Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main kitchen in that: [NAME] B took the dinner rolls with her hands to place them on the residents plates when plating the lunch meal. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings includedDuring an observation and interview on 09/03/2025 at 11:20 AM revealed [NAME] B was seen plating the meals for lunch time. [NAME] B was touching the meal tickets, using a suction grabber device to grab the hot plates and then using the serving ladles to place the food on the plates. [NAME] B was then seen taking a dinner rolls with her bare hands and placing them on the meal plates. The Culinary Manger was present in the kitchen at the time of the food being served. The Surveyor asked the Culinary Manager if it was okay for [NAME] B to be taking the rolls with her bare hands and placing them on the plate. The Culinary Manager said no and went and provided [NAME] B with a pair of tongs and asked her to use the tongs instead of her bare hands to place the dinner rolls on the plate. During an interview on 09/03/2025 at 2:28 PM the Manager said that [NAME] B should not have touched the dinner rolls with her bare hands as that could possibly contaminate the rolls. The Culinary Manager said the cook had been working at the facility for about 10 years and she knew that she was not supposed to touch the rolls but instead use something else to serve the rolls. The Culinary Manager said she believed that [NAME] B had gotten nervous and forgotten to use something like tongs to serve the rolls. During an interview on 09/04/2025 at 2:02 PM the Administrator was made aware of the observation of [NAME] B using her hands to grab the dinner rolls and placing them on the resident's meal plate. The Administrator said the cook should have used another method for placing the rolls on the plate as that could lead to the spread of infections. Record review of the facility's undated document title Infection control overview and policy indicated in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty, before and after eating or handling food (hand washing with soap and water), consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. In addition to proper hand hygiene, it is important for staff to use appropriate personal protective equipment (PPE) as a barrier to exposure to any body fluids whether known to be infected or not. For example, in situations identified as appropriate gloves and other equipment such as gowns and masks are to be sued as necessary to the control the spread of infections. Wearing intact disposable gloves in good condition and that are changed after each use helps reduce the spread of microorganisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #5, and Resident #1) and 4 of 4 (NA #A, MA #F, ADON, and Director of Rehab) staff members reviewed for infection control in that;The facility failed to ensure NA A changed her gloves after they became contaminated during incontinent care while assisting Resident #5.The facility failed to ensure LVN B performed hand hygiene between glove changes while providing wound care for Resident #1.The facility failed to ensure NA #A, ADON, and Director of Rehab were tested for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs, upon hire.The facility failed to ensure MA #F and Director of Rehab completed a Tuberculosis Health Risk Screen upon hire and yearly. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: 1. Record review of Resident #5's electronic admission record dated 09/04/2025 indicated he was admitted to the facility on [DATE] with diagnoses of muscle weakness and dementia. He was [AGE] years of age. Record review of Resident #5's quarterly MDS dated [DATE] indicated in part: BIMS = 6 indicating the resident had severe impairment. Bladder and bowel: Urinary continence = Always incontinent. Bowel continence = Always incontinent. Record review of Resident #5's care plan dated 07/22/2025 indicated in part: Resident is incontinent of bowel/bladder. The resident will be clean with minimal incontinence related skin breakdown through next review date. Check frequently for wetness and soiling and change as needed. During an observation on 09/02/2025 at 11:30 AM revealed CNA E and NA A performed incontinent care on Resident #5. Both aides entered the resident's room and explained to the resident what they were going to do then they went into the restroom and washed their hands. NA A put some gloves on and unfastened the resident's brief, then took some wet wipes and wiped his peri area. Both staff then turned the resident on his right side and NA A wiped Resident #5's rectal area. Resident #5 had a bowel movement, so NA A wiped the bowel movement with some wet wipes. NA A's gloves were observed to come in contact with some of the bowel movement. While still wearing the same gloves, NA A took the new brief and fastened it on Resident #5. While still wearing the same gloves, NA A adjusted the resident's draw sheet and repositioned the resident in bed. During an interview on 09/04/2025 at 11:32 AM NA A said she should have changed her gloves after they became contaminated. NA A said by not changing her gloves that could lead to cross contamination and the spread of infections. NA A said she had gotten nervous and forgotten to change her gloves. Record review of face sheet for Resident #1 revealed an [AGE] year-old male admitted to the facility 07/17/2025 with the following diagnoses: Type two diabetes mellitus (condition in which the body has trouble controlling blood sugar), obesity, dependence on renal dialysis (a medical treatment that removes waste products and excess fluid from the blood), hemiplegia following cerebral infarction (paralysis or weakness on one side of the body caused by stroke), pressure ulcer of right heal unstageable, non-pressure chronic ulcer of left lower leg. Record review of Resident #1's current Physician's orders dated 8/29/2025 revealed an order for daily wound care to right lower leg. Record review of Resident #1's annual MDS dated [DATE] revealed BIMS of 15 indicating no cognitive impairment. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers and received pressure ulcer/injury care. Record review of Resident #1's Comprehensive Care Plan, revised on 07/25/25 revealed the resident was at risk for skin breakdown with approaches to follow skin care protocol and perform weekly skin assessments. On 9/03/25 at 4:41 PM, observed LVN B perform wound care to Resident #1's right heel. LVN B sanitized her hands before putting on gloves and personal protective equipment prior to starting wound care. LVN B removed the wound dressing to the right heel, then changed her gloves. LVN B put on new gloves and performed care to Resident #1's right lower leg wound, per physician's orders. LVN B then changed gloves and placed a dressing to the right lower leg wound, per physician's orders. LVN B did not perform hand hygiene between glove changes. LVN B repositioned Resident #1 and exited the room. LVN B did not sanitize her hands prior to leaving the room or upon exiting the room. During an interview on 19/03/25 at 5:00PM with LVN B, she stated she did not sanitize her hands between glove changes while performing wound care for Resident #1. LVN B stated she should have used hand sanitizer or washed her hands between glove changes and after performing wound care. She stated her failure to properly sanitize her hands during and after wound care was just an oversight. LVN B stated she had been trained at the facility on proper hand hygiene. LVN B stated a potential negative outcome for failure to properly sanitize hands during and after wound care would be infection and cross contamination. During an interview on 09/04/2025 at 1:56 PM the DON said NA A should have changed her gloves to prevent the spread of infections and to prevent cross contamination. The DON said the NA probably got nervous and forgot her steps. The DON the staff probably needed more training and they would be doing that. During an interview on 09/04/2025 at 2:04 PM the Administrator was made aware of the observation of incontinent care performed by NA A. The Administrator said the NA should have changed her gloves once they became contaminated as that could lead to cross contamination. During an interview on 9/04/25 at 2:27 PM with the DON, she stated she was not aware that staff failed to observe proper hand hygiene during and after wound care. She stated the facility's policy for hand hygiene during and after wound care was that hands were sanitized prior to beginning the procedure and with each glove change, before putting on clean gloves. She stated hands should be washed prior to exiting the room and after performing wound care. She stated her expectation of staff for proper hand hygiene during and after wound care was that staff practice proper hygiene according to facility-provided education as well as their nursing education. The DON stated a potential negative outcome for failure to observe proper hand hygiene was cross contamination and infection. Record review of the facility's policy titled “Hand hygiene” dated 11/12/2017 indicated in part: “Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Before applying and after removing personal protective equipment (PPE) including gloves. Record review of the facility's policy titled “Incontinence care” dated 2/14/2020 indicated in part: “Purpose – To outline a procedure for cleansing the perineum and buttocks after an incontinence episode. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. Wash hands. 2. Record review of human resource records for NA A indicated NA A was hired on 05/05/2025. NA A completed a Tuberculosis Health Risk Screen on 05/05/2025. NA A was not tested for Tuberculosis upon hire. Record review of human resource records for MA F indicated MA F was hired on 08/23/2024. MA F was tested for Tuberculosis and completed a Tuberculosis Health Risk Screen on 08/19/2024. MA F did not complete an annual Tuberculosis Health Screen since 08/19/2024. Record review of human resource records for the ADON indicated the ADON was hired on 07/23/2025. The ADON completed a Tuberculosis Health Risk Screen on 07/24/2025. The ADON was not tested for Tuberculosis upon hire. Record review of human resource records for the Director of Rehab indicated the Director of Rehab was hired on 02/01/2023. The Director of Rehab did not complete a Tuberculosis Health Risk Screen and Tuberculosis test upon hire. The Director of Rehab completed a Tuberculosis Health Risk Screen on 06/12/2024. The Director of Rehab did not complete an annual Tuberculosis Health Screen since 06/12/2024. During an interview on 09/04/2025 at 3:43 PM the Human Resources staff member said she had provided everything that was performed for NA A, MA F, the ADON, and the Director of Rehab. She said what was missing was not completed. She said that could cause TB issues for all residents and staff. She said Nursing staff were responsible for performing TB tests and annual screening. During an interview on 09/04/2025 at 4:22 PM with the Regional Director and the Admin, the Regional Director said the lapse in Tuberculosis screening and testing was a problem. The Regional Director said they were currently rectifying it now. Record review of the facility's policy titled “Infection prevention and control program” dated 03/26/2024 indicated in part: “The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmissions of communicable diseases and infections as per accepted national standards and guidelines. The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff and infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance and investigations of exposures of infectious diseases. Standard precautions – all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures”. Record Review of the facility's policy titled “Infection Control-Tuberculosis Screening and Testing Guideline revised 5/1/25 indicated in part: “Tuberculosis (TB) screening and/or testing of residents and health care personnel is recommended as part of a TB Infection Prevention and Control Plan. Facilities must ensure adherence to local regulations as well as state and federal regulations. TB screening is a process that includes: a baseline individual TB risk assessment, TB symptom evaluation, A TB test unless a prior positive test is documented and copy supplied by employer. Annual screenings after hire are required for all healthcare personnel.” HJ

