**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure the call light was in reach for 1 resident (Resident #7) of 52 residents observed for call light accessibility. The findings include: Review of the facility's policy titled, Answering the Call Light, dated 3/2021, showed .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #7 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Anxiety, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident was moderately cognitively impaired and required substantial/ maximum staff assistance with personal hygiene. Review of Resident #7's comprehensive care plan revised 4/2/2024, showed .Resident has need for extensive to total care related to .decreased functional status .call light within reach . During an observation and interview on 4/8/2024 at 9:50 AM, in Resident #7's room, showed Resident #7 was seated in a reclining chair with her call light clipped to the privacy curtain. Further observation showed Resident #7's call light was out of her reach. Resident #7 stated when she needed help from the staff, she used her call button to alert them. Further interview showed Resident #7 did not know where her call light was located. During an observation and interview on 4/8/2024 at 9:52 AM, in Resident #7's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #7's call light was not within the resident's reach and was not accessible for the resident's use. During an observation and interview on 4/9/2024 at 10:25 AM, in the resident's room, with Certified Nursing Assistant (CNA) #1, showed Resident #7 was seated in a reclining chair with the call light draped over the side of the bed. Further observation showed the resident's call light was out of her reach and not accessible for use. CNA #1 stated the call light is supposed to be within the resident's reach and confirmed the call light was not accessible to Resident #7. During an interview on 4/10/2024 at 1:05 PM, the Director of Nursing (DON) stated it was the facility's expectation when residents are in the bed or sitting up in the chairs in their rooms, the call lights would be in their reach and available for use. DON confirmed the facility failed to ensure the call light was accessible for Resident #7's use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide a resident with information regarding a resident's right to formulate an advanced directive upon admission to the facility for 1 resident (Resident #3) of 18 residents reviewed for advanced directives. The findings include: Review of the facility policy titled Advance Directives, revised 12/2016, showed .Upon admission, the resident will be provided with written information .to formulate an advance directive . Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Review of Resident #3's Advanced Directive Acknowledgement form showed the resident nor the resident representative had not signed the form upon the resident's admission to the facility on 7/14/2023. During an interview on 4/10/2024 at 8:22 AM, the Admissions Director stated Resident #3 nor the resident's representative was provided information regarding the right to formulate an advanced directive upon the resident's admission to the facility on 7/14/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure appropriate notifications were conducted following a resident fall for 1 resident (Resident #454) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Assessing Falls and Their Causes, revised 3/2018, showed .Notify the following individuals when a resident falls .The resident's family .The Attending Physician .The Director of Nursing Services .The Nursing Supervisor on duty . Resident #454 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Depression with Psychotic Features, Anxiety, Hypotension, and Urinary Tract Infection. Review of a Progress Note dated 1/27/2024 at 8:44 PM, showed Resident #454 was .ambulatory with a mostly steady gait, transfers herself numerous times and is at a high safety risk for all ADL's [activities of daily living] related to her severe cognitive decline related to her progressing Lewy Body Dementia [dementia that leads to a decline in thinking, reasoning, and independent function] . Review of a Fall Risk Acuity dated 1/27/2024, showed Resident #454 had a Fall Risk Score of 24, which indicated the resident was at risk for falls. Review of a Brief Interview for Mental Status assessment dated [DATE], showed Resident #454 was moderately cognitively impaired. Review of Resident #454's Progress Note dated 1/30/2024 at 1:56 AM, showed the resident was found on the floor in the doorway of her room. Further review showed there was no documentation to indicate the resident's physician, nurse practitioner (NP), Director of Nursing (DON), or the resident's family representative were notified of the resident's fall. Review of Resident #454's history and physical note dated 1/30/2024 at 2:51 PM, showed no documentation to indicate the Nurse Practitioner was notified of Resident #454's fall on 1/30/2024. Review of Resident #454's event report dated 1/30/2024, showed the resident had an unwitnessed fall with no injuries on 1/30/2024 at 1:00 AM. Continued review showed .NOTIFICATIONS .Physician Notified: No .Resident Representative Notified: No . During an interview on 4/10/2024 at 8:45 AM, the DON stated staff were expected to notify the physician, DON, and family representative of a resident's fall with or without injury. The DON stated .even during the night .some [staff] will wait until the morning if there is no injury .I've told them [staff] not to do that . The DON confirmed Resident #454's physician, family, and the DON were not notified of the resident's fall on 1/30/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of a daily room cleaning check off sheet, observations, and interviews the facility failed to maintain a safe, clean, homelike environment for 6 residents (Residents #30, #25, #50, #3, #35, and #17) on 1 of 4 hallways observed. The findings include: Review of the facility's policy titled, Homelike Environment, revised 2/2021, showed .Residents are provided with a safe, clean .and homelike environment .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized, homelike setting .The characteristics include .clean, sanitary .environment . Review of an Environmental Services/Housekeeping Daily Room Cleaning Check-Off sheet undated, showed .Toilet Cleaned .Floors Mopped . Resident #30 was admitted to the facility on [DATE] with diagnoses including Diabetes, Schizophrenia, Anxiety Disorder, and Depression. During an observation on 4/8/2024 at 8:05 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was missing. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. During an observation on 4/9/2024 at 7:50 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. During an observation on 4/10/2024 at 8:00 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. Resident #25 was admitted to the facility on [DATE] with diagnoses including Fracture of Femur, Acute Kidney Failure, Dementia, and Repeated Falls. Resident #50 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, Hypertension, and Cognitive Communication Deficit. During an observation on 4/8/2024 at 8:10 AM, showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. During an observation on 4/9/2024 at 7:55 AM, showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. During an observation on 4/10/2024 at 8:23 AM, showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension. During an observation on 4/8/2024 at 8:15 AM, showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint and there was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. During an observation on 4/8/2024 at 8:05 AM, showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint and there was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. During an observation on 4/10/2024 at 8:29 AM, showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint and there was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. Resident #35 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Chronic Pain, and Major Depressive Disorder. During an observation on 4/8/2024 at 8:30 AM, showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. During an observation on 4/9/2024 at 8:40 AM, showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. During an observation on 4/10/2024 at 8:30 AM, showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Psychosis, Anxiety Disorder, and Chronic Pain. During an observation on 4/8/2024 at 8:35 AM, showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. During an observation on 4/9/2024 at 8:48 AM, showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. During an observation on 4/10/2024 at 8:36 AM, showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. During an observation and interviews on 4/10/2024 at 8:37 AM, with the Assistant Administrator (AA), Housekeeping Director (HD), and the Maintenance Director (MD) showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint. There was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. The AA, HD, and MD confirmed Resident #'3 room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:40 AM, with the AA, HD, and MD showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. The AA, HD, and MD confirmed Resident #25 and #50's room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:44 AM, with the AA, HD, and MD showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was missing. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. The AA, HD, and MD confirmed Resident #30's room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:48 AM, with the AA, HD, and MD showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. The AA, HD, and MD confirmed Resident #17's room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:53 AM, with the AA, HD, and MD showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. The AA, HD, and MD confirmed Resident #35's room was not maintained in a safe, clean, homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #20 was admitted to the facility on [DATE] with Heart Failure, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. Review of Resident #20's current physician order dated 2/29/2024, showed .Eliquis 2.5 mg take one by mouth twice daily . Review of a quarterly MDS assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Further review showed the MDS did not include an anticoagulant medication. During an interview on 4/10/2024 at 9:10 AM, the Registered Nurse (RN) MDS Coordinator stated Resident #20 received an anticoagulant medication and confirmed the anticoagulant medication was not captured accurately on the quarterly MDS assessment dated [DATE]. Resident #14 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Venous Thrombosis (blood clot). Review of Resident #14's current physician order dated 8/26/2023, showed .Eliquis 5 mg take one by mouth twice daily . Review of a quarterly MDS assessment dated [DATE], showed Resident #14 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired and the active diagnosis list did not include diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. Further review showed Resident #14 did not take an anticoagulant medication. During an interview on 4/10/2024 at 8:10 AM, the RN MDS Coordinator stated Resident #14 received an anticoagulant medication and had active diagnoses of Depression, Anxiety, and Bipolar Disorder. The RN MDS Coordinator confirmed the anticoagulant medication and the active diagnoses of Depression, Anxiety, and Bipolar Disorder was not accurately captured on the quarterly MDS assessment dated [DATE]. Based on review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 Residents (Resident #31, #20, and #14) of 10 Residents reviewed for anticoagulant use, and failed to accurately capture active diagnoses for 1 resident (Resident #14) of 18 resident reviewed for accurate MDS assessments. The findings include: Review of the RAI Version 3.0 Manual, Chapter 3, dated 10/2023, showed .Anticoagulant [medication used to prevent blood clotting] .Which may or may not require laboratory monitoring .should be coded on MDS .during the 7-day look-back period .code if taking and indication noted .if the item was used . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolism, Benign Prostatic Hyperplasia, Diverticulitis, and Depression. Review of Resident #31's current physician order dated 1/5/2024, showed .Eliquis (anticoagulant medication) 2.5 mg [milligram] take one by mouth twice daily . Review of a quarterly MDS assessment dated [DATE], showed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review showed the MDS did not include an anticoagulant medication. During an interview on 4/9/2024 at 3:50 PM, Licensed Practical Nurse (LPN) MDS Coordinator stated Resident #31 received an anticoagulant medication. LPN MDS Coordinator confirmed the anticoagulant medication was not captured accurately on the quarterly MDS assessment dated [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan to include a colostomy (a surgical procedure which places a hole in the abdominal wall which allows waste to leave the body) for 1 resident (Resident #31) of 18 residents reviewed for care planning. The findings include: Review of the facility's policy titled, CARE PLAN POLICY, dated 12/2016, showed .A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed .for each resident .person centered care plan will .incorporate identified problem areas .reflect the residents expressed wishes regarding care and treatment goals .reflect currently recognized standards of practice for problem areas and conditions . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolism, Benign Prostatic Hyperplasia, Diverticulitis, Depression, and Dementia with Behavioral Disturbance. Review of an admission Minimum Data Set (MDS) dated [DATE], showed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact, required moderate assistance for activities of daily living (ADLs), and had an ostomy (colostomy). Review of Resident #31's comprehensive care plan revised 3/28/2024, showed the facility had not developed a care plan related to the resident's colostomy. Review of Resident #31's current physician orders dated 4/2024, showed .change colostomy and provide colostomy care . During an interview on 4/9/2024 at 3:50 PM, the Unit Manager confirmed Resident #31's colostomy was not identified on the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to revise a comprehensive care plan to reflect a new fall intervention for 1 resident (Resident #14) of 18 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, showed .care plans are revised as information about the residents and the residents' conditions change . Resident #14 was admitted to the facility on [DATE] with diagnoses including Abnormalities of Gait and Mobility, Muscle Weakness, and Need for Personal Care. Review of a post fall investigation dated 2/16/2024, showed Resident #14 was reaching for a drink and fell onto the floor from the bed. The immediate fall intervention was to remove the air mattress from the bed and place a regular mattress on the bed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitively impaired and was dependent upon staff assistance for transfers. Further review showed Resident #14 had a fall since admission. Review of Resident #14's comprehensive care plan revised 4/5/2024, showed .Alternating air mattress .At risk for fall related injury related to: mobility impairments .previous fall hx [history] . During an observation and interview on 4/9/2024 at 11:10 AM, in the resident's room, showed Resident #14 had a regular mattress applied to the bed. Resident #14 stated the air mattress was removed from the bed after his last fall (2/16/2024). During an interview on 4/10/2024 at 8:45 AM, the Unit Manager (UM)/LPN MDS Coordinator stated Resident #14's immediate fall intervention implemented on 2/16/2024 was to remove the resident's air mattress from the bed and to apply a regular mattress to the resident's bed. The UM/LPN MDS Coordinator stated it was the facility's expectation to update the care plan after fall interventions are implemented. The UM/LPN MDS Coordinator confirmed Resident #14's care plan had not been updated to reflect the fall intervention to remove the air mattress from the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interviews, the facility failed to ensure resident medications were secured in a locked location for 1 resident (Resident #30) of 2 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Storage of Medications, revised 9/2020, showed .Drugs and biologicals used in the facility are stored in locked compartments .Only persons authorized to prepare and administer medications have access to locked medications .nursing staff is responsible for maintaining medication storage and preparation areas . Review of the facility policy titled, Administering Medications, revised 4/2019, showed .No medications are kept on top of the cart .the cart must be .inaccessible to residents or others passing by . Resident #30 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Schizophrenia, and Anxiety Disorder. During an observation on 4/9/2024 at 8:55 AM, Licensed Practical Nurse (LPN) #2 prepared medications for Resident #30 in the medication room. LPN #2 left the medication room, the medication cart was left in the medication room, and the medication door was not locked. The LPN left a 473 ml (milliliter) bottle of Valproic Acid 250mg (milligram)/5mL liquid, approximately ¼ full, on top of the medication cart. The LPN walked away from the medication cart, went across the hall and administered medications to Resident #30. The medication cart was not visible to LPN #2. During an interview on 4/9/2024 at 9:05 AM, LPN #2 confirmed she left a 473 ml bottle of Valproic Acid, approximately ¼ full, on top of the medication cart unsecured. During an interview on 4/10/2024 at 8:24 AM, the Director of Nursing stated it was the facility's expectation for medications to be secured and locked.

Based on review of the facility's Payroll Based Journal (PBJ) report dated 10/1/2023-12/31/2023, daily nursing staff posting sheets, time clock punches, and interviews, the facility failed to provide the minimum requirement of 8 hours per day of Registered Nurse (RN) coverage on 20 days reviewed on the PBJ report and 12 days reviewed on 1/1/2024-4/10/2024 (not a PBJ report). The findings include: Review of the facility's PBJ dated 10/1/2023-12/31/2023 showed the following dates with no RN coverage: 10/7/2023 (Saturday), 10/14/2023 (Saturday), 10/15/2023 (Sunday), 10/29/2023 (Sunday), 11/4/2023 (Saturday), 11/5/2023 (Sunday), 11/12/2023 (Sunday), 11/18/2023 (Saturday), 11/26/2023 (Sunday), 12/2/2023 Saturday), 12/10/2023 (Sunday), 12/24/2023 (Sunday), and 12/31/2023 (Sunday). Review of the facility's daily staffing posting sheets, and time clock punches showed: 10/1/2023 (Sunday): 1.25 hours of RN coverage 10/21/2023 (Saturday): 3.02 hours of RN coverage 10/28/2023 (Saturday): 5.25 hours of RN coverage 11/11/2023 (Saturday): 2.83 hours of RN coverage 11/23/2023 (Monday): 1.48 hours of RN coverage 12/16/2023 (Saturday): 2.5 hours of RN coverage 12/23/2023 (Saturday): 1.13 hours of RN coverage Review of the facility's daily staffing posting sheets showed the following: 1/6/2024 (Saturday), 1/17/2024 (Wednesday), 1/18/2024 (Thursday), 3/10/2024 (Sunday), 3/16/2024 (Saturday), 3/23/2024 (Saturday), 3/24/2024 (Sunday), 3/30/2024 (Saturday), 3/31/2024 (Sunday), 4/5/2024 (Friday), 4/6/2024 (Saturday), and 4/7/2024 (Sunday): no RN coverage. During an interview on 4/8/2024 at 10:40 AM, the Staff Development Coordinator (SDC)/Infection Control Nurse stated the facility typically had an RN daily Monday-Friday. The RN who was scheduled to work Saturday and Sundays quit a few weeks ago and the facility was actively trying to hire a replacement. The SDC/Infection Control Nurse confirmed the facility did not have consistent RN coverage currently on Saturday and Sundays During an interview on 4/10/2024 at 1:35 PM, the Administrator, Assistant Administrator, Director of Nursing, and the Controller confirmed the facility failed to meet the minimum requirement of 8 hours RN coverage per day.

Based on facility policy review, observation and interview the facility failed to post accurate staffing information to reflect daily staffing levels. The findings include: Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, showed .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents During an observation on 4/8/2024 at 7:40 AM, of the daily nurse staffing showed the staffing information posted was the staff scheduled for 4/5/2024 and had not been updated to reflect the current staff in the facility on 4/8/2024. During an interview on 4/10/2024 at 2:035 PM, the Director of Nursing stated the Unit 1 Charge Nurse was responsible for posting the daily staffing sheet.

