, Director of Nursing, Assistant Director of Nursing, or Risk Manager. The Surveyor verified and validated onsite through review of in-service record and signature sheets, working schedules and assignment sheets, Relias staff training rosters and assignments, and staff interviews. Education was initiated with Licensed Clinical S[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 6 staff members (Registered Nurse (RN #1) and Licensed Practical Nurse (LPN #1) failed to perform hand hygiene. RN #1 failed to perform hand hygiene after providing incontinent care and before medication administration. LPN #1 failed to perform hand hygiene after the disposal of bloody biohazard products. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 3/1/2023, revealed .Perform hand hygiene after removing gloves .Before preparing or handling medications after handling clean or soiled dressings, linens .After handling items potentially contaminated with blood, body fluids, secretions, or excretions .After assistance with personal body functions . Review of the facility's policy's titled, Infection Prevention and Control Program, dated 10/24/2022, revealed .Staff shall perform hand hygiene before and after performing resident care procedures . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes Morbid (Severe) Obesity, Obstructive Sleep Apnea, Anxiety, and Weakness. Review of the assessment dated [DATE] revealed Resident #57 was cognitively intact and had Heart Failure, Diabetes, and Depression. a. Observation on 5/8/2023 at 10:49 AM in Resident #57's room, revealed RN #1 provided incontinent care, removed her gloves, and did not wash her hands before administering medication to Resident #57. During an interview on 5/8/2023 at 11:20 AM, RN #1 was asked if she should have removed her gloves and washed her hands, after performing incontinent care and before administering medication . RN #1 stated, Yes. b. Observation on 5/8/2023 at 11:21 AM in Resident #57's room, revealed LPN #1 placed blood soiled linen in a biohazard bag and placed the biohazard bag in the biohazard room. Observation on 5/8/2023 at 11:26 AM, revealed LPN#1 did not wash her hands after she placed the biohazard bag in the biohazard room. During an interview on 11:29 AM, LPN #1 was asked should she have washed her hands after handling biohazard products. LPN #1 stated, Yes, I should have. 3. During an interview on 5/8/2023 at 11:30 AM, the Director of Nursing confirmed staff should perform hand hygiene after incontinent care, before medication administration, and after handling blood soiled linen. 1. Review of the facility's policy titled, Hand Hygiene, dated 3/1/2023, revealed .Perform hand hygiene after removing gloves .Before preparing or handling medications after handling clean or soiled dressings, linens .After handling items potentially contaminated with blood, body fluids, secretions, or excretions .After assistance with personal body functions . Review of the facility's policy's titled, Infection Prevention and Control Program, dated 10/24/2022, revealed .Staff shall perform hand hygiene before and after performing resident care procedures . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes Morbid (Severe) Obesity, Obstructive Sleep Apnea, Anxiety, and Weakness. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status score of 15, indicating intact cognition, had Heart Failure, Diabetes, and Depression. a. Observation on 5/8/2023 at 10:49 AM in Resident #57's room, revealed RN#1 provided incontinent care, removed her gloves, and did not wash her hands before administering medication to Resident #57. During an interview on 5/8/2023 at 11:20 AM, RN#1 was asked if she should have removed her gloves and washed her hands, after performing incontinent care and before administering medication . RN #1 stated, Yes. b. Observation on 5/8/2023 at 11:21 AM in Resident #57's room, revealed LPN #1 placed blood soiled linen in a biohazard bag and placed the biohazard bag in the biohazard room. Observation on 5/8/2023 at 11:26 AM, revealed LPN#1 did not wash her hands after she placed the biohazard bag in the biohazard room. During an interview on 11:29 AM, LPN #1 was asked should she have washed her hands after handling biohazard products. LPN #1 stated, Yes, I should have. 3. During an interview on 5/8/2023 at 11:30 AM, the Director of Nursing confirmed staff should perform hand hygiene after incontinent care, before medication administration, and after handling blood soiled linen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to inform of and provide written information regarding residents' rights to formulate an advanced directive for 11 of 20 residents (Residents #8, #22, #24, #43, #47, #54, #57, #60, #79, #259, and #260) sampled for advanced directives. The findings include: 1. Review of the facility's policy titled, Advance Directives, with a revision date of 10/18/2021, revealed An Advance Directive is a written instruction given by the patient that either appoints another person to make health decisions for the resident or states the resident's health care preferences, or both .The facility representative will discuss and provide written information explaining the Advance Directive Program upon admission to the facility . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses Obsessive Compulsive Personality Disorder, Paranoid Personality Disorder, and Paraplegia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview, to recall, and made decisions regarding tasks of daily life at a modified independent level, had some difficulty in new situations. Review of the medical record revealed Resident #8 had no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and Seizures. Review of the quarterly MDS dated [DATE] revealed Resident #22 had short-term and long-term memory problem. Review of Resident #22's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 4. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Diabetes, Post-Traumatic Stress Disorder, Chronic Obstructive Pulmonary Disease, Hypertension, and Seizures. Review of the quarterly MDS dated [DATE], revealed Resident #24 had a BIMS score of 15, indicating intact cognition. Review of Resident #24's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 5. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of Bipolar Disorder, Dementia, and Non-traumatic Brain Dysfunction. Review of the admission MDS dated [DATE], revealed Resident #43's BIMS score of 14, indicating intact cognition. Review of Resident #43's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 6. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of Pneumonia, Acute Embolism, Altered Mental Status. Review of the admission MDS dated [DATE], revealed Resident #47 had a BIMS score of 5, indicating severe cognitive impairment. Review of Resident #47's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 7. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Aphasia, and Cerebral Hemorrhage. Review of the quarterly MDS dated [DATE] revealed Resident #54 had short-term and long-term memory problem. Review of Resident #54's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 8. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Obstructive Sleep Apnea, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 BIMS score of 15, indicating intact cognition. Review of Resident #57's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 9. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with of diagnoses Dementia, Huntington's Disease, Psychotic Disorder, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #60 had a BIMS score of 15, indicating intact cognition. Review of Resident #60's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 10. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Chronic Respiratory Failure, Dysphagia, and Anxiety. Review of the MDS dated [DATE], revealed Resident #79 had a BIMS score of 12, indicating moderately impaired cognition. Review of Resident #79's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 11. Review of the medical record review revealed Resident #259 was admitted to the facility on [DATE] with diagnoses of Hypotension, Schizophrenia, Epilepsy, Hallucinations, and Intellectual Disabilities. Review of the admission MDS dated [DATE], revealed Resident #259 had a BIMS score of 10, indicating moderately impaired cognition. Review of Resident #259's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 12. Review of the medical record revealed Resident #260 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Pain, Nicotine Dependence, Depression, and Insomnia. Review of the admission MDS dated [DATE] revealed Resident #260 had a BIMS score of 12, indicating moderately impaired cognition. Review of Resident #260's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or their legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 13. During an interview on 5/17/2023 at 9:27 AM, the Regional Nurse Consultant, was asked should all residents have the advanced directive education explained to them on admission. The Regional Nurse Consultant stated, Yes ma'am . During an interview on 5/25/2025 at 5:56 PM, the Administrator confirmed all residents should be educated, offered and/or have an Advance Directive and proof of the resident's refusal or the resident's Advance Directive should be in the resident's medical record.