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 5 residents (Residents #14, Resident # 17) reviewed for resident rights. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #14's or their Responsible Party for Mirtazapine, an antidepressant used to treat depression (a mood disorder that causes a persistent feeling of sadness or loss of interest) prior to administering the medication. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #17 or their Responsible Party for Divalproex- a medication used to treat agitation in people with dementia (a cognitive disorder causing memory loss and personality changes) prior to administering medication. The facility failed to obtain consent based on information of the benefits, risks, and options available from Resident #17 or their Responsible Party for Melatonin - a supplement used to treat insomnia (difficulty sleeping) prior to administering the medication. These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings included: Review of Resident #14's admission Record, dated 8/21/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including depression and dementia. She was on hospice. Review of Resident #14's Quarterly MDS Assessment, dated 7/1/24 revealed: She had long and short-term memory impairment with severely impaired decision-making skills. She took an anti-depressant. Review of Resident #14's Care Plan revealed: Revised 3/13/24 Resident #14 has altered sleep pattern related to insomnia. The Goal was the Resident will obtain optimal amounts of sleep as evidenced by rested appearance, verbalization of feeling rested, and improvement of sleep pattern by next review date. Identified interventions included: Administer medications as ordered. Review of Resident #14's Order Summary Report, dated 8/21/24, revealed orders: Acceptable to Evaluate and Treat by Hospice dated 8/9/24. Lorazepam 1mg 1 capsule by mouth every 4 hours as needed for anxiety. Dated 8/11/24. Mirtazapine Tablet 7.5 mg Give 3 table by mouth at bedtime for Appetite Supplement. Take 3 tablets to equal 22.5 mg beginning 8/15/24. Review of the Misc. section of Resident #14's electronic chart found a consent for Mirtazapine signed by the doctor on 8/13/24. There was no signature of the Resident's Representative. In an interview on 8/22/24 at 3:29 p.m. the DON stated the doctor or Nurse Practitioner would sign any anti-psychotic or neuroleptic consent. The DON said the doctor signed Resident #14's Mirtazapine consent but did say no one else had signed it. The DON said it was not a valid consent because it needed the resident's or resident's Responsible Party to be valid. The DON said the consent needed to be valid because the consent was part of the resident's treatment plan and part of the resident's right to accept or not accept. Review of Resident #17's admission Record, dated 8/22/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, depression with psychotic features, and anxiety. Resident #17 was on hospice. Review of Resident #17's Significant Change MDS, dated [DATE], revealed: He scored a 2 of 15 on his mental status exam (indicating severe cognitive impairment) with signs of delirium including inattention, disorganized thinking, and altered level of consciousness. He used an antipsychotic and an anti-anxiety medication. Review of Resident #17's Care Plan revealed: Initiated 3/30/24 Resident #17 used psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression and, generalized anxiety disorder. The identified goal was the Resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic drug use during the next 90 days. Identified interventions included: administer medications as ordered. Evaluate effectiveness and side effects of medications routinely for possible decrease/elimination of psychotropic medications. Review of Resident #17's Order Summary, dated 8/22/24, revealed orders: Divalproex Extended Release 250 mg 1 tablet two times a day related to Alzheimer's Disease and Major Depressive Disorder with Psychotic Symptoms for two weeks beginning 8/16/24 and ending 8/30/24. Divalproex Delayed Release 500 mg at bedtime relate to Alzheimer's Disease and Major Depressive Disorder with Psychotic Symptoms for two weeks beginning 8/16/24 and ending 8/30/24. Melatonin Extended Release Give 2 tablets by mouth at bedtime for sleep beginning 8/15/24. Review of the Misc. Section of Resident #17's electronic chart found no consent for the Divalproex or Melatonin . In an interview on 8/22/24 at 3:47 p.m. the DON said she did not find a consent for Resident #17's Divalproex. The DON said the facility should not need a consent for Resident #17's Melatonin. The Corporate RN joined the conversation and explained to the DON the facility did need a consent because the facility was using the supplement to help Resident #17 sleep . Review of the facility's policy and procedure on Clinical Practice Guidelines Use of Psychotropic Medication, revised 10/18/23 revealed: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines. 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 3., The attending physician or psychiatric physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. 4. Informed consent for Psychotropic Medication prior to administration. 6. Resident and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/ non-pharmacological interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's quarterly MDS assessment for 1 (Residents #27) of 6 residents reviewed for electronic transmission of MDS data to the CMS system. The facility failed to transmit quarterly MDS data to the CMS system within 14 days of the completion of Resident #27's quarterly MDS Assessment. This failure could place residents at risk of not having specific information transmitted in a timely manner. Findings included: Review of Resident #27's admission MDS Assessment, dated 3/26/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, high blood pressure, high cholesterol, and dementia. He scored a 4 of 15 on his mental status exam (indicating severe cognitive impairment) and showed signs of delirium including inattention. Review of Resident #27's e-chart MDS section revealed there was a Quarterly MDS completed on 6/26/24., In an interview and computer review on 8/21/24 at 4:21 p.m. the MDS Coordinator stated Resident #27 was admitted to the facility on [DATE] and his 5-day MDS Assessment was completed but not submitted because he was managed care. The MDS Coordinator stated Resident #27's 14-day admission MDS Assessment was completed and accepted on 3/26/24. The MDS Coordinator stated Resident #27's next MDS was a quarterly and it was completed on 6/26/24 and her program showed it was completed and accepted. Upon confirmation in the CMS program, the MDS Coordinator stated the 6/26/24 Quarterly MDS didn't go through and was not pulled from the MDS section to the transmission's sections for the CMS program to accept. The MDS Coordinator stated this was the first time this had happened to her. The MDS Coordinator called her supervisor on the speaker phone. The MDS Supervisor explained the MDS transmission was a two-step validation process.: The MDS was first completed in the facility's computer program then it was pulled out and submitted into the CMS approved program. The MDS Supervisor stated they would have to do a correction and re-submit Resident #27's quarterly MDS. The MDS Coordinator stated it was important because without the information the facility did not get paid and the residents did not get services. The MDS Coordinator said CMS got the numbers for the Quality Measures the facility used for their Quality Assessment and Performance Improvement meetings from the MDS Assessments. The MDS Coordinator said if the Quality Measures were off it could be difficult for the facility to come up with accurate plans and that with a census of 34 residents one person could skew the measures . Record review of the CMS RAI Version 3.0 Manual, last revised October 2023, reflected: For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date . Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #2) of 15 residents reviewed for pharmaceutical services. LVN A did not administer Resident #2's scheduled multivitamin with minerals as indicated by the physician orders. These failures could place residents at risk of not receiving the therapeutic benefit of medications and under dosed. The findings were: Record review of Resident #2's admission Record, dated 08/21/2024, indicated she was admitted to the facility on [DATE] with diagnoses of anxiety and vitamin deficiency. She was [AGE] years of age. Record review of Resident #2's order summary report dated 08/21/2024 indicated in part: Multiple Vitamins with Minerals. Give 1 tablet by mouth one time a day for dietary supplement. Order status = active. Order date 08/30/20. Start date 06/07/22. During an observation on 08/21/24 at 11:04 AM LVN A administered Resident #2 her medications. LVN A poured one multi-vitamin with iron into a pill cup then gave it to Resident #2 to take by mouth. During an interview on 08/21/24 at 11:45 AM LVN A said she had accidentally administered the wrong vitamin to Resident #2 during the medication pass. LVN A said she meant to administer the vitamin with minerals but had gotten nervous and poured the vitamin with iron instead of the one with minerals. LVN A said if she did not administer the correct vitamin then the resident would not receive the minerals as ordered. During an interview on 08/21/24 at 12:10 PM the DON was made aware of the observation of LVN A administering Resident #2 a vitamin without minerals while on her orders it indicated to give a vitamin with minerals. The DON said the nurse should have administered the vitamin with minerals as they did have them in stock in the medication room. The DON said she monitored the nurses by conducting rounds at times, but she could not see everything that was going on. The DON said LVN A simply administered the wrong vitamin . During an interview on 08/22/24 at 02:07 PM the Administrator was made aware of the observation of LVN A administering Resident #2 a vitamin without minerals while on her orders it indicated to give a vitamin with minerals. The Administrator said that LVN A should have administered the vitamin as ordered. The Administrator said that the DON and the ADON would monitor the nurses to make sure they were following the physician orders. The Administrator said that by looking through their computer system the DON and the ADON could see if the nurses were documenting that the medications were being administered. The Administrator said if a nurse did not administer the correct vitamin, then the resident could not receive the desired outcome intended by the doctor's order. Record review of the facility document titled Medication-Treatment administration and documentation and dated 4/6/2023 indicated in part: Anticipated outcome: To provide a process for accurate timely administration and documentation of medication and treatments. Fundamental information: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Process: Administer the medication according to the physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 4 residents reviewed for care plans (Residents #18, #28, #32). 1. Residents #18, #28, and #32 did not have care plans in place to address their need for Enhanced Barrier Precautions (EBP). 2. Resident #32 did not have a care plan in place to address her pressure ulcer. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #18 Review of Resident #18's admission Record revealed she was a [AGE] year-old female originally admitted to the facility on [DATE], with a most recent admission date of 3/16/22. She had diagnoses which included myelodysplastic syndrome (condition, considered a type of cancer, in which the blood-forming cells in the bone marrow become abnormal), B-cell lymphoma (cancer of a type of immune system cell) of the spleen, chronic kidney disease stage 3 (progressive damage and loss of function to the kidneys), anemia, and a stage 3 pressure ulcer of the left heel. Review of Resident #18's care plan revealed the following: Focus - Pressure Ulcer: Resident #18 has a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities. She refused to wear any other shoes besides her slip-ons and refused to stay out of wheelchair with feet elevated and heels offloaded to promote wound healing. (12/21/23 right heel resolved, left heel reclassified to an unstageable. Wound with slow but progressive healing. 5/17/24 left heel reclassified to a stage 3 and treatment order changed. 6/20/24 pressure ulcer to left heel was improving well, resident has been taking her sock and dressing off the past few days and digging/scratching at the wound with her dirty hands and has caused the wound to increase in size and depth.) (Initiated: 7/24/23, Revision: 8/19/24) Goal - Resident's pressure ulcer will show signs of healing through next review date (Revision: 11/28/23). Interventions - Encourage resident to leave dressing and sock in place (Initiated: 6/20/24). Encourage resident to stop touching the stray cats and instruct her to wash her hands when she was observed messing with the cats (Initiated: 6/20/24). Notify physician and responsible party of changes in status (Initiated: 7/24/23). Administer analgesics for discomfort or pain. If necessary, provide pain management prior to dressing changes and repositioning (Initiated: 7/24/23). Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling (Initiated: 7/24/23). Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician (Initiated: 7/24/23). Low air loss mattress (Initiated: 7/24/23). There was no care plan focus area in place to address EBP (Enhanced Barrier Precautions) related to Resident #18's pressure ulcers. Review of Resident #18's Significant Change MDS Assessment, dated 8/14/24, revealed: She scored a 9 on her mental status exam indicating moderate cognitive impairment, she required moderate assistance for all ADLs except for eating and oral hygiene which required only supervision or set-up, she used a wheelchair for mobility, she had an active diagnosis of a pressure ulcer of the left heel stage 3, she was at risk for developing pressure ulcers/injuries, she had one stage 3 pressure ulcer present at the time of the assessment that was not present at the time of admission/entry or reentry to the facility, she had moisture associated skin damage (MASD ), she had a pressure reducing device for her chair and bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, applications of ointments/medications (other than to feet), and applications of dressings to feet (with or without topical medications). Review of Resident #18's Order Summary Report, dated 8/22/24, revealed the following orders : - Med Plus 2.0 (fortified nutrition shake) - 60ml by mouth three times a day for supplemental needs regarding wound healing (Order Date: 8/20/24) - Weekly Skin Assessment - day shift every Thursday (Order Date: 8/27/23) - Monitor reddened areas to the left and right gluteal areas, apply barrier cream for each incontinent episode - every shift for skin integrity (Order Date: 8/8/24) - Red area on buttocks: clean with wound cleanser apply mupirocin 2% ointment - two times a day for redness (Order Date: 6/6/24) - Stage 2 decubitus (pressure) ulcer to heel: cleanse wound to left heel with wound cleanser, pat dry, apply collagen powder to wound bed only, cover with padded dressing, apply barrier cream to surrounding skin, and cover with Kerlex (clingy gauze wrap) - one time a day, every day shift related to pressure ulcer of left heel stage 3 (Order Date: 8/21/24) - Stage 2 decubitus ulcer to heel: cleanse wound to left heel with wound cleanser, pat dry, apply collagen powder to wound bed only, cover with padded dressing, apply barrier cream to surrounding skin, and cover with Kerlex (clingy gauze wrap) - as needed when dressing soiled related to pressure ulcer of left heel stage 3 (Order Date: 8/21/24) Resident #28 Review of Resident #28's admission Record revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admission date of 7/27/24. She had diagnoses which included malignant neoplasm of the pancreas (cancer), diabetes, protein-calorie malnutrition, anemia, and stage 2 pressure ulcer to coccyx (tailbone). Review of Resident #28's admission MDS Assessment, dated 8/2/24, revealed the following: She scored a 14 on her mental status exam indicating she was cognitively intact, she required maximum assistance for showering/bathing but only required set-up assistance for all other ADLs, she required a wheelchair for mobility, she was at risk of developing pressure ulcers/injuries, she had one stage 2 pressure ulcer that was not present at the time of admission/entry or reentry to the facility, she had a pressure reducing device for her bed and pressure ulcer/injury care, and she received hospice care. Review of Resident #28's care plan, revised 8/13/24, revealed the following: Focus - Pressure Ulcer [NAME]: Resident has a pressure ulcer to coccyx (Initiated 7/29/24, Revision: 8/13/24). Goal - The resident will be free of further breakdown through next review date (Revision: 8/13/24). Interventions - Resident requesting personal mattress topper in addition to low air loss mattress. Educated on increased risk for pressure ulcers. Verbalizes understanding, as well as continued use of topper (Initiated: 8/13/24). Reposition frequently or more often as needed or requested (Initiated: 7/29/24). Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physicians (Initiated: 7/929/24). Low air loss mattress to bed with pressure relieving overlay, mattress has been changed 3 times since admission due to resident complaints of discomfort (Revision: 8/7/24). Maintain the bed as flat as possible to reduce shear (Initiated: 7/29/24). There was no care plan focus area in place to address EBP (Enhanced Barrier Precautions) related to Resident #28's pressure ulcer. Review of Resident #28's Order Summary Report, dated 8/22/24, revealed the following orders: - Low air loss mattress to aid in the healing/prevention of actual/prevention skin breakdown - every shift, check every shift and document settings (Order Date: 7/27/24) - Perform head to toe skin assessment. Document any changes in skin integrity in the medical record - every Monday day shift for wound prevention/early identification; notify the physician of any changes in skin integrity (Order Date: 7/27/24) - Stage 2 Coccyx: clean with wound cleaner, apply skin prep and cover with dry foam padded dressing every other day (Monday, Wednesday, Friday) - day shift every Monday, Wednesday, Friday for wound healing (Order Date: 8/4/24 ) Resident #32 Review of Resident #32's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses which included dementia, protein-calorie malnutrition, urinary tract infection, and stage 2 pressure ulcer to the left foot. Review of Resident #32's care plan, revised 5/13/24, revealed the following: Focus - Pressure Ulcer Risk: Resident #32 has the potential for the development of a pressure ulcer due to history of pressure ulcer, incontinence, and malnutrition (Initiated: 2/8/24, Revision: 5/13/24). Goal - Resident's current skin concerns will show signs of healing with a decrease in size through the next review date (Initiated: 2/8/24). Interventions - Reposition frequently or more often as needed or requested (Initiated: 2/8/24). Check frequently for wetness and soiling, every two hours and provide incontinence care as needed (Initiated: 2/8/24). Briefs or adult incontinence products as needed for protection (Initiated: 2/8/24). Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling (Initiated: 2/8/24). Bathe per schedule (Initiated: 2/8/24). Diet as ordered. Offer substitutes if resident does not eat. Record intake and report a decline in intake to the physician (Initiated: 2/8/24). There were no care plan focus areas in place to address Resident #32's active pressure ulcer or EBP (Enhanced Barrier Precautions) related to her pressure ulcer. Review of Resident #32's Quarterly MDS Assessment, dated 7/27/24, revealed the following: She scored an 11 on her mental status exam indicating mild cognitive impairment, she had functional limitation in range of motion in both upper extremities and required a wheelchair for mobility, she required moderate to maximum assistance for most ADLs, required supervision for eating and personal/oral hygiene, she was at risk of developing pressure ulcers/injuries, she had no reported pressure ulcers at the time of the assessment (the stage 2 pressure ulcer to her left foot was identified on 8/6/24), and she had a pressure reducing device for her chair and her bed. In an interview on 8/22/24 at 5:41 p.m. the MDS Coordinator stated she would do a care plan on pressure ulcers if she was asked to or if she was the nurse that found it. The MDS Coordinator stated if it did not happen in her 7-day look-back period for the MDS Assessment she did not know about it. The MDS Coordinator stated Resident #32 was admitted with a Stage III pressure ulcer that was healed and the care plan was discontinued. The MDS Coordinator said there was now a pressure ulcer on her medial foot that developed 8/6/24. The MDS Coordinator said this occurred after her MDS was completed but a care plan should have been done. The MDS Coordinator said nursing should have developed an acute care plan. The MDS Coordinator said she was not part of nursing, so she did not know if nursing had someone designated to do acute care plans. The MDS Coordinator stated Resident #32's pressure ulcer care plans consisted of the one that was resolved and her risk factors. The MDS Coordinator explained the facility did not have a stable DON for the last few months so there was miscommunication. The MDS Coordinator said the nursing department did not understand she was there for reimbursement and had this assumption that the MDS Coordinator was responsible for acute care plans. The MDS Coordinator said between MDS Assessments the residents obviously did not get their care plan in. The MDS Coordinator stated pressure ulcer interventions included wound care orders that were already established, nutrition, positioning, incontinence, and hydration. The MDS Coordinator stated it was probably slipping through the cracks without the care plan. The MDS Coordinator said she paid attention to weight loss, falls with major injuries, and stage II pressure sores that did not resolve in 2 weeks. The MDS Coordinator said EBP would require a care plan and it would depend on if the resident was admitted with it or not if she was responsible for doing it or the nurses were responsible for doing the acute care plan . In an interview on 8/22/24 at 6:22 p.m. the Administrator and the Regional Nurse Consultant stated care plans were supposed to be done in morning meetings as an interdisciplinary approach. The Regional Nurse Consultant said anyone in the morning meetings could do the care plan, including the Administrator. The Regional Nurse Consultant said there was another Corporate Nurse who was responsible for overseeing MDS and she had the conversation about nursing and the MDS department working better together before. The Regional Nurse Consultant said it was ongoing . Review of facility policy Care Plans and CAAs (Care Area Assessments), revised 10/12/22, revealed, in part: The purpose of this guide is to ensure that an Interdisciplinary Team (IDT ) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Procedure: All admission and Significant Change care plans that are generated by the MDS - CAAs will be coordinated by a Registered Nurse (RN). The facility IDT team is responsible for addressing their assigned CAT/CAA triggered by the MDS and deemed necessary at the time of the MDS Assessment. Case Mix Manager (CMM ) or designee will be responsible for: Pressure Ulcer. Care Plan Updates: CMS updates care plans after Assessment before review by IDT at care plan meeting. The IDT will review the care plans on Admission/readmission, Quarterly, Annually, and as needed by the IDT. Acute Care Plans: As acute problems or changes to interventions or goals are identified, an appropriate care plan will be developed or modified by a Nursing staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of 2 residents reviewed for incontinent care and 3 (Resident #18, #28, and #32) of 4 residents reviewed for Enhanced Barrier Protections (EBP) for infection control practices. 1. CNA B washed her hands then closed the faucet with her bare hands before providing personal care for Resident #4. CNA B also did not sanitize her hands in between glove change during personal care provided to Resident #4. 2. The facility failed to ensure Residents #18, #28, and #32 were identified for and implemented Enhanced Barrier Precautions related to pressure ulcers. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Resident #4 Record review of Resident #4's admission record dated 08/21/2024 indicated she was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder, dementia, and muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #4's care plan revised 06/07/2023 indicated in part: Focus: Incontinence: Resident is incontinent of bowel/bladder related to cognitive impairment secondary to dementia and is at risk for the complications of incontinence, Physical limitations GOAL: The resident will remain free from skin breakdown due to incontinence and brief use through next review date. Interventions: INCONTINENT: Check frequently for wetness and soiling, every two hours, and change as needed. Record review of Resident #4's Quarterly MDS dated [DATE] indicated in part: BIMS of 15 (indicating she was cognitively intact), Bladder and bowel: Urinary continence and Bowel continence = Always incontinent. In an observation on 08/21/24 at 01:30 PM CNA B performed incontinent care for Resident #4. CNA B entered the residents' room and proceeded to wash her hands. CNA B turned the faucet on and washed her hands with soap, rinsed them then proceeded to close the faucet with her bare hands. CNA B then dried her hands put on a pair of gloves and proceeded to perform personal care to Resident #4. During the incontinent care, it was noted that the resident had a bowel movement. CNA B used several wet wipes to wipe off the bowel movement from Resident #4's rectal area. CNA B then removed her gloves and put on a new pair of gloves without first sanitizing her hands and then proceeded to perform care for the resident. In an interview on 08/22/24 at 10:12 AM the DON was made aware of the incontinent care performed by CNA B. The DON said it was expected for the CNA to use a paper towel to turn off the faucet to prevent re-contamination of her hands. The DON said the CNAs were expected to wash their hands in between glove change to prevent cross contamination and the use of gloves did not replace hand washing. The DON said if the staff did not close the faucet with a paper towel or washed their hands at the appropriate time that could lead to the spread of infections. The DON said the staff were trained every 2 months on infection control. The DON said that perhaps the failure occurred because the CNA got nervous and forgot her steps. In an interview on 08/22/24 at 11:00 AM CNA B said she should have closed the faucet with a paper towel but had gotten nervous and forgot. CNA B said if she touched the faucet with her bare hands her hands could get re-contaminated. CNA B said that she was supposed to wash her hands in between glove changes but she had forgotten to do that when she had provided care for Resident #4. CNA B said her closing the faucet with her bare hands and not washing her hands before changing gloves could lead to cross contamination. In an interview on 08/22/24 at 02:10 PM the Administrator was made aware of the incontinent care performed by CNA B. The Administrator said that staff was expected to close the faucet with a paper towel to prevent from contaminating their hands. The Administrator said staff were expected to sanitize or wash their hands in between glove changes to prevent contamination. The Administrator said the DON and ADON conducted quarterly training with staff regarding infection control. The Administrator said if staff did not wash their hands correctly or at the appropriate time then that could lead to cross contamination. The Administrator said the failure probably occurred because the staff member got nervous and forgot the steps. Resident #18 Review of Resident #18's admission Record revealed she was a [AGE] year-old female originally admitted to the facility on [DATE], with a most recent admission date of 3/16/22. She had diagnoses which included myelodysplastic syndrome (condition, considered a type of cancer, in which the blood-forming cells in the bone marrow become abnormal), B-cell lymphoma (cancer of a type of immune system cell) of the spleen, chronic kidney disease stage 3 (progressive damage and loss of function to the kidneys), anemia, and a stage 3 pressure ulcer of the left heel. Review of Resident #18's care plan revealed the following: Focus - Pressure Ulcer: Resident #18 has a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities. She refused to wear any other shoes besides her slip-ons and refused to stay out of wheelchair with feet elevated and heels offloaded to promote wound healing. (12/21/23 right heel resolved, left heel reclassified to an unstageable. Wound with slow but progressive healing. 5/17/24 left heel reclassified to a stage 3 and treatment order changed. 6/20/24 pressure ulcer to left heel was improving well, resident has been taking her sock and dressing off the past few days and digging/scratching at the wound with her dirty hands and has caused the wound to increase in size and depth.) (Initiated: 7/24/23, Revision: 8/19/24) Goal - Resident's pressure ulcer will show signs of healing through next review date (Revision: 11/28/23). Interventions - Encourage resident to leave dressing and sock in place (Initiated: 6/20/24). Encourage resident to stop touching the stray cats and instruct her to wash her hands when she was observed messing with the cats (Initiated: 6/20/24). Notify physician and responsible party of changes in status (Initiated: 7/24/23). Administer analgesics for discomfort or pain. If necessary, provide pain management prior to dressing changes and repositioning (Initiated: 7/24/23). Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling (Initiated: 7/24/23). Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician (Initiated: 7/24/23). Low air loss mattress (Initiated: 7/24/23). There was no care plan focus area in place to address EBP (Enhanced Barrier Precautions) related to Resident #18's pressure ulcers. Review of Resident #18's Significant Change MDS Assessment, dated 8/14/24, revealed: She scored a 9 on her mental status exam indicating moderate cognitive impairment, she required moderate assistance for all ADLs except for eating and oral hygiene which required only supervision or set-up, she used a wheelchair for mobility, she had an active diagnosis of a pressure ulcer of the left heel stage 3, she was at risk for developing pressure ulcers/injuries, she had one stage 3 pressure ulcer present at the time of the assessment that was not present at the time of admission/entry or reentry to the facility, she had moisture associated skin damage (MASD), she had a pressure reducing device for her chair and bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, applications of ointments/medications (other than to feet), and applications of dressings to feet (with or without topical medications). Review of Resident #18's Order Summary Report, dated 8/22/24, revealed the following orders: - Med Plus 2.0 (fortified nutrition shake) - 60ml by mouth three times a day for supplemental needs regarding wound healing (Order Date: 8/20/24) - Weekly Skin Assessment - day shift every Thursday (Order Date: 8/27/23) - Monitor reddened areas to the left and right gluteal areas, apply barrier cream for each incontinent episode - every shift for skin integrity (Order Date: 8/8/24) - Red area on buttocks: clean with wound cleanser apply mupirocin 2% ointment - two times a day for redness (Order Date: 6/6/24) - Stage 2 decubitus (pressure) ulcer to heel: cleanse wound to left heel with wound cleanser, pat dry, apply collagen powder to wound bed only, cover with padded dressing, apply barrier cream to surrounding skin, and cover with Kerlex (clingy gauze wrap) - one time a day, every day shift related to pressure ulcer of left heel stage 3 (Order Date: 8/21/24) - Stage 2 decubitus ulcer to heel: cleanse wound to left heel with wound cleanser, pat dry, apply collagen powder to wound bed only, cover with padded dressing, apply barrier cream to surrounding skin, and cover with Kerlex (clingy gauze wrap) - as needed when dressing soiled related to pressure ulcer of left heel stage 3 (Order Date: 8/21/24) Resident #28 Review of Resident #28's admission Record revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admission date of 7/27/24. She had diagnoses which included malignant neoplasm of the pancreas (cancer), diabetes, protein-calorie malnutrition, anemia, and stage 2 pressure ulcer to coccyx (tailbone). Review of Resident #28's admission MDS Assessment, dated 8/2/24, revealed the following: She scored a 14 on her mental status exam indicating she was cognitively intact, she required maximum assistance for showering/bathing but only required set-up assistance for all other ADLs, she required a wheelchair for mobility, she was at risk of developing pressure ulcers/injuries, she had one stage 2 pressure ulcer that was not present at the time of admission/entry or reentry to the facility, she had a pressure reducing device for her bed and pressure ulcer/injury care, and she received hospice care. Review of Resident #28's care plan, revised 8/13/24, revealed the following: Focus - Pressure Ulcer [NAME]: Resident has a pressure ulcer to coccyx (Initiated 7/29/24, Revision: 8/13/24). Goal - The resident will be free of further breakdown through next review date (Revision: 8/13/24). Interventions - Resident requesting personal mattress topper in addition to low air loss mattress. Educated on increased risk for pressure ulcers. Verbalizes understanding, as well as continued use of topper (Initiated: 8/13/24). Reposition frequently or more often as needed or requested (Initiated: 7/29/24). Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physicians (Initiated: 7/929/24). Low air loss mattress to bed with pressure relieving overlay, mattress has been changed 3 times since admission due to resident complaints of discomfort (Revision: 8/7/24). Maintain the bed as flat as possible to reduce shear (Initiated: 7/29/24). There was no care plan focus area in place to address EBP (Enhanced Barrier Precautions) related to Resident #28's pressure ulcer. Review of Resident #28's Order Summary Report, dated 8/22/24, revealed the following orders: - Low air loss mattress to aid in the healing/prevention of actual/prevention skin breakdown - every shift, check every shift and document settings (Order Date: 7/27/24) - Perform head to toe skin assessment. Document any changes in skin integrity in the medical record - every Monday day shift for wound prevention/early identification; notify the physician of any changes in skin integrity (Order Date: 7/27/24) - Stage 2 Coccyx: clean with wound cleaner, apply skin prep and cover with dry foam padded dressing every other day (Monday, Wednesday, Friday) - day shift every Monday, Wednesday, Friday for wound healing (Order Date: 8/4/24) Resident #32 Review of Resident #32's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses which included dementia, protein-calorie malnutrition, urinary tract infection, and stage 2 pressure ulcer to the left foot. Review of Resident #32's care plan, revised 5/13/24, revealed the following: Focus - Pressure Ulcer Risk: Resident #32 has the potential for the development of a pressure ulcer due to history of pressure ulcer, incontinence, and malnutrition (Initiated: 2/8/24, Revision: 5/13/24). Goal - Resident's current skin concerns will show signs of healing with a decrease in size through the next review date (Initiated: 2/8/24). Interventions - Reposition frequently or more often as needed or requested (Initiated: 2/8/24). Check frequently for wetness and soiling, every two hours and provide incontinence care as needed (Initiated: 2/8/24). Briefs or adult incontinence products as needed for protection (Initiated: 2/8/24). Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling (Initiated: 2/8/24). Bathe per schedule (Initiated: 2/8/24). Diet as ordered. Offer substitutes if resident does not eat. Record intake and report a decline in intake to the physician (Initiated: 2/8/24).There were no care plan focus areas in place to address Resident #32's active pressure ulcer or EBP (Enhanced Barrier Precautions) related to her pressure ulcer. Review of Resident #32's Quarterly MDS Assessment, dated 7/27/24, revealed the following: She scored an 11 on her mental status exam indicating mild cognitive impairment, she had functional limitation in range of motion in both upper extremities and required a wheelchair for mobility, she required moderate to maximum assistance for most ADLs, required supervision for eating and personal/oral hygiene, she was at risk of developing pressure ulcers/injuries, she had no reported pressure ulcers at the time of the assessment (the stage 2 pressure ulcer to her left foot was identified on 8/6/24), and she had a pressure reducing device for her chair and her bed. Observation on 8/22/24 from 1:20 pm through 1:40 pm revealed that Resident #18, Resident #28, and Resident #32's rooms did not have signs posted outside their doors stating the residents were on EBP or explaining the protocol for PPE use while providing resident care. No PPE was noted outside or inside of the resident's rooms. In an interview on 8/22/24 at 3:29 pm with the ADON, she stated that she had been ADON for about one year and in the Infection Control Preventionist role off and on for that year. She stated that EBP was for when a resident has a catheter and they (facility staff) take extra precautions to prevent infections with PPE and hand hygiene while providing care. She stated EBP was not just for residents with catheters. She stated she did not have a lot of experience with EBP because she just received full training on it a few weeks ago. The ADON stated the training was basic and just went over the steps of how to implement EBP. She stated that there had been a lot of turnover in nursing management so the facility had not been implementing the EBP guidance but she was aware it had been around for a little while. She stated that a resident that was colonized with MRSA would be placed on EBP. She stated that a resident with a pressure ulcer would be placed on EBP dependent on the type of pressure ulcer. For example, an MDRO wound she would wear full PPE but a wound that had a clean culture she would not. She stated she was not aware if there was a specific EBP policy and she would ask the corporate RN if they had one. She stated she thought the staff had been in-serviced about EBP but could not be certain because she had been out on medical leave when the facility first began putting EBP in place. In an interview on 8/22/24 at 5:33 pm, the Regional Nurse Consultant stated that she was notified about the EBP guidelines in April. She stated that the information came from her corporate office, and she sent the information out to her facilities as soon as she received it (4/1/24 for the initial information and 4/23/24 for a refresher). She stated that training was given to facilities on EBP the same week the guidelines came out, and it was done as a step-by-step roll out. The roll out was done with the guidelines, a log form for residents that were placed on EBP, the laminated cards given to management with the basic information for EBP, a training video for staff, the CMS guidance, how to do care plans pertaining to EBP, resident/family education on EBP, and all of that was followed up with their weekly meetings with management staff. She stated that residents were given the option to have the PPE stored on the back of their door or out of sight, like in a drawer (Resident #16). She stated that the goal for the roll out was to keep the homelike feel for the residents as much as possible. She stated that the DON who was at the facility at the time of the roll out was no longer employed with the company and the ADON was out on medical leave. She stated that it was apparently hit or miss with the previous DON implementing the policy for residents. She stated the current DON began working in the facility in July 2024, but the ADON was the main ICP The Regional Nurse Consultant stated that the facility needed to go back over the roll out and review all current residents to make sure all residents had the appropriate precautions in place. In an interview on 8/22/24 at 5:41 p.m. CNA E stated she wore PPE when she did catheter care or was doing isolation precautions. CNA E stated she would not wear PPE when taking care of a resident with a pressure sore. CNA E stated the facility had one resident who just came out of isolation and Resident #16 had a catheter, no one else needed any type of isolation for any reason. CNA E stated she got training on when to wear PPE when she did her classroom training on being a CNA and the interim DON did an in-service on how and when to wear PPE. CNA E said with Resident #16 she put on gloves, a gown, and set up a barrier on the ground because she did not want to make a mess and getting anything on her (CNA E). CNA E stated she did not help with wound care and wound dressings typically did not get dirty unless the resident had a big bowel movement and then she would let the nurse know. In an interview on 8/22/24 at 5:41 p.m. the MDS Coordinator stated EBP was used with residents with cancer, catheters, respirators, tracheostomies, and feeding tubes. The MDS Coordinator said any kind of ostomy that would require care would also require EBP. The MDS Coordinator stated Resident #32 was admitted to the facility in January 2024 with a Stage III pressure ulcer that was healed sometime in May but there was now a pressure ulcer on her left medial foot that developed 8/6/24. She did not have any comment regarding Resident #18 or Resident #28's pressure ulcers or why the residents with pressure ulcers required EBP. In an interview on 8/22/24 at 6:22 p.m. the Regional Nurse Consultant said residents were reassessed and those who needed EBP had signs posted. She stated she had an EBP in-service set up for the staff for 8/23/24. In an interview on 08/22/24 at 06:30 pm, LVN C said she had been working at the facility for almost a year. LVN C said she had heard about EBP and that currently there were no residents in the facility that were on EBP. LVN C said she usually worked on halls B and C. LVN C said EBP meant for resident's that were in isolation such as COVID or C-Diff. LVN C said she had received training regarding EBP a few months ago. LVN C said Resident's like Resident #16 and Resident #23 could be on EBP, but she had not seen any PPE or signs posted outside the door. LVN C said she did not think they specified which residents were on EBP in the facility. In an interview on 08/22/24 at 06:44 pm, NA D said that EBP meant for staff to use infection control precautions for all residents. NA D said that he worked all the halls. NA D said that he knew of one resident that was on EBP and that was Resident #16 because the resident had urinary catheter. NA D said whenever he assisted Resident #16, he would wear PPE which was located in the resident's room. Review of facility policy Hand Hygiene, dated 11/12/2017, revealed, in part: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy explanation and compliance guidelines: Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in but not limited to the attached hand hygiene table. The use of gloves does not replace hand washing. Wash hands after removing gloves. Hand hygiene table: Between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before performing resident care procedures, when during resident care moving from a contaminated body site to a clean body site. Review of facility policy Incontinence Care, dated 04/10/2017, revealed, in part: Purpose to outline a procedure for cleaning the perineum and buttocks after an incontinence episode. Procedure knock on door and request entrance. Introduce self and explain procedure and provide privacy. Wash hands. If feces present remove with toilet paper or disposable wipe by wiping from front or perineum toward rectum. Discard soiled materials and gloves. Wash hands. Put on non-sterile, latex free gloves. Review of facility policy Infection Prevention and Control Program, revised 3/26/24, revealed, in part: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and investigations of exposures of infectious diseases. Enhanced Barrier Precautions: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply; Wounds and/or indwelling medical devices (e.g. central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. All staff are expected to provide care consistent with infection control practices. Direct care staff shall demonstrate competence in resident care procedures established by our facility. The Infection Control Preventionist implements/monitors/validates that staff are trained in infection control practices.