Based on facility policy review, observations, and interviews, the failed to ensure there was hot water was available for staff to wash/sanitize their hands in 1 of 2 kitchen hand washing sinks. The facility failed to maintain kitchen equipment in a sanitary manner and failed to ensure the kitchen floor was maintained in a sanitary manner, which had the potential to affect 52 of 52 residents. The findings include: Review of the facility policy titled, Sanitization, revised 10/2008, showed .All .kitchen areas .shall be kept clean .free from litter and rubbish .all equipment shall be kept clean .washed to remove soils .using mechanical means necessary . Observation and interview on 4/8/2024 at 8:35 AM, with the Dietary Manager (DM), at the kitchen handwashing station (located at the entry door), showed this surveyor attempted to wash her hands and the water remained cold. Further observation showed the water temperature did not change. The DM stated this sink had been transitioned from an eye wash station into a hand washing sink and the hot water had not been hooked up. Observation of the food preparation area on 4/8/2024 at 8:50 AM, with the DM, showed the outer door and bottom edge of the food warmer and the 6 temperature dials had thick layers of sticky, black food debris. Observation of the dishwashing area on 4/8/2024 at 8:55 AM, with the DM, showed the floor area under the dishwasher had food debris scattered on the floor. Further observation showed a plastic cup and plastic fork was on the floor beneath the dishwasher. Observation of the dishwashing area on 4/9/2024 at 9:00 AM, with the DM, showed the floor area under the dishwasher had food debris scattered on the floor. Further observation showed a plastic cup and plastic fork was on the floor beneath the dishwasher. During an interview on 4/9/2024 at 9:10 AM, the DM stated it was her expectation the kitchen equipment and kitchen floors were cleaned daily and deep cleaned weekly. The DM confirmed the kitchen equipment and kitchen floors were not maintained in a sanitary condition. During an interview on 4/9/2024 at 9:59 AM, the DM stated it was her expectation hot water would be available for kitchen staff use at the handwashing station. The DM confirmed hot water was not available for the kitchen staff at the handwashing station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, facility investigation, medical record review, and interview, the facility failed to protect the resident's rights to be free from physical and mental abuse of 1 resident (Resident #2) of 5 reviewed for abuse and neglect. The findings included: Review of a facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program' revised April 2021, showed .residents have the right to be free from abuse .Abuse is defined as willful infliction of injury .all altercations, including those that may represent resident-to resident abuse, shall be investigated, and reported . Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Schizophrenia, Major Depressive Disorder, Generalized Anxiety Disorder, Type 2 Diabetes Mellitus, Pseudobulbar Affect and Parkinson's Disease. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The resident had potential indicators of psychosis including delusions, and behavioral symptoms not directed toward others 4 to 6 days during the assessment period. The resident was dependent with 2-person assist for locomotion, dependent with 1-person assist for eating, required extensive assist of 2-person assist for bed mobility, transfer, dressing, toilet use personal hygiene, and always incontinent of bowel and bladder. Medical record review revealed Resident #3 was admitted to the facility on [DATE], discharged on 7/17/2023, and readmitted on [DATE], with diagnoses including Schizoaffective Disorder, Depression, Parkinson's Disease, Epilepsy, Polyneuropathy, and Insomnia. Review of Resident #3's quarterly MDS dated [DATE], showed a BIMS score of 6 indicating severe cognitive impairment. The resident had potential indicators of psychosis of delusions, behaviors of physical behavioral symptoms directed toward others 1 to 3 days, verbal behavioral symptoms directed toward others daily, and rejection of care 1 to 3 days during the assessment period. The resident was dependent with 2-person assist for bed mobility, transfer, dependent with 1-person assist for toilet use, personal hygiene, required extensive assist with 1-person assist for locomotion, dressing, supervision with set up for eating and walking did not occur. He was always incontinent of bowel and bladder. Review of Resident #3's comprehensive care plan dated 6/27/2023, showed .At risk and active behavioral problems .physically abusive .verbally abusive .resists care .yelling hitting staff cursing .report to physician changes in behavioral status .provide non-confrontational environment for care .reduce the following stressors that may be contributing to resident's inappropriate behavior: noise/boredom .administer and monitor the effectiveness and side effects of medications as ordered .investigate/monitor need for psychological/psychiatric support .invite and encourage activity programs consistent with resident's care .intervene as needed to protect the rights and safety of others, approach in calm manner, divert attention, remove from situation and take to another location as needed . Review of Resident #2's Nursing Progress Note dated 7/17/2023 at 9:24 AM, showed .At approximately 7:20 AM, [Resident #2] was sitting in the .hall dining room waiting to be served breakfast when another resident [Resident #3] became agitated at her and was striking out. Staff separated them. Resident [Resident #3] that was striking out was removed from the dining room. [Resident #2] remained in the dining room . Review of a facility investigation dated 7/17/2023, showed CNA #1 and CNA #3 were getting report from the outgoing shift. During shift change the CNAs heard a commotion in the dining room area, as they went to investigate, they observed Resident #3 striking at Resident #2. The CNAs immediately intervened. The documentation revealed Resident #3 appeared to become agitated when Resident #2 was on the other side of the dining room and was talking out loud. Resident #3 spoke with Resident #2 and Resident #3 struck out at Resident #2. After the facility obtained witness statements and reviewed the video footage the facility determined that the incident did occur .Resident #3 was sent to a Geri-psych inpatient facility. The incident resulted in