Based on policy review, medical record review, observation, and interview, the facility failed to promote and maintain residents' dignity when staff failed to provide a privacy bag for 2 of 6 sampled residents (Resident #40 and #53) reviewed with indwelling urinary catheters. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 5/24/2021, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity .Maintain resident privacy . Review of the medical record, revealed Resident #40 had diagnoses of Urinary Tract Infection, Diabetes, Pressure Ulcer Sacral Region, Pressure Ulcer Buttock, and Neuromuscular Dysfunction of Bladder. Review of the Physician's Order dated 4/25/2021, revealed Resident #40 had an indwelling urinary catheter. Review of the Care Plan dated 5/4/2021, revealed .[Named Resident #40] needs catheter related to Neurogenic Bladder .Keep drainage bag covered to promote dignity . Observation in the resident's room on 6/21/2021 at 11:24 AM, 2:53 PM, and 3:44 PM, revealed Resident #40 was lying in the bed, her urinary catheter bag was hanging on the left side of the bed, facing the door, uncovered, with amber colored urine. Review of the medical record, revealed Resident #53 had diagnoses of Neurogenic Bladder, Severe Obesity, Chronic Respiratory failure, Heart Failure, Diabetes, Bipolar Disorder, and Anxiety Disorder. Review of the Physician's Order dated 6/7/2021, revealed Resident #53 had an indwelling urinary catheter. Review of the Care Plan dated 2/17/2021, revealed .[Named Resident #53] needs catheter related to Neurogenic Bladder .Keep drainage bag covered to promote dignity . Observation in the resident's room on 6/21/2021 at 11:13 AM and 12:59 PM, revealed Resident #53 was resting in bed, his urinary catheter bag was hanging on the right side of the bed facing the door, and the urinary catheter bag was uncovered. During an interview on 6/23/2021 at 9:11 AM, the Director of Nursing (DON) was asked if indwelling urinary catheter should bags be covered. The DON stated, Yes .should be in the privacy bags.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a sanitary environment for 2 of 85 resident rooms (Resident #9's and #52's rooms) when there were sheets with yellow and brown stains, a wheelchair with brown stains, a washcloth with brown stains, and odors in the rooms. The findings include: Observation in the resident's room on 6/21/2021 at 10:36 AM and 1:05 PM, revealed Resident #52 was lying in bed on his left side, the bottom sheet was noted with a large amount of yellow and brown stains and a foul odor. Resident #52 had a large brown stain smeared across the right side of the seat of his wheelchair, from the front to the back, and a washcloth with a large brown stain and a foul odor, was in the crease of the wheelchair seat. Observation in the resident's room [ROOM NUMBER]/22/2021 at 10:18 AM, revealed Resident #52 was lying in bed on his left side, the bottom sheet was noted with a large amount of yellow and brown stains and a foul odor. Resident #52 had a large brown stain smeared across the right side of the seat of his wheelchair, from the front to the back. During an interview on 6/22/2021 at 10:19 AM, the Director of Nursing (DON) confirmed that the large brown stains on Resident #52's bed sheet and wheelchair were feces. The DON confirmed that the sheet and wheelchair should not have feces on them. Observation in the resident's room [ROOM NUMBER]/21/2021 at 3:20 PM, revealed Resident #9 was resting in bed and his bottom sheet was noted with a large amount of yellow and brown stains. Observation in the resident's room on 6/22/2021 at 10:34 AM, revealed Resident #9 was out of the room and the bottom bed sheet was noted with a large amount of yellow and brown stains. During an interview on 6/22/2021 at 10:36 AM, the DON confirmed that Resident #9's sheets should not have brown and yellow stains. The DON confirmed that the residents' sheets should be changed daily and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, when plastic cutlery was not provided for 1 of 2 sampled residents (Resident #65) reviewed for accident hazards. The findings include: Review of the facility's policy titled, Accidents and Supervision, revised 3/20/2020, revealed .The resident environment remains as free of accident hazards as is possible .This includes .Identifying hazard(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s) .using specific interventions to try to reduce a resident's risks from hazards in the environment .Communicating the interventions to all relevant staff . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Dementia with Lewy Bodies, Abdominal Aortic Aneurysm, Mood Disorder, Psychotic Disorder, and Cognitive Communication Deficit . Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #65 had severe cognitive impairment and was coded for wandering behaviors and behaviors that put others at risk for injury. Review of a Clinical Note dated 5/15/2021 at 5:52 PM, revealed .wandering in and out of other residents room .room [ROOM NUMBER] .sat down on A beds [bed's] side in chair with a butter knife trying to cut the bed cord .two techs [technicians] entered the room .removed the knife .he pulled a spoon out of his pocket .staff was able to remove pt [patient] [Resident #65] and spoon/knife out of room .pt is to have plasticware from now on . Review of the Care Plan dated 5/20/2021, revealed .Plasticware to be used at meals . Observation in the resident's room on 6/21/2021 at 1:00 PM, 6/22/2021 at 8:03 AM and 5:44 PM, and on 6/23/2021 at 8:45 AM, revealed Resident #65 was lying in bed, awake with a vacant stare, his meal tray was on the over bed table, and silverware was on the table beside the meal tray. Observation and interview in the resident's room on 6/23/2021 at 8:48 AM, the Assistant Director of Nursing (ADON) confirmed Resident #65 had silverware on his tray. The ADON confirmed she was unaware of the Clinical Note stating Resident #65 should have plastic ware. During an interview on 6/23/2021 at 12:24 PM, the ADON stated, He [Resident #65] is supposed to have plastic [ware] and I am starting my education now. The ADON was asked when she was made aware that Resident #65 should have plastic ware. The ADON stated, When you told me.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification, review of resident trust funds, and interview, the facility failed to provide an appropriate notice to the resident and/or legal representative in writing when skilled services were terminated for 1 of 3 sampled residents (Resident #65) reviewed and failed to refund the residents' funds within 30 days of death or discharge for 5 of 5 sampled residents (Resident #186, #189, #190, #191, and #193) reviewed for trust funds. The findings include: Review of the facility's policy titled, RESIDENT TRUST ACCOUNT PROCEDURES MANUAL, dated 8/2018, revealed .all refunds must be made within 30 days of discharge or expiration . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Dementia, Chronic Obstructive Pulmonary Disease, Mood Disorder, and Psychotic Disorder. Review of the SNF Beneficiary Protection Notification revealed .Last day of Part A service [DATE] .Was the NOMNC [Notice of Medicare Non-Coverage/Beneficiary Protection Notification] provided to the resident? No . During an interview conducted on [DATE] at 8:14 AM, the Business Office Coordinator confirmed that a NOMNC should have been provided to Resident #65 or his representative, but the facility failed to provide it. Review of medical record, revealed Resident #186 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed that no check had been issued. Review of medical record, revealed Resident #189 was admitted [DATE] and expired on [DATE]. Review of the trust funds revealed that no check had been issued. Review of medical record, revealed Resident #190 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed that no check had been issued. Review of medical record, revealed Resident #191 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed a check was not issued until [DATE], greater than 30 days after Resident #191 expired. Review of medical record, revealed Resident #193 was admitted [DATE] and expired on [DATE]. Review of the trust funds revealed that no check had been issued. During an interview conducted on [DATE] at 4:28 PM, the Business Office Coordinator stated, .[Named Resident #186] he has a balance .I did not realize that he had a refund .I have not gotten his processed .he expired 1/6 [2021] .[Named Resident #189] expired on 2/7 [2021] .it was sent out for approval on 6/11 [2021] .[Named Resident #190] .expired on 4/5 [2021] .sent in to request a check on 6/11 [2021] .[Named Resident #191] .expired 1/1 [2021] .refund was 5/25 [2021] .[Named Resident #193] .expired on 5/16 [2021] .balance of $2534.82 has not been refunded yet . The Business Office Coordinator confirmed that the residents' families or representatives should have received a refund within 30 days of the residents' discharge or death.