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated. 2. The facility failed to ensure food items remained covered prior to food service. 3. The facility failed to ensure the refrigerator's thermometers reflected similar temperatures. 4. The facility failed to ensure expired food items were discarded by the expiration date. 5. The facility failed to maintain cleanliness in the kitchen. The dry storage had food particles on the shelves and the ice machine had a brown substance on the ice making mechanism. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: During the initial tour of the kitchen on 8/20/24 from 11:20 am to 12:00 pm the following observations were made: - A coffee filter was noted sitting on top of a clear plastic bin next to the coffee machine with approximately 1 (one) cup of coffee scooped in it. The filter and coffee were not covered. - 7 (seven) metal bins of various sizes containing food were noted on the steam table at the time of entrance to the kitchen, none of which had covers. The food on the steam table remained uncovered for no less than thirty minutes until the kitchen staff began plating and serving the residents lunch at approximately 11:55 am. - Refrigerator temperature reading on built-in thermometer located on outside of the unit read 40.7 degrees Fahrenheit while internal, removable thermometers (2 noted inside on different shelves) read 45 degrees Fahrenheit and 44 degrees Fahrenheit. - 1 (one) resealable, clear plastic bag labeled lettuce, 8/19/24, Use By 8/25/24 found with bag of lettuce in original package with open end rolled up and shoved into open resealable plastic bag with open side down. Original lettuce package label stated weight of 5-pounds. Resealable plastic bag noted to be too small to contain the original packaging, therefore it was not sealed, and the original packaging bag for the [pp; lettuce was sticking out approximately 4-inches from the opening of the resealable bag. - 1 (one) 2-gallon resealable plastic bag labeled shredded cheese, 8/17/24, Use By 9/17/24 noted in refrigerator, resealable plastic bag not properly sealed and original packaging inside not sealed. - Clear plastic tub with blue lid noted on shelf in dry storage with facility label stated Product: rice crispy; Date: 7/7/24; Use By: 8/7/24. - White plastic 5-gallon storage bucket with lid and facility label stated Product: elbow noodles; Date: 7/20/24; Use By: 9/20/24; Received: 7/11/24 noted on bottom shelf in dry storage with large crack on the side of the bucket preventing the lid from sealing. - Loose noodles noted on bottom shelf where pastas stored in dry storage. - White powder and gritty white substance noted on bottom shelf where flour, sugar, and salt stored in dry storage. - Floor in dry storage room and surrounding refrigerator sticky when walking. - Vent above dishwasher sink appears furry with collection of debris - unable to inspect closely due to height . In an interview on 8/20/24 at 12:05 pm, the Dietary Manager stated that the lettuce should not have been shoved into a resealable bag that was too small to hold it. She stated she did not know why anyone would have thought that was acceptable. The lettuce was immediately disposed of. She stated that the shredded cheese was not properly sealed and removed it from the refrigerator. She stated that the cheese looked like someone was in a hurry when putting it away and it did not get sealed completely. She stated she would throw it away just to be safe. The Dietary Manager stated that the dietary staff was supposed to use the built-in thermometer reading when logging refrigerator temperatures and she had not been told anything about the internal thermometers reading too high. The Dietary Manager and the State Surveyor returned to the refrigerator to check the internal and built-in thermometers and the built-in temperature read 39.9 degrees Fahrenheit while the internal thermometers read 44 degrees Fahrenheit and 44 degrees Fahrenheit respectively. The Dietary Manager stated that the two internal thermometers were old, and she had purchased replacements that she would place in the refrigerator immediately to see if it changed the readings. She stated that the plastic bin containing expired cereal was not a food the facility used anymore and immediately disposed of the bin. She stated she understood that having outdated food was still an issue even if it was not being used. The Dietary manager stated that she was aware of the broken storage bin containing the elbow noodles and that she had ordered new bins that were to be delivered hopefully today or tomorrow. She stated the staff had continued using the noodles from the broken bin. She stated she did not recall how long the storage bin had been broken. She stated that the loose pasta and the collection of flour and salt or sugar on the bottom shelves in the dry storage room could become a pest control issue because having food on the floor would bring in rodents and bugs. She stated that the floor in the dry storage room was always sticky and was hard to keep clean, but she had not noticed the floor in the kitchen being sticky. When the Dietary Manager was shown the coffee filter with coffee in it sitting next to the coffee machine she asked, is that not ok? The Dietary Manager was made aware that upon the State Surveyor's entry to the kitchen for observation, 7 containers of food were noted to be on the steam table with no covers for at least thirty minutes until lunch service began and the Dietary Manager asked, should they be covered? Observation on 8/20/24 at 12:30 pm revealed brown liquid build-up noted on the lip of the ice dispenser on the inside of the ice machine in the dining room. The brown liquid was noted to be the entire length of the white plastic piece of the machine where the ice dropped down into the holding bin. When the build-up was touched, the State Surveyor's fingers came away with a watery, brown, gritty substance on them. The build-up did not appear to drip into the holding bin and the ice in the bin appeared clean. In a follow-up observation on 8/21/24 at 12:02 pm, the built-in thermometer on the refrigerator read 40.2 degrees Fahrenheit and the internal thermometers read 44 degrees and 45 degrees Fahrenheit respectively. The Dietary Manager stated that the thermometers inside the refrigerator had been replaced with the newly purchased thermometers on 8/20/24 and that when the temperatures had been logged that morning, both internal thermometers had read 40 degrees. The Dietary Manager stated she did not understand why the new thermometers were reading higher during the observation. In an interview on 8/21/24 at 12:15 pm, the Food Service Bench Manager stated that she had been made aware of the issues identified on 8/20/24 by the Dietary Manager but wanted to go over everything anyway. She stated that she had already started in-serving the dietary staff on food storage protocols. She stated that she did not know why the staff would think it was ok to try to shove a 5-pound bag of anything into a 1-gallon resealable bag because it would never fit or properly seal. She stated that she was not aware that the dietary staff had continued to use the elbow noodles from the broken storage bin instead of throwing them out and using resealable bags to store the noodles until the new bin arrived. She stated that as soon as the broken bin was discovered, it and the noodles should have been thrown away due to the risk of cross contamination. The Food Service Bench Manager stated that the food on the bottom shelves in the dry storage room was a risk for rodents and insects coming into the building and having the broken bin in the room contributed to that too. She stated that all food items should have been properly covered at all times whether they were in the refrigerator, on the steam table, or on the counter. She had no explanation for why there was a coffee filter full of coffee sitting on the counter. She stated that the corporate policy was that food was not to be held on the steam table. - She stated that the food should be coming straight from the oven or stove to the steam table and being served. There should not have been a reason for the steam table to have food sitting uncovered for thirty or more minutes. She stated she would have to investigate what happened during the lunch service on 8/20/24 to cause the food to sit out that long at all, but especially uncovered. She stated that the steam table being uncovered was a risk for cross contamination because anything could have been blown into the food with it open to air. The Food Service Bench Manager stated that the Dietary Manager was incorrect about the logs for the refrigerator temperatures, and that the staff should be recording the internal temperatures. She stated that she had checked them herself that morning and the temperatures were within range. She stated that cleaning the vent above the dishwasher sink was the responsibility of maintenance. She stated that she had noticed how dirty it was and felt like it was a risk for contamination if some of the debris fell off or got blown into the food while the staff were cooking or serving food. She stated that the kitchen was old and could look dirtier than it was but that was no excuse for it to not be kept clean. She stated that there was a lot of education that needed to be done with the kitchen staff. In a follow-up observation on 8/22/24 at 11:05 am, the built-in thermometer on the refrigerator read 40.6 degrees Fahrenheit and the internal thermometers read 40 degrees Fahrenheit and 41 degrees Fahrenheit respectively. Review of facility policy Equipment Cleaning Procedures, revised 1/2013, revealed, in part: Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning Frequency: Daily - Kitchen and storeroom floors should be swept and mopped daily. Weekly - Clean refrigerator and freezer weekly. Appropriate chemical should be used to mop freezer floor. Monthly - Wash walls, ceilings, doors, and vents monthly or as needed. Review of facility policy Food Safety and Sanitation Plan, revised 11/2017, revealed, in part: Cross Contamination: the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, towels, or utensils which are not cleaned after touching raw food and then touching ready-to-eat foods. It can also occur when raw food drips onto cooked or ready-to-eat foods. Food Contamination: the unintended presence of potentially harmful substances, including but not limited to microorganisms, chemicals, or physical objects in food. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food: food that requires time/temperature control for safety to limit the growth of pathogens. Proper Refrigeration Storage: foods will be stored at 41 degrees Fahrenheit or below. All cooked or prepared foods shall be protected at all times from cross contamination. Ice - Appropriate ice and water handling practices prevent contamination and the potential for waterborne illness. Keeping the ice machine clean and sanitary will help prevent contamination of the ice. Contamination risks associated with ice and water handling practices may include, but are not limited to unclean equipment, including the internal components of ice machines that are not drained, cleaned, and sanitized as needed according to manufacturer's specifications. Review of facility policy Dry Food and Supplies Storage, revised 11/15/17, revealed, in part: All bulk food items that are removed from original containers into food grade containers must have tight fitting lids; Dry storage areas will be kept neat, clean, and orderly. Routine cleaning of walls, flooring and shelving will be maintained. Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lids. All opened products must be resealed effectively and properly labeled, dated, and rotated for use. 'Use by', 'Best by' and Sell by' dates should be routinely checked to ensure that items which have expired are discarded appropriately. Review of facility policy Frozen and Refrigerated Foods Storage, revised 11/16/17, revealed, in part: PHF/TCS (potentially hazardous foods/time temperature controlled for safety foods) must be kept in refrigerated units at or below 41 degrees Fahrenheit. All refrigerator and freezer units in the facility used to store facility-purchased food for residents must be equipped with an internal thermometer even if an external thermometer is present. Refrigerator and freezer temperatures should be checked and logged a minimum of twice daily, once in the morning and once in the evening. Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled, and dated for continued storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, The facility failed to maintain complete and accurately documented medical records on 3 (Resident #3, #6, and #7) of 9 residents reviewed. The facility failed to have matching documentation of shower logs vs shower task in electronic system for Residents #3, #6, and #7. This failure could place residents at risk of not having proper hygiene. Findings Included: Resident #3 Record review of Resident #3's face sheet, dated 4/12/24, reflected an [AGE] year-old female with an admission date of 2/15/24. Resident #3 had a diagnosis which included Orthopedic aftercare, type 2 diabetes mellitus, and hypothyroidism. Record review of Resident #3's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 7, indicating moderate cognitive impairment. Record review of Skin observation worksheet indicated Resident #3 received showers on 3/21/24 and 4/3/24. Documented by CNA C. Record review of electronic system bathing task indicated Resident #3 did not receive a shower on 3/21/24 or 4/3/24. Resident #6 Record review of Resident #6's face sheet, dated 4/12/24, reflected an [AGE] year-old male with an admission date of 2/29/24. Resident #6 had a diagnosis which included Cerebral infraction, hypertension, and insomnia. Record review of Resident #6's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 11, indicating no cognitive impairment. Record review of Skin observation worksheet indicated Resident #6 received showers on 4/2/24 and 4/4/24. Record review of electronic system bathing task indicated Resident #6 did not receive a shower on 4/2/24 or 4/4/24. Resident #7 Record review of Resident #7's face sheet, dated 4/12/24, reflected a [AGE] year-old male with an admission date of 7/26/23. Resident #7 had a diagnosis which included Heart failure, anxiety disorder, and Hypertension. Record review of Resident #7's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 15, indicating no cognitive impairment. Record review of Skin observation worksheet indicated Resident #7 received showers on 4/2/24 and 4/4/24. Record review of electronic system bathing task indicated Resident #7 did not receive a shower on 4/2/24 or 4/4/24. During an interview on 4/11/24 at 1:35 PM CNA C stated she started rushing sometimes and forgot to put in the bathing task indicating what she had done for that day in the electronic system. She stated sometimes she also forgot to do a skin observation worksheet. She stated she knew she should do both at the same time so the dates match but forgot to or got too busy. During an interview on 4/11/24 at 1:45 PM CNA D stated he forgot to go into the showering task in the electronic system to put the shower was complete. He stated there were probably multiple days in which he had a skin observation worksheet completed, but no shower completed in the electronic system because he gets too busy and forgot. During an interview on 4/12/24 at 2:15 PM ADON stated based on the shower logs being reviewed, Resident #8 had not had a shower for over a month. She stated she was not exactly sure why there were skin observation worksheets and bathing task in the electronic system that do not match. She stated it should not be like that and she was not sure why they do not match. She stated shower log sheets should match the task completed in the electronic system. She stated but ours do not match. Record review of facility's policy titled: Clinical document guidelines with a review date of 2/14/20 indicated: the patients clinical record provides a record of the health status, including observations, measurements, history, and prognosis and serves as the primary document describing healthcare services provided to the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 5 (Residents #1, #2, #3, #4, and #5) of 10 residents reviewed for staffing concerns. 1. The facility failed to ensure there were sufficient staff per the facility assessment. 2. The facility failed to ensure there were sufficient staff to ensure Residents #1-#5 received their showers. This failure could place residents at risk of not getting needed care and services, a decrease in quality of care and quality of life and/or injury. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 4/12/24, reflected a [AGE] year-old male with an admission date of 12/8/23. Resident #1 had a diagnosis which included Dementia, Hyperlipidemia, and muscle wasting. Record review of Resident #1's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. During an interview on 4/10/24 at 11:15 am, Resident #1 stated there had been a few occasions in the past month or two in which he was told by staff that he would not get a shower that day because the staff did not have time. He stated that she has no skin issues and that as long as she got a shower during the week, he was happy. Resident #2 Record review of Resident #2's face sheet, dated 4/12/24, reflected a [AGE] year-old female with an admission date of 3/16/22. Resident #2 had a diagnosis which included Lymphoma, mild intellectual disabilities, and muscle wasting. Record review of Resident #2's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 7, indicating moderate cognitive impairment. Record review of Resident #2's shower log indicated from 3/28/24 to 4/6/24 no shower received, notating shower, not applicable. During an interview on 4/11/24 at 11:45 PM, Resident #2 stated there have been days she had missed her showers because she was told that they could not get to her due to staffing. She stated she could not remember exact dates. She stated she missed a shower on average once a week. She stated she did not have any issues with her skin even when missing a shower. She stated missing showers here and there did not really affect her in any way. Resident #3 Record review of Resident #3's face sheet, dated 4/12/24, reflected a [AGE] year-old female with an admission date of 2/15/24. Resident #3 had a diagnosis which included Orthopedic aftercare, type 2 diabetes mellitus, and hypothyroidism. Record review of Resident #3's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 7, indicating moderate cognitive impairment. Record review of Resident #3's shower log indicated from 3/22/24 to 4/3/24 no shower received, notating shower, not applicable. During an interview on 4/11/24 at 12:55 PM, Resident #3 stated that she got a shower on 04/10/24 but before that it had been two weeks since her previous shower. She stated that she does not have any skin issues at all and is not concerned with missing a shower. Resident #4 Record review of Resident #4's face sheet, dated 4/12/24, reflected a [AGE] year-old female with an admission date of 11/2/23. Resident #4 had a diagnosis which included kidney disease, anemia, and type 2 diabetes. Record review of Resident #4's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 11, indicating moderate cognitive impairment. During an interview on 4/11/24 at 1:00 PM Resident #4 stated she had received a shower the day before yesterday but before that it's been about a week. She stated she did not mind missing a shower and she did not have any skin issues due to missing any showers. Resident #5 Record review of Resident #5's face sheet, dated 4/12/24, reflected a [AGE] year-old female with an admission date of 10/21/22. Resident #5 had a diagnosis which included pulmonary disease, anemia, and kidney disease. Record review of Resident #5's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 15, indicating no cognitive impairment. Record review of Resident #5's shower log indicated no shower received on 3/27/24, 4/5/24, and 4/10/24 notating shower, not applicable. During an interview on 4/12/24 at 12:45 PM Resident #5 stated that she had missed a few showers a month or so ago. She stated she was told by staff that there was not enough staff, and they could not get to her shower for that day. She stated she didn't care about missing showers and she did not have any skin break down due to missing her showers. Record review of Facility's Staff Clocking in and Clocking out per shift time sheets revealed the following: February 2024: 2/1/24 Night shift from 10pm to 6 am with one RN and one CNA. 2/2/24 Night shift two RN and one CNA. 2/3/24 Night shift one RN and two CNA. 2/4/24 Night shift two RN and one CNA. 4/2/24 Day shift from 6AM to 11:15AM one CNA, showers missed. 4/6/24 Day shift from 7AM to 2PM two RN's and 2 CNA's, showers missed. 4/7/24 Night shift from 10 PM to 11:45 PM one HA and one LVN. During a telephone interview on 4/10/24 at 11:30 AM LVN A stated that staffing was not good at the facility. She stated there had been times when it was just one RN and CNA or one RN and one HA. She stated the biggest issues they were running into was that residents were not getting their showers because of the lack of staffing. She stated she did inform both the DON and Administrator and they stated to her they were working on it. During an interview on 4/10/24 at 1:05 PM the Ombudsman stated he was first emailed by staff on March 8th regarding the cold showers for residents. He stated showers have been missed either because there was not enough staffing or because the showers were too cold, and residents did not want a cold shower. During an interview on 4/10/24 at 1:45 PM CNA B stated that on 4/6/24 Saturday she stated she knows she could not do showers that day because there were not enough employees. She stated it happens more than it should. She stated its mainly a lack of CNAs to get the showers complete. She stated there were times where it was one RN and one CNA during a day shift or the same for a night shift. During an interview on 4/11/24 at 1:35 PM CNA C stated there were days where she just could not get to resident showers due to not having enough employees on shift for her to do everything. She stated she cannot remember exactly which days but tried her best to get them done. She stated it was difficult to get everything done even with 3 CNA's but there was a lot of time where they only have 2 CNAs for the 38 residents. During an interview on 4/11/24 at 2:15 PM CNA D stated last week he did not get to showers at all on 4/2/24 Tuesdays, because he stated he was the only CNA, and the DON was the only RN. He stated from 6am to 11am it was only him and the DON in the facility. He stated this kind of thing happens more than it should. During a telephone interview on 4/12/24 at 11:45 AM LVN E stated that on 4/7/24 there was a time from about 10 pm to 11:45 pm that he was the only nurse and he had one HA with him. He stated that due to the staffing concerns and issues he had requested with his agency he no longer wants to work for the facility because the staffing was putting the residents at risk. During an interview on 4/12/24 at 2:30 PM the Administrator stated staffing was a little hard right now. She stated that they lost an RN and nights were a little short. She stated that just recently in April she had resulted in using agency to really try and cover all the shifts. She stated she was working hard to have multiple HA's finish getting certified and have more CNA's. She stated she knows they have been short here or there. During an interview on 4/12/24 at 2:45 PM the DON stated staffing was difficult at this time. She stated that the numbers were difficult because of being in a small town and getting people to stay. She stated that the facility was trying their best to not only get more staff but use agency to cover everything. She stated that she knows some showers have been missed they do try their best to get them within a day or two. She stated she knows that this was not right for the residents because they could get rashes or other skin breakdown due to lack of showers. Record review of Facility assessment dated [DATE] indicated Average Nurse Aide/Resident Ratio (Direct Care Staff) 1/13 (1 Nurse Aide to 13 residents) and Average Licensed Nurse/Resident ratio (Direct care Staff) 1/19 (1 Licensed Nurse to 19 residents). During an interview on 4/11/24 at 11:30 AM, the Administrator stated that the 1/13 ratio listed in facility assessment was for how many CNAs needed to be on staff per residents in the building. With the facility census of 38 and the 1/13 ratio, the facility should be staffed with 3 CNAs per shift in the building. The 1/19 ratio for RN's/LVN's should be 2 Licensed Nurse per the census in the building. She stated that that was the correct numbers that she understood for the building. She stated that at night, facility administration would reduce to 1 RN and 2 CNA due to less medication being given, no showers and residents were usually sleeping. She stated she was not sure if night staffing was notated in the facility assessments but does not think so. She stated she did not know that a reduction in night staff should be notated in the facility assessment, so based on the facility assessment she should have 3 CNA's and 2 RN's. Record review of Facility policy dated 4/10/22 titled: Nursing services and Sufficient Staff indicated: it is the policy of this facility to provide sufficient staff with appropriate competencies and skillsets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care Equipment in safe operating condition for 2 (Hot water heater #1 and #2) of 3 reviewed for essential equipment. The facility failed to repair or replace the hot water heater that supplied hot water for Halls 1, 2 and 3, 4 for days. This failure could place residents at risk for poor hygiene and health. Findings include: Observation on 4/10/24 at 4:15 AM revealed hot water in all showers on halls 1 (hot water heater #1) and 4 (hot water heater #2) went from hot water to cold water in 10 min. At 4:25 AM water in shower on hallway 1 was cold to touch. At 4:27 AM water in shower on hallway 4 was cold to touch. Record review of Plumbing company A dated 3/7/24 indicated work to be done on both water heaters by replacing piping on both water heater #1 and #2. Record review of Plumbing company B dated 4/3/24 indicated and estimate to have both hot water heaters replaced. During an interview on 4/8/24 at 10:10am with the facility Administrator stated that she first heard about the shower temperature not staying hot in early March 2024. She stated that the facility finally requested 2 different quotes to replace the hot water heaters on 4/3/24. She stated they just made the decision on 4/8/24 to fix 2/3 of the hot water heaters that provided water to hallways 1,2 and 3,4. During an interview on 4/8/24 at 10:34am, the Maintenance Director stated the hot water heater for Halls 1,2 and 3, 4 were not working as they should. He stated that he had tried to fix the issue but believed both hot water heaters were just too small for this facility. He stated they still can produce hot water but not for very long. He stated they should have been replaced about a month ago. He stated the hot water does not stay hot in the showers which only gives about 10min of hot water at a time for the resident's showers. During an interview with the DON and Administrator on 4/12/24 at 3:15 PM the staff was asked for the policy for maintenance equipment. The policy was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 5 residents (Resident #1 and Resident #2) reviewed for respiratory care. Resident #1 and Resident #2 did not have physician's orders for oxygen administration. This deficient practice could affect the residents who received