Resident #2 having a small red area approximately 2.0 cm by 0.5 cm area to her right cheek. Review of Resident #2's Nurse Practitioner (NP) Progress Note dated 7/17/2023, showed .Staff reports altercation with patient and another resident this morning. Reportedly the patient was continuously yelling 'help me.' And the other resident [Resident #3] was shaking his fist at her to 'shut up' and made contact with the right side of her face. Patient without acute injury . Review of Resident #2's Psychiatric Periodic Evaluation dated 7/20/2023, showed .Follow-up Evaluation .she is being seen for a GDR [Gradual Dose Reduction] request of her Nuplazid [used for treatment of hallucinations and delusions associated with Parkinson's Disease]. This morning she is awake and alert lying in bed. She is in a pleasant mood initially but then tearful when asked questions .She reports she continues to have lability with frequent crying at baseline. She denies any pain this morning. She says that she is sleeping well at night. She reports feeling anxious and depressed . During an interview with Licensed Practical Nurse (LPN) #1 on 8/28/2023 at 10:55 AM, she stated .I came in and I was told that [Resident #3] was striking out at [Resident #2] from the video it appeared he only made contact on her right cheek it was not hard her head did not move, but she did yell out. She was upset during the altercation but as soon as they took him out of the dining room she calmed down. This was the closest one to her face, the other strikes it was plain on the video that he did not make contact with her .She stayed in the dining for a few minutes then we took her to her room for a skin check. She wasn't tearful, she was a little anxious, she did not show signs of being fearful.if I recall she had a very small area to her right cheek that was reddened but no open areas, when I went in later to check on her it had already gone away . During an interview with Certified Nursing Assistant (CNA) #3 on 8/28/2023 at 12:00 PM, she stated .I was down the hall and I heard them [Resident #2 and Resident #3] yelling .[CNA#1] was with me were about to serve meal trays .we took off running to the dining room .he [Resident #3] was swinging at her [Resident #2] but I never saw him make contact .she [Resident #2] was yelling he hit me .I didn't' see any red marks on her face .she was upset and yelling .her [Resident #2]reaction was a normal reaction for her to anything that upsets her and sometimes when nothing has happened she will be tearful and yell . During an interview with CNA #1 on 8/28/2023 at 12:10 PM, she stated .we were getting shift report, on the hall and we heard some yelling, so we all ran to the dining room. We saw him [Resident #3] striking at her [Resident #2], but we were not sure if he [Resident #3] made contact with her [Resident #2] or not it was not an accident, he [Resident #3] was striking at her [Resident #2] .there was not any other residents close to them [Resident #2 and Resident #3] but there were other residents in the dining room .she [Resident #2] was yelling at him Resident #3], and he [Resident #3] was yelling at her [Resident #2] .she was upset .I don't recall her being tearful . During an interview with the Administrator on 8/29/2023 at 9:15 AM, he stated .I was notified of the incident .Staff interviews could not confirm that there was actual physical contact only that [Resident #3] was hitting at [Resident #2]. I did watch the video footage [Resident #2] was talking loudly, he [Resident #3] was 2 tables over on the other side of the dining room. It appeared he [Resident #3] was going to exit the dining room she [Resident #2]was still talking loudly. He became upset he thought she was yelling at him and began to swat at her as that was taking place you could hear the CNAs responding and running to prevent anything from happening but by the time, they [CNAs] reached him he [Resident #3] it was viewed on the video that he did make contact one time on her right cheek with the outer part of his right hand. She reacted by yelling at him saying don't do that .His [Resident #3]'s actions were not a reflex he was responding to her yelling. After watching the video, the facility did substantiate that abuse did occur .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#17) of 24 residents reviewed for medical records. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Cognitive Communication Deficit, Dysphasia, Dementia without Behavioral Disturbance, Paranoid Schizophrenia, and Essential Hypertension. Review of the Care Plan dated 6/30/2021 showed Resident #17 was a full code. Review of the medical record showed Resident #17 had a Tennessee Physician Orders for Scope of Treatment (POST) form with the resident's name, full code, full treatment choices, and section C, Artificially Administered Nutrition was not filled out. The document was signed by the Physician, the Resident, and a Licensed Practical Nurse and dated 6/23/2021. During an interview on 10/26/2021 at 2:06 PM, the Director of Nursing confirmed Resident #17's POST was incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on professional standards review, facility policy review, record review, observation, and interview, the facility failed to maintain infection control practices to ensure signage was posted on 1 resident's door (Resident #251) of 2 residents sampled for transmission-based precautions of 6 residents reviewed for infection control. The findings include: Review of the Centers for Disease Control Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes dated 9/10/2021, showed .unvaccinated residents who are new admissions .should be placed in a 14-day quarantine . Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, dated October 2018, showed .