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner when 3 of 13 staff (Certified Nursing Assistant (CNA) #1, #4 and #6) failed to don appropriate Personal Protective Equipment (PPE) and perform hand hygiene during dining. The findings include: Review of the facility's policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy & [symbol for and] Protocol, 5/20/2021, revealed .REQUIRED TRANSMISSION BASED PRECAUTIONS .The required PPE is a gown, gloves, N95 face mask [a safety device that covers the nose and mouth and helps protect the wearer from breathing in hazardous airborne substances] or procedure mask, goggles or a face shield . Review of the facility's policy titled Hand Hygiene, dated 3/15/2021, revealed .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed .Between resident contacts .Before applying and after removing personal protective equipment (PPE), including gloves .Before and after providing care for residents in isolation . Observation on the 500 Hallway during dining on 6/21/2021 at 12:10 PM, revealed CNA #4 did not wash her hands and entered Resident #74's room, placed the plate on the over bed table, exited the room, and did not wash her hands. CNA #4 entered Resident #37's room, placed the plate on the over bed table, did not wash her hands, exited the room and entered Resident #52's room, placed the plate on the over bed table, and did not wash her hands. Observation on the 500 Hallway during dining on 6/21/2021 at 12:24 PM, revealed CNA #4 removed a cup from the nourishment cart with her bare hand, and holding the cup in her bare hand, she scooped some ice from the ice chest into the cup. CNA #4 then entered Resident #1's isolation room without donning the proper PPE. Observation on the 200 Hallway on 6/22/2021 at 5:42 PM, revealed Resident #236, #237, and #238 had signs on the door of their rooms that revealed, Droplet Precautions Everyone Must .Make sure their eyes, nose and mouth are fully covered before room entry. Observation on the 500 Hallway on 6/22/2021 at 5:43 PM, revealed CNA #6 entered an isolation room with a gown, gloves, and mask. CNA #6 failed to wear a face shield during the dining observation. Observation on the 200 Hallway on 6/22/2021 at 5:45 PM, revealed CNA #1 wore a surgical mask, donned a gown and gloves, failed to don appropriate protective eye wear, and then entered Resident #237's room to prepare for meal service. Observation on the 200 Hallway on 6/22/2021 at 5:50 PM, revealed CNA #1 wore a surgical mask, donned a gown and gloves, failed to don appropriate protective eye wear, and entered Resident #237's room with his meal tray. CNA #1 removed her PPE and washed her hands, exited the room, and went across the hall to Resident #236's room. CNA #1 donned a gown and gloves, failed to don appropriate protective eye wear, and entered Resident #236's room with his meal tray. CNA #1 removed her PPE, performed hand hygiene and went down the hall to Resident #238's room. CNA #1 donned a gown and gloves, failed to don appropriate protective eye wear, and entered Resident #238's room with her meal tray. Observation on the 500 Hallway on 6/22/2021 at 6:31 PM, revealed CNA #4 was standing in the hallway during dining when she touched a resident on the shoulder, did not wash her hands, and entered Resident #56's room, placed a meal tray on the over bed table, and did not wash her hands. Observation on the 500 Hallway on 6/22/2021 at 6:59 PM, revealed CNA #6 donned a gown and gloves, entered Resident #1's isolation room, and failed to don appropriate protective eyewear during the dining observation. During an interview on 6/22/2021 at 7:05 PM, CNA #4 confirmed that she should not have scooped the ice into a cup with her bare hands. CNA #4 confirmed that she should have washed her hands or used hand sanitizer between each resident. CNA #4 confirmed that when she touched a resident or contaminated her hands, she should have performed hand hygiene. CNA #4 confirmed that she should have donned her gloves, gown, mask and face covering before going into an isolation room. During an interview on 6/23/2021 at 9:11 AM, the Director of Nursing (DON) confirmed that the staff should perform hand hygiene or sanitize their hands between each resident during dining observation. The DON confirmed that the staff should don their PPE (gloves, mask, face shield and gown) outside the residents' room when a resident is in isolation. During an interview on 6/23/2021 at 8:00 PM, the Assistant Director of Nursing (ADON) confirmed that staff should not enter the room of a resident in Droplet