respiratory treatments and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet, dated 03/21/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease - COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and systolic and diastolic heart failure (a group of signs and symptoms, caused by an impairment of the heart's blood pumping function). In an observation and interview on 03/20/24 at 1:20 pm, Resident #1 was sitting up in bed receiving oxygen via nasal cannula at 2 lpm. Resident #1 stated she has COPD and was admitted with oxygen and requires oxygen continuously. Record review of Resident #1's Order Summary Report, dated 03/21/24, revealed there was no physician's order for Resident #1 to receive oxygen. Record review of Resident #1's admission progress note, dated 03/18/24 at 9:40 pm, revealed Resident #1 was receiving oxygen at 2 lpm via nasal cannula. Record review of Resident #1's progress note, dated 03/19/24 at 9:35 am, revealed Resident #1 was receiving oxygen at 2 lpm via nasal cannula. Record review of Resident #1's progress note, dated 03/19/24 at 11:28 pm, revealed Resident #1 was receiving oxygen at 2 lpm via nasal cannula. Record review of Resident #1's progress note, dated 03/20/24 at 12:26 pm, revealed Resident #1 was receiving oxygen at 2 lpm vis nasal cannula. In an interview on 03/21/24 at 10:00 am, the DON said it was ultimately her responsibility to make sure resident's orders were correct upon admission. She said the DON and ADON were checking to make sure resident's physician orders were correct but didn't know how it got missed. The DON stated I failed to get orders for oxygen for Resident #1. She said a potential negative outcome would be residents would not get the treatment they needed. Resident #2 Record review of Resident #2's face sheet, dated 03/20/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of dementia (the general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities) and shortness of breath. Resident #2 was discharged from the facility on 03/17/24. Record review of Resident #2's Physician Order Summary, dated 03/20/24 revealed Resident #2 did not have an order for Oxygen PRN. Record review of Resident #2's progress note, dated 07/05/23 at 10:01 am, revealed Resident #2 was placed on Oxygen 3 lpm via nasal cannula due to her oxygen levels being below 90%. Record review of the Nurse Practitioner progress note, dated 07/05/23 at 12:52 pm, revealed Nurse Practitioner A placed Resident #2 on oxygen for shortness of breath. Record review of Resident #2's progress note, dated 07/10/23 at 5:50 pm, revealed the resident was receiving Oxygen 2 lpm via nasal cannula. Record review of Resident #2's progress note, dated 08/25/23 at 11:53 am, revealed Resident #2 was placed on Oxygen 2 lpm via nasal cannula due to shortness of breath. Record review of Resident #2's progress note, dated 03/17/24 at 1:15 pm, revealed Resident #2 was placed on Oxygen at 3 lpm for shortness of breath. In an interview on 03/20/24 at 12:45 pm, LVN B said Resident #2 had an oxygen concentrator in her room and Resident #2 would have shortness of breath from time and time and she would be placed on Oxygen 2 lpm PRN. LVN A said she thought Resident #2 had a physician order for Oxygen PRN. In an interview on 03/21/24 at 2:30 pm, the Clinical Regional Nurse Consultant said when Resident #2 was placed on oxygen on 07/05/23, that was when Resident #2 should have had a Physicians Order for Oxygen to be administered PRN. She said the nurse at the time failed to get an order from the doctor. She said there was no order in Resident #2 Physicians Orders for Oxygen PRN. In an interview on 03/21/24 at 3:07 pm, Nurse Practitioner A said Resident #2 only required Oxygen PRN. She remembered an incident a while back in which Resident #2 received Oxygen PRN but did not recall whether if an order was written for Resident #2 to receive Oxygen PRN. Record review of the facility policy Following Physician Orders, dated as implemented 09/28/21, revealed the following [in part]: Policy: This policy provides guidance on receiving and following physician orders. Policy Explanation and Compliance Guidelines: 2. For consulting physician/practitioner orders received via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. 3. For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement the physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for one of three residents (Resident #1) reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings include: Record review of Resident #1's face sheet, dated 03/14/24, reflected an 81- year- old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included constipation, dysuria (discomfort when urinating), hemiplegia (partial paralysis) and hemiparesis (partial weakness). Record review of Resident #1's Quarterly MDS assessment, dated 03/07/24, reflected Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident #1 was occasionally incontinent of bladder. Observation of incontinence care for Resident #1 on 03/14/204 at 11:06 a.m. revealed CNA A washed his hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. He did not change gloves but continued to clean the resident. His gloves were visibly soiled with urine. He did not wash his hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. CNA A removed his gloves and picked up the trash. CNA A washed his hands before leaving Resident #1's room. In an interview on 03/14/24 at 11:16 a.m. with CNA A, he revealed he should have changed his gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated he had been in the facility for 18 months and received infection control training about a month ago. He said cross contamination was transferring germs to residents. CNA A noted the resident could acquire an infection when he did not follow good infection control practices which included changing gloves before retrieving the clean brief. Record review of the facility's infection prevention and control program policy, revised 04/12/23, reflected: : This facility has established and maintains an infection prevention and 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. 4. Standard Precautions . b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for eight (Resident #1, #2, #3, #4, #5, #6, #7, and #8) of eight residents reviewed for food preferences and the accommodation of resident's meal choices. The facility kitchen failed to offer alternative meals for residents. This failure placed residents at risk for dissatisfaction, poor intake, weight loss and decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis include Parkinson's Disease (progressive disorder that effects the nervous system), Anemia (low red blood cells that carry oxygen), Heart Failure, and Muscle Weakness. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Type 2 Diabetes, Peripheral Vascular Disease (circulatory condition which narrows blood vessels) and Hypertension (high blood pressure). Record review of Resident #2's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Follicular Lymphoma, Gastro Esophageal Reflux Disease (stomach acid flows back into the tube connecting your mouth and stomach), and Lower Back Pain Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. Diagnosis include Heart Failure, Dependence on Supplemental Oxygen, Cerebral Infarction (stroke) and Hypotension (low blood pressure). Record review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Mild Protein-Calorie Malnutrition, Hypertension and Muscle Wasting/Atrophy (hardening of the muscles). Record review of Resident #5's admission MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. . Resident #6 Record review of Resident #6's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis include Cerebral Palsy (group of disorders that affect a person's ability to move and maintain balance/posture), Hypertension, Chronic Kidney Disease, Spinal Stenosis (narrowing of the spaces between the spine bones), and Heart Disease. Record review of Resident #6's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis include Moderate Protein-Calorie Malnutrition, Hypertension, Gastro-Esophageal Reflux Disease, and Adult Failure to Thrive. Record review of Resident #7's admission MDS dated [DATE] revealed a BIMS score of 8 indicating moderate cognitive impairment. Resident #8 Record review of Resident #8's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Heart Failure, Cerebral Infarction (stroke), Muscle Weakness, Vitamin Deficiency, and Hypertension. Record review of Resident #8's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 02/21/2024 at 10:35 AM Resident #1 stated that he is a vegetarian and in the past he was able to pick food preferences from the two alternative meals for the day. Resident #1 stated that he feels that he doesn't have a choice of what he is able to eat daily. Resident #1 stated that the kitchen staff had not talked with him (in a while- unable to state how long) in regard to his preferences so he feels like he gets the same foods weekly. Interview on 02/21/2024 at 10:50 AM Resident #2 stated that she has only been at the facility for one week but does not like the food offered. Resident #2 stated that she did not know that there were alternative meals offered. Stated that she is brought her meal trays (in her room) and has never been informed that she could ask for an alternative meal. Interview on 02/21/2024 at 11:08 AM Resident #3 stated she wasn't happy with the meals served. Resident #3 stated that she was not aware of alternative meals choices. Interview on 02/21/2024 at 11:21 AM Resident #4 stated that in the past the facility would allow him to choose which alternative meal he wanted for the day but has not in a long time. Stated that he will just eat what is served to him (he stated he eats in his room). Interview on 02/21/2024 at 11:35 AM Resident #5 stated that she has never been offered options when it comes to the meals at facility. Resident #5 stated she feels that the same foods are served over and over and would like a larger variety. Interview on 02/21/2024 at 1:10 PM Resident #6 stated that he is not given a choice when it comes to the meals served. Resident #6 stated that he was not informed of alternative meals. Stated that he has his family bring in food from outside the facility since he does not always like what is served. Interview on 02/21/2024 at 1:30 PM Resident #7 stated he does not have choices with his meals and stated that he cannot always eat what is served. Resident #7 stated that some meals are too sweet or too salty and will cause him to have diarrhea. Interview on 02/21/2024 at 1:54 PM Resident #8 stated that the facility used to allow her to choose her preference but the facility stopped doing this. She stated that she believes this stopped approximately 5-6 months ago. Resident #8 stated that she had not asked why this happened. Resident #8 stated that she is not offered alternative meals when she does not eat her meal. Interview on 02/21/2024 at 2:30 PM The Dietary Manager stated that she started in this position three days ago and is in the process of reviewing the current dietary meal book to update recipes, to check for repeat meals and work on alternative diet meals. The Dietary Manager stated that the kitchen staff informed her that the last manager did not order food correctly and the staff would have to cook what was available which resulted in the cook not following the scheduled menu. The Dietary Manager stated that the regional PRN Dietary Manager (that used to supervise over the kitchen) has been ordering food after the last manager quit two weeks ago and stated she has not had any staff inform her that they were not able to follow scheduled menu due to lack of supplies. Interview on 02/21/2024 at 3:00 PM The Dietary Assistant stated that the last Dietary Manager would not order enough supplies to cover the menu and the kitchen staff would have to work with the food available. The Dietary Assistant stated that residents would ask for alternative meals, but the kitchen staff would not be able to provide alternatives due to not having substitute menu supplies available. The Dietary Assistant stated that she was not aware that the residents were not receiving a form where they could request a preference between two meal choices. The Dietary Assistant stated that since the previous Dietary Manager quit (approximately two weeks ago) the regional PRN Dietary Manager has been ordering the food for the facility and they are now able to follow the scheduled menu and have enough food to provide an alternative menu. Interview on 02/21/2024 at 3:22 PM The Dietary [NAME] stated that when she was working under the previous Dietary Manager, she tried to follow the scheduled menu but due to lack of food/supplies ordered she was not always able to do this. She stated that she spoke with the previous Dietary Manager during this time and could not get resolution to the ordering issues. The Dietary [NAME] stated that she spoke with the administrator and Regional Consultant about the issues she was experiencing and was not getting solutions provided., She stated that the regional consultant would take the Dietary Manager's word that he was ordering enough supplies. The Dietary [NAME] stated that after the previous Dietary Manager quit, they have not had issues getting enough food/supplies to follow the scheduled. Interview on 02/29/2024 at 1:18 PM with The Regional Facility Consultant stated that she was not aware that that the previous Dietary Manager was not ordering supplies/food for the kitchen correctly. She stated that she did not recall speaking with the Kitchen Cook. She stated that she arrived at the facility today to assist the new Dietary Manager with upgrading the scheduled weekly menu and to check on the supplies/food available in the kitchen. She stated that she has put a new monitoring system in place with the Dietary Manager to ensure alternate meals are offered, to have check and balances on hall tray temperatures and times it takes for residents to receive their trays. She stated that she is going over all the procedures in the kitchen to see if she needs to implement new systems. but will speak with the Dietary manager about implementing this process. Interview on 02/29/2024 at 3:00 PM The Administrator stated that she was aware of process to allow residents to