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door . Resident #251 was admitted to the facility on [DATE] with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure, Atherosclerotic Heart Disease, Bipolar Disorder, and Cerebral Infarction. Review of a COVID-19 Vaccination Record Card showed Resident #251 received the COVID-19 vaccination on 10/19/2021 (5 days post admission). Observation of Resident #251's room on 10/26/2021 (12 days post admission) at 8:00 AM, showed no isolation signage was posted on the entrance door. During an interview conducted on 10/26/2021 at 8:10 AM, the Administrator stated Resident #251 was unvaccinated for Covid-19 upon admission and was placed on transmission-based precautions. The Administrator further stated Resident #251 was moved to a different room and the isolation sign had not been reposted on the room entrance door. During an interview conducted on 10/27/2021 at 7:10 AM, the Administrator confirmed Resident #251 was unvaccinated upon admission and was placed in isolation for 14 days. The Administrator further confirmed signage was not posted on Resident #251's room entrance on 10/26/2021 to indicate transmission-based precautions were in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to administer medications timely to 3 residents (Residents #46, #30, and #36) observed for medication administration and maintain a medication error rate less than 5 percent as evidenced by 14 medication errors out of 29 medication administration opportunities resulting in a medication error rate of 44.8 percent. The findings include: Review of the facility policy, Administering Medications dated 4/2019 revealed .Medications are administered in accordance with prescriber orders, including any required time frames .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . Resident #46 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, Schizophrenia, and Anxiety Disorder. Review of the medical record for Resident #46 showed the monthly Physician Orders dated 10/2021 showed Resident #46 was ordered Metformin (medication to treat diabetes) 500 mg/5 ml (milliliter) twice daily at 8 AM and 8 PM, Risperdal (medication to treat mental and mood disorders) 4mg tablet take one by mouth twice daily at 8 AM and 8PM, and Alprazolam (medication to treat anxiety and panic disorder) take 1 mg tablet take 1 tablet by mouth twice daily at 8AM and 8PM. Observation on 10/25/21 at 11:40 AM, with LPN #2 during medication pass on the 500 hallway revealed LPN #2 prepared and administered the following medications to Resident #46 (2 hours and 40 mintues late). -Metformin 500 mg/5 ml -Risperdal 4mg tablet -Alprazolam 1 mg tablet Resident #30 was admitted to the facility on [DATE] with diagnoses including Diabetes, Anemia, Hypertension, Vitamin D Deficiency, Restless Leg Syndrome, Dementia, Depression, and Chronic Obstructive Pulmonary Disease. Review of the monthly Physician Orders dated 10/2021 showed Resident #30 was ordered Gabapentin (medication for nerve pain) 400 mg (milligrams) capsule take one by mouth every day at 9 AM, 2 PM, and 9 PM, Tolterodine (medication to treat frequent urination)Tart ER (extended release) 2 mg take 1 tablet by mouth every 12 hours 9 AM and 9 PM, Bactrim (medication to treat bladder infection) DS (double strength) take 1 tablet by mouth twice daily, Wellbutrin (medication to treat Depression) SR (sustained release) 200 mg tablet take 1 tablet by mouth twice daily. Observation on 10/25/2021 at 11:48 AM, with Licensed Practical Nurse (LPN) #3 on the 400-hallway revealed LPN #3 prepared and administered the following medications for Resident #30 1hour and 45 mintues late. -Gabapentin 400 mg -Tolterodine Tart ER 2 mg -Bactrim DS 1 tablet -Wellbutrin SR 200 mg Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Anxiety, Schizoaffective Disorder, Depression, Type II Diabetes, and Hypertension. Review of the monthly Physician Order dated 10/2021 showed Resident #36 was ordered Bepreve (medication to treat watery, itchy eyes) 1.5% Eye Drops twice daily instill one drop into each eye, Flonase Allergy Relief 50 MCG (micrograms) spray 2 sprays in each nostril twice daily, Clonazepam (medication to treat anxiety) 0.5 mg by mouth twice daily, Hydralazine (medication to lower blood pressure) 100 mg tablet by mouth twice daily, Benztropine (medication to treat movement disorder) 0.5 mg tablet by mouth twice daily, Atenolol (medication to lower blood pressure) 50mg tablet by mouth twice daily. Observation on 10/25/2021 at 12:00 PM, with Licensed Practical Nurse (LPN) #3 on the 400-hallway revealed LPN #3 prepared and administered the following medications for Resident #36, (1 hour and 45 mintues late). -Bepreve 1.5.% Eye Drops -Flonase Nasal Spray -Clonazepam 0.5 mg -Hydralazine 100 mg -Benztropine 0.5 mg -Atenolol 50 mg During an interview on 10/25/2021 at 12:05 PM, LPN #3 confirmed the medications administered to Resident #30 and Resident #36 were scheduled to be administered at 9 AM on 10/25/2021. Continued interview confirmed the medications were administered 1 hour and 45 mintues late to Resident #30 and Resident #36. During an interview on 10/26/2021 at 10:15 AM, LPN #2 confirmed Resident #46's medications were ordered to be administered at 8:00 AM and were not administered until 11:40 AM, (2hours and 40 mintues late). LPN #2 confirmed she did not administer the medications timely. During an interview on 10/26/2021 at 10:27 AM, the Assistant Director of Nursing (ADON)/Compliance Director confirmed medications ordered for 9 AM must be administered between 8:00 AM and 10:00 AM. Continued interview confirmed the medications for Resident #30 and Resident #36 were not administered timely. During an interview on 10/27/2021 at 9:10 AM, the Physician for Resident #30 revealed the medications administered later than scheduled would not have caused harm to the resident. He stated his expectation was for medication to be administered as ordered. During an interview on 10/27/2021 at 10:00 AM, the Director of Nursing (DON) stated it would be her expectation for nurses to administer medications timely. She stated Resident #46's medications should have been administrered between 7:00 AM-9:00 AM. The DON stated LPN #2 failed to follow the facility policy for medication administration. During a telephone interview on 10/27/2021 at 10:30 AM, the Medical Director stated it was his expectation for medications to be given within the time frame ordered. He stated the late medications administered would not cause significant changes to Resident #36 or Resident #46.