Precautions without protective eye wear. The ADON confirmed that personal prescription eyeglasses were not considered appropriate protective eye wear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure appropriate infection control practices were followed when 2 of 6 nurses (Licensed Practical Nurse (LPN) #1 and #2) failed to don appropriate Personal Protective Equipment (PPE) in isolation rooms, an indwelling catheter bag was on the floor for 1 of 6 sampled residents (Resident #53) reviewed with indwelling urinary catheters, and a contaminated oxygen tubing was reconnected, a bi-level positive airway pressure (BIPAP) tubing was lying on the floor, and the BIPAP mask was uncovered for 1 of 5 sampled residents (Resident #53) reviewed receiving oxygen therapy. The findings include: Review of the facility's policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy & [symbol for and] Protocol, revised 5/20/2021, revealed .REQUIRED TRANSMISSION BASED PRECAUTIONS .The required PPE is a gown, gloves, N95 face mask [a safety device that covers the nose and mouth and helps protect the wearer from breathing in hazardous airborne substances] or procedure mask, goggles or a face shield . Review of the medical record, revealed Resident #1 was admitted on [DATE] with diagnoses of Hypertension, Chronic Respiratory Failure, Staphylococcus Aureus, Asthma, Morbid Obesity, Diabetes, and Gastroparesis. Review of the Physician's Orders dated 6/22/2021 revealed an order for isolation precautions for Methicillin-Resistant Staphylococcus Aureus (MRSA) in the sputum. Review of the Nurses' Note dated 6/21/2021, revealed .droplet isolation . Observation and interview of Resident #1's room on 6/21/2021 at 10:32 AM, revealed the door was open, with an isolation cart hanging on the door, no isolation sign was posted on the outside of the door, and multiple isolation gowns were hanging on the bed, furniture and back of the door. One isolation gown was lying on the floor. LPN #1 was at the bedside wearing a surgical mask and gloves. LPN #1 stated, .She is in contact isolation . Observation and interview of Resident #1's door on 6/21/2021 at 4:40 PM, with the Assistant Director Of Nursing (ADON), revealed an isolation cart hanging on the door with 1 pair of green goggles present. The ADON confirmed that the goggles should be cleaned after each use and that staff should not share goggles. The ADON confirmed that the staff should don their gown, gloves, mask, and face covering before entering the resident's room. Review of the medical record, revealed Resident #53 had diagnoses of Neurogenic Bladder, Severe Obesity, Chronic Respiratory Failure, Heart Failure, Diabetes, Bipolar Disorder, and Anxiety Disorder. Review of the Physician's Order dated 6/7/2021, revealed Resident #53 had an indwelling urinary catheter. Observation in the resident's room on 6/21/2021 at 11:13 AM and 12:59 PM, revealed Resident #53 was resting in the bed, his urinary catheter bag with was hanging on the bed, with approximately 400-500 ml of dark amber urine, and the bottom half of the urinary catheter bag was lying on the floor. The floor was covered with a large amount of unknown white, flaky particles (that appeared to be dry skin). The resident's BIPAP tubing was lying on the floor and the BIPAP mask was lying on the over bed table uncovered. Observation in the resident's room on 6/22/2021 at 8:53 AM, revealed Resident #53's oxygen tubing was disconnected, and the end of the tubing that connects to the oxygen concentrator was lying on the floor. Resident #53 activated the call light, CNA #4 entered the room, and reconnected the contaminated oxygen tubing to the concentrator. Observation on the 100 Hallway on 6/22/2021 at 5:28 PM, during medication pass, revealed LPN #2 donned gown & gloves and stated, .He's [Resident #60] been vaccinated so this is just precautionary for both of us . LPN #2 entered Resident #60's room without eye protection. (Resident #60 was on the observation hall for new admissions where residents remain in droplet precautions for 14 days after admission). During an interview on 6/21/2021 at 4:32 PM, the ADON confirmed staff should wear masks, gowns, gloves, and face shield or goggles when entering a Droplet Isolation room. During an interview on 6/23/2021 at 9:11 AM, the Director of Nursing (DON) confirmed indwelling urinary catheter bags should not be touching the floor. The DON confirmed that the BIPAP mask should be covered, the BIPAP tubing should not be touching the floor, and the oxygen tubing should not be reconnected after it has been contaminated.