Based on facility policy review, observation, and interview, the facility failed to monitor and document daily temperature checks for 2 medication refrigerators (400 hall and 600 hall) of 2 medication refrigerators sampled. The findings include: Review of the facility policy titled Refrigerators and Freezers dated December 2014, showed .Monthly tracking sheets for all refrigerators and freezers will be posted .Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily . Observation on 10/26/2021 at 3:10 PM, of the 600-hall medication room with the Director of Nursing (DON) showed the Daily Refrigerator Temperature Monitor log dated October had 15 (10/1/2021, 10/3/2021, 10/4/2021, 10/10/2021, 10/11/2021, 10/13/2021, 10/15/2021, 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 10/20/2021, 10/21/2021, 10/22/2021, and 10/24/2021) undocumented daily temperature checks. Observation on 10/26/2021 at 3:40 PM, of the 400-hall medication room with the Assistant Director of Nursing showed the Daily Refrigerator Temperature Monitor log dated 10/2021, had 12 (10/1/2021, 10/2/2021, 10/7/2021, 10/8/2021, 10/14/2021, 10/15/2021, 10/16/2021, 10/20/2021, 10/21/2021, 10/22/2021, 10/23/2021, 10/25/2021) undocumented daily temperature checks. During an interview on 10/27/2021 at 11:05 AM, the DON confirmed it was the facility policy for staff to monitor medication refrigerator temperature and record the temperatures daily .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility staff failed to protect the right to a dignified existence and self-determination for 1 resident (#36) of 14 sampled residents. The findings include: Review of the facility policy, Smoking Policy - Residents, version 2.0 undated, revealed .Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Nicotine Dependence, and Chronic Obstructive Pulmonary Disease. Medical record review of a Quarterly Minimum Data Set, dated [DATE] revealed the Resident's Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. Medical record review of Resident #36's current comprehensive care plan (undated) revealed the resident is care planned for burns/injuries related to smoking with interventions including .Smoke breaks will be supervised by facility policy. I am noncompliant with smoking policy at times . Further review revealed the resident is care planned for being uncooperative with staff with interventions including .Respect resident's right to choice [choose] not to be compliant . Medical record review of Resident #36's Smoking Risk assessment dated [DATE] revealed a score of 10, indicating the resident is recommended for supervision only for smoking. Observation on 4/03/19 at 10:23 AM, on the 400 hall smoking area, revealed Certified Nursing Assistant (CNA) #1 putting a smoking apron on Resident #36. As CNA #1 was putting it over Resident #36's head, the resident stated .Don't put that on me . Continued observation revealed CNA #1 continued putting the apron on Resident #36 and firmly stated .We have to for safety . Further observation revealed Resident #36 cursed in response. Further observation on 4/03/19 at 10:28 AM revealed the resident was wearing the apron and smoking. Interview with CNA #1 on 4/03/19 at 10:43 AM, on the 400 hall, confirmed the resident declined the smoking apron and she continued to put it on the resident. Interview with the Director of Nursing (DON) on 4/03/19 at 11:03 AM, in the conference room, confirmed the facility failed to protect Resident #36's right to dignity and self-determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure supervision of one resident (# 2) resulting in a fall of 3 residents reviewed for falls of a total of 14 sampled residents. The findings include: Review of the facility policy Falls .Assessment and Recognition revised October 2010 revealed .risk factors for subsequent falls include .gait and balance disorders, cognitive impairment . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Encephalopathy, Dementia, Muscle Weakness, and Repeated Falls. Medical record review of a Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 8 indicating moderately impaired cognition. Continued review of the MDS revealed the resident required supervision and 2 person physical assistance with transfers. Medical record review of a Nurse's Note dated 8/22/18 revealed .pt [patient] was observed on floor by nursing students .v/s [vital signs] within normal limits .nursing students were attempting to transfer patient, then left alone and unattended at the side of the bed .patient is not to be left alone and unattended during transfers . Review of the facility fall investigation report dated 8/22/18 revealed .nursing students were assigned to care for patient .for reasons undetermined, students left patient alone and unattended .when students reentered room found .patient was observed on floor .no apparent injury . Interview with the Director of Nursing on 4/2/19 at 2:50 PM, in the conference room, confirmed the resident was not to be left unattended and the facility failed to follow the facilities fall policy.

Based on medical record review and interview the facility failed to ensure Tennessee Physician Orders for Scope of Treatment (POST) form was completed for 1 resident (#257) of 24 residents reviewed for POST forms, of a total of 14 sampled residents. The findings include: Medical record review revealed Resident # 257 was admitted to facility on 3/27/19 with diagnoses including Cancer of Prostate, Chronic Kidney Disease Stage 4, Diabetes Mellitus Type II, and Heart Failure. Medical record review of the POST form dated 3/27/19 revealed the physician failed to sign and date the resident's POST form. Interview with the Director of Nursing (DON) on 4/3/19 at 8:57 AM, in the Conference Room, confirmed POST form for Do Not Resuscitate (DNR) status had not been signed per physician, .if not signed resident would be full code until signed by doctor .this form should have been signed by doctor .

Based on review of facility documentation and interview, the facility failed to ensure the Medical Director attended quarterly quality assessment and assurance meetings. The findings include: Review of the facility's Quality Assurance Performance Improvement Plan (QAPI) (undated), revealed .The purpose of QAPI .is to take a proactive approach to continually improve the way we care for and engage with our residents .to provide the highest level of person-centered care .to continually implement innovative strategies . Review of Quality Assurance Performance Improvement documentation (undated), revealed .QAPI meetings are held monthly and the following staff members in attendance are .Medical Director . Review of the Quality Assurance Performance Improvement Committee Meeting Attendees List documentation dated 4/2018, 5/18/18, 6/20/18, 7/22/18, 8/22/18, 9/26/18, 10/2018, 11/18/18, 12/19/18, 1/24/19, 2/21/19, and 3/21/19 revealed blanks in the boxes for the Medical Director's name and signature. Interview with the Administrator on 4/03/19 at 4:22 PM, in the Administrator's office, confirmed . the Medical Director did not sign in on the sheets .the medical director usually attends at least quarterly, he hasn't made it [to the QAA meetings] this year .

Review of the facility policy Laundry and Bedding, Soiled revised July 2009 revealed .Place contaminated laundry in a bag or container at the location where it is used .Place and transport contaminated laundry in bags or containers . Observation on 4/3/19 at 9:45 AM, of the 500 and 600 hall resident shower room, revealed 3 wet and soiled towels, 1 wet and feces soiled wash cloth, 3 pair of soiled disposable gloves scattered on the shower room floor, and 1 wet and soiled wash cloth on a shower chair. Interview with the Wound Care Licensed Practical Nurse (LPN) #2 and observation of the 500 and 600 hall shower room, on 4/3/19 at 9:45 AM, revealed the shower room was soiled with dirty linen on the floor and the shower chair .the dirty linen .was usually put in barrels . Continued interview confirmed the soiled linens were not handled according to infection control practices. Interview with LPN #3 and observation of the 500 and 600 hall shower room, on 4/3/19 at 9:50 AM, revealed the soiled linens .are supposed to be put in a bag or a barrel and not thrown on the floor . Interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse on 4/3/19 at 10:00 AM, in the ADON office, confirmed the soiled linen left on the floor and on the shower chair in the 500 and 600 shower room did not follow infection control practices or policy. Based on facility policy review, observation, and interview the facility failed to ensure infection control was maintained during medication administration for one resident (#7) of three residents observed for medication administration, and failed to ensure infection control was maintained in 1 of 3 shower rooms observed. The findings include: Review of the facility policy Administering Medications revised December 2012 revealed .Medications shall be administered in a safe and timely manner .22. Staff shall follow established facility infection control procedures . Observation on 4/3/19 at 9:58 AM, on the secure unit, revealed Licensed Practical Nurse (LPN) #1 administering medications to Resident #7. Continued observation revealed the LPN pulled medications from the medication cart and placed the medications in a medication cup. Further observation revealed the LPN spilled the medications on the medication cart and picked the medications back up with an ungloved hand and placed back in the medication cup. Continued observation revealed LPN #1 entered Resident #7's room and administered the medications to the resident. Interview with LPN #1 on 4/3/19 at 10:03 AM, on the secure unit, confirmed infection control was not maintained during the medication pass .I should have discarded the medications when spilled . Interview with the Director of Nursing on 4/3/19 at 10:22 AM, in the conference room, confirmed the facility infection control policy was not followed during the medication pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Observations of the dining service on 4/1/19 at 12:30 PM, revealed the meals were distributed and served in the main dining room on food service meal trays to 11 residents. Continued observation revealed the residents were not given a choice or preference on whether to have the meals remain on the food service trays during dining or have the items removed from the tray. Observations on 4/2/19 at 7:40 AM, and on 4/3/19 at 7:30 AM and 12:30 PM, revealed the meals were distributed and served in the main dining room on food service meal trays to the residents. Continued observation revealed the residents were not given a choice or preference on whether to have the meals remain on the food service tray during dining or have the items removed from the tray. Interviews with Residents #17, #27, #37, and #55 on 4/2/19 at 2:30 PM, during a Resident Council meeting, in room [ROOM NUMBER], revealed the fine dining services (alternate meal offered in addition to the regularly scheduled meal with salad and dessert bar, served in the main dining room without use of food service meal trays) had been cancelled for 2 weeks as a result of a broken steam table. Continued interviews revealed the residents preferred fine dining and did not want the food items to remain on the food service trays during the meal. Further interviews revealed there were times residents opted not to attend the dining room due to the cancellation of the fine dining service. Interview with the Certified Dietary Manager (CDM) on 4/3/19 at 7:34 AM, in the conference room, revealed the facility did not have a policy for fine dining, homelike environment or meal service. Continued interview revealed the fine dining service was conducted at lunch and the meals were not served on food service meal trays. Further interview revealed .some residents are not coming up there [dining room] because we are not having fine dining . Further interview revealed residents had made complaints to the CDM regarding the cancellation of fine dining and had requested the fine dining service be resumed. Interview with the Administrator on 4/3/19 at 7:55 AM, in the conference room, confirmed the steam table had been inoperable for 2 weeks and fine dining service had been cancelled as a result. Interview with the Director of Nursing (DON) on 4/3/19 at 10:00 AM, in the conference room, confirmed the facility did not have a policy for fine dining, or meal service. Continued interview revealed the residents served in the main dining room had meals served on food service meal trays and the staff were unaware of the need to offer the residents a choice on whether the food items remained or removed from the food service meal trays. Based on review of the facility policy, review of facility documentation, observation, and interview, the facility failed to maintain a homelike environment by failing to maintain doors and handrails in good repair on 2 of 4 hallways, and failing to ensure fine dining services were provided in 1 of 3 dining rooms. The findings include: Review of the facility policy Maintenance Service, revised December 2009, revealed .The Maintenance Department is responsible for maintaining the buildings .in good repair . Review of facility maintenance documentation titled Handrails dated 6/12/18 revealed .Comments .Touch up paint needed no paint ., 7/25/18 .Comments: 600 needs touch up paint ., 8/14/18 .Comments: need touch up paint ., 9/11/18 .Comments: Hand rails need painting still no funds to purchase paint ., 10/25/18 .Comments: need touch up paint ., 11/12/18 Comments: need touch up paint ., 1/4/18 .Comments: touch up paint needed ., 2/13/19 .Comments: touch up paint needed ., 3/28/19 .Comments: all handrails need painting no money available . Review of facility maintenance documentation titled Nursing Home dated 11/12/18 revealed .Comments: waiting on funding from corporate . Observation and interview with the Maintenance Director on 4/03/19 at 3:02 PM, on the 500 hall, revealed room [ROOM NUMBER]'s door was scraped up, had black marks on it, was in overall poor repair and .Is in need of replacement . Observation and interview with the Maintenance Director on 4/03/19 at 3:07 PM, on the 500 hall, revealed room [ROOM NUMBER]'s door was scraped up, had black marks on it, was in overall poor repair and .It's pitiful . Observation and interview with the Maintenance Director on 4/03/19 at 3:09 PM, on the 500 hall, revealed room [ROOM NUMBER]'s door was scraped up, had black marks on it, was in overall poor repair and .It needs something done to it . Observation and interview with the Maintenance Director on 4/03/19 at 3:09 PM, on the 500 hall, revealed room [ROOM NUMBER]'s door was scraped up, had black marks on it, was in overall poor repair and .It needs sanding and repolishing . Observation and interview with the Maintenance Director on 4/03/19 at 3:11 PM, on the 500 hall, revealed the handrails had the paint scraped off and were in poor cosmetic repair because of funding. Continued interview confirmed .these handrails need repainting . Further interview revealed . Find me a handrail [on the 500 or 600 hall] that isn't scuffed . Observation and interview with the Maintenance Director on 4/03/19 at 3:12 PM, on the 600 hall, revealed room [ROOM NUMBER]'s door was in overall poor repair and .It's in dire need of staining . Further observation revealed scraped up handrails. Interview with the Maintenance Director on 4/3/19 at 3:27 PM, in the conference room, revealed .room [ROOM NUMBER]'s window has been broke for [NAME] ages; I've asked for money for it . that has been our biggest issue; the funding. I've operated for over a year with no budget .