pick alternatives with meals, but was not aware that this process was discontinued. The Administrator stated that this process had already been put back into place. The Administrator stated that she did not recall the Kitchen [NAME] informing her of inadequate supplies/food being ordered for the kitchen when the previous Dietary Manager was working at the facility. Record review of all sampled residents with weight loss revealed that weight loss was due to medical conditions and not due to failure to provide alternative menu options. Review of facility's policy Diets, Nutrition and Hydration revision dated 8/2023, did not address alternative meals but did reveal, in part, diets may be liberalized to allow more freedom in meal selection .therapeutic and calorie restricted diets are available for residents who are candidates for liberalized diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents had the right to be treated with dignity and respect for 2 (Resident #6 and Resident #8) of 3 residents who were reviewed for rights. For Resident #6 and Resident #8, the facility failed to move the residents' personal possessions when the residents were moved to a different room when the ceiling leaked. This failure placed the residents' property at risk for being lost, stolen, or damaged and could cause them worry and distress. Findings include: Record review of Resident #6's Face Sheet, dated 12/06/2023, revealed a [AGE] year-old female who was admitted to the nursing facility on 12/24/2020. Resident #6's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Unspecified Severity, without Behavioral Disturbance, and Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #6's Annual MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate impairment. Record review of Resident #8's Face Sheet, dated 12/07/2023, revealed a [AGE] year-old male who was admitted to the nursing facility on 08/31/2022. Resident #8's diagnoses included Parkinson's Disease without Dyskinesia (a progressive, age-specific neuro-degenerative disorder characterized by slowness of movements and tremors), without mention of fluctuations (changes in the ability to move) and Anxiety Disorder (type of mental health condition when you respond to certain things or situations with fear or dread). Record review of Resident #8's Quarterly MDS assessment, dated 11/17/2023, revealed a BIMS score of 15, which meant intake cognitive response. During an observation on 12/06/2023 at 12:31 p.m., observed room [ROOM NUMBER] located on Hall 4 of the facility for physical environment. Observed Resident #6's possessions on a shelf in the room, which included pictures of her family, stuffed animals, and other personal items and personal pictures hung on the wall. Resident #6 had previously resided in the room and was moved to room [ROOM NUMBER] on 10/11/2023 when the ceiling began to leak. Observed a stuffed animal that sat on a shelf that was damp and smelled musky. During an interview on 12/07/2023 at 10:04 a.m., Resident #6's Family Member said she was aware Resident #6's personal belongings were in her old room because Resident #6's Family Member said she thought the room change was temporary. Resident #6's Family Member said she would prefer Resident #6 had her personal pictures in the room with her so she could see the pictures of all Resident #6's family and not forget them. During an interview on 12/06/2023 at 12:38 p.m., Resident #6 said she had moved from her old room a few weeks prior into room the current room she lived in. Resident #6 said the ceiling had leaked on the floor and staff helped her move to her new room. Resident #6 said that a man had told Resident #6 that her pictures were in her old room and Resident #6 would move back soon to room [ROOM NUMBER]. Resident #6 told this investigator she wanted her belongings in the room with her. During an interview on 12/06/2023 at 2:55 p.m., RN C said Resident #6 resided in room [ROOM NUMBER] at the time when the ceiling began to leak and was moved across the hall to room [ROOM NUMBER]. RN C said the ceiling began to leak the first week in October 2023. RN C said the items currently observed in room [ROOM NUMBER], with the collapsed ceiling, belonged to Resident #6. RN C said she was not sure why Resident #6's pictures and personal belongings were in room [ROOM NUMBER] with the water damage and collapsed ceiling. During an interview on 12/06/2023 at 3:30 p.m., the Maintenance Supervisor said Resident #6's personal possessions were currently in room [ROOM NUMBER] even though Resident was moved out in October 2023. The Maintenance Supervisor said at the time Resident #6 was moved to the current room she lived in because room [ROOM NUMBER] had a water leak from the ceiling, the move was supposed to be temporary. During an interview on 12/07/2023 at 1:20 p.m., Resident #8 said he was moved to the current room he lived in from room [ROOM NUMBER] after the ceiling began leaking on 10/25/2023. Resident #8 said the Administrator said the room change would be temporary, but he had been in the current room he lived in for over month. Resident #8 said at the time he moved, all his belongings were left in room [ROOM NUMBER], which upset him. Resident #8 said the staff brought some of his property to room [ROOM NUMBER] a few days after he moved but until the week prior, Resident #8 said his belongings were still located in room [ROOM NUMBER]. Resident #8 said the Administrator told him that the roof over room [ROOM NUMBER] had been patched but the facility staff had to wait to see if the ceiling would leak so Resident #8 had to wait to move back into room [ROOM NUMBER]. Resident #8 said that could take months because no one knew when the area would have rain. During an interview on 12/07/2023 at 11:42 a.m., the Administrator said the roof was patched over and the ceiling was repaired in room [ROOM NUMBER], which was the room Resident #8 was moved out of and relocated from. The Administrator said Resident #8 was not able to return to the room until the facility was sure the ceiling would not leak. The Administrator said she was aware that Resident #8 was not happy when Resident #8 had to change rooms, but she said the move was supposed to be temporary. The Administrator said the facility should have moved Resident #8's personal possessions with him to the current room he lived in when Resident #8 was relocated. The Administrator said Resident #6's personal items should have been moved when she was relocated and were moved to her room the evening prior, on 12/06/2023. Record review of the facility's policy, Resident Rights, dated 02/23/2016, revealed the resident had the right to be treated with respect and dignity including: the right to retain and use personal possessions. Record review of the facility's admission form signed by the resident and/or responsible person at admission into the facility, Statement of Resident Rights, not dated, revealed the resident had the right to keep or use personal property, secure from theft or loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure 2 of 3 (Resident #6 and Resident #8) residents reviewed for rights, received written notice prior to room change. The facility failed to ensure Resident #6, and Resident #8 received written notice, or the responsible person was contacted prior to room change. The facility failure could place the residents at risk of decreased quality of life due to a change in living environment. Findings include: Record review of Resident #6's Face Sheet, dated 12/06/2023, revealed a [AGE] year-old female who was admitted to the nursing facility on 12/24/2020. Resident #6's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Unspecified Severity, without Behavioral Disturbance, and Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #6's Annual MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate impairment. Record review of Resident #8's Face Sheet, dated 12/07/2023, revealed a [AGE] year-old male who was admitted to the nursing facility on 08/31/2022. Resident #8's diagnoses included Parkinson's Disease without Dyskinesia (a progressive, age-specific neuro-degenerative disorder characterized by slowness of movements and tremors), without mention of fluctuations (changes in the ability to move) and Anxiety Disorder (type of mental health condition when you respond to certain things or situations with fear or dread). Record review of Resident #8's Quarterly MDS assessment, dated 11/17/2023, revealed a BIMS score of 15, which meant intake cognitive response. During an interview on 12/07/2023 at 10:04 a.m., Resident #6's family said she was not notified when Resident #6 was moved to a different room on 10/11/2023 after the ceiling began to leak. Resident #6's family said she arrived at the facility and went into Resident #6's old room and Resident #6 was not in her room. Resident #6's family said she asked the housekeeper who was in the hall and was told that Resident #6 was moved because the ceiling had leaked. Resident #6's family said she thought the facility was going to repair the ceiling and move Resident #6 back into room [ROOM NUMBER], but she had been relocated for couple of months. During an interview on 12/07/2023 at 11:42 a.m., the Administrator said the room that Resident #6 resided in, room [ROOM NUMBER], started to have ceiling issues on 10/11/2023 and it started out as a drip. The Administrator said the ceiling caved in after Resident #6 was moved to a different room. The Administrator said the nurse on duty at the time Resident #6 and Resident #8 were moved to different rooms would have been responsible to contact Resident #6's family member and talk to Resident #8 about his options. The Administrator said her expectation was for the facility to contact the family in all situations of room changes. During an interview on 12/07/2023 at 1:20 p.m., Resident #8 said he was moved to the current room he lived in from room [ROOM NUMBER] after the ceiling began leaking on 10/25/2023. Resident #8 said the Administrator said the room change would be temporary, but he had been in the current room he lived in for over a month. Resident #8 said he was not told he was moving or had any say in which room he moved into. Resident #8 said the staff came in room and told him to get up because they were moving him to a different room. Resident #8 said the Administrator told him that the roof over room [ROOM NUMBER] had been patched but the facility staff had to wait to see if the ceiling would leak. Resident #8 said that could take months because no one knew when the area would have rain. Resident #8 said he decided to stay in room [ROOM NUMBER] but was not happy about how the situation was handled. Record review of the facility's policy, Resident Rights, dated 02/23/2016, revealed the resident had the right to be treated with respect and dignity including: the right to receive written notice, including the reason for the change, before the resident's room in the facility was changed. Record review of the facility's admission form signed by the resident and/or responsible person at admission into the facility, Statement of Resident Rights, not dated, revealed the resident had the right not to be relocated within the facility, except in accordance with nursing facility regulations. Record review of Resident #6's progress notes revealed no documentation of change in room on 10/11/2023. Record review of Resident #8's progress notes revealed no documentation of change in room on 10/25/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 4 halls (hall 1 and hall 4) and the 1 of 1 dining room reviewed for environmental conditions. 1. The facility failed to repair room [ROOM NUMBER] on Hall 1 that had severe water damage to the ceiling. 2. The facility failed to repair room [ROOM NUMBER] on Hall 4 that had severe water damage where the ceiling had fallen and caved in. 3. The facility failed to maintain the ice machine in the dining room to prevent water damage to the floor and mineral deposits to form on the outside of the machine. These failures could place residents at risk of being in an unsafe environment, a decrease in quality of life and self-worth. Findings include: During an observation on 12/06/2023 beginning at 12:02 p.m., observed an industrial size ice machine in the dining room area standing on discolored tile, that was stained, and water damaged. The area was colored a light grey and lighter than other tile and had chalky residue on the floor. Observed a white, hard chalky deposit on the bottom left leg of the machine and bottom trim in the front and on the left bottom side. Observed a white, chalky deposit on the rim of the ice machine to the left of the hinge on the door used to open the machine to remove ice. Observed behind the machine, and observed the tile was white with chalky residue and water damaged. During an interview on 12/06/2023 at 12:12 p.m., CNA B said she had been employed at the facility for five years. CNA B said room [ROOM NUMBER], located on Hall 4 had issues with the ceiling leaking approximately one to two months prior when it rained. CNA B said the resident who lived in room [ROOM NUMBER] was moved to a different room. CNA B said room [ROOM NUMBER] on Hall 1 and room [ROOM NUMBER] on Hall 2 had leaked and the residents who resided in both rooms were moved to different rooms. During an observation on 12/06/2023 at 12:31 p.m., observed room [ROOM NUMBER] located on Hall 4 of the facility. Observed the door was closed and when opened, the room had an odor that was musty and the air felt wet, humid, and damp. Observation revealed the ceiling had collapsed and a hole that opened into the ceiling in the middle of the room that was approximately 2 feet by 2 feet square. The ceiling was a solid drywall stipple (bumpy) ceiling that was painted with a mixture of drywall. Observed pieces of ceiling drywall and pink insulation that hung down from the hole approximately 10 inches in length in several places. Saw a 55-gallon trash can placed on the floor under the hole in the ceiling. Observed several chunks of drywall and water-damaged ceiling placed in a pile next to the trash can in the floor. Observed several damp towels were on the floor by the trash can. During an interview on 12/06/2023 at 12:38 p.m., Resident #6 said she had moved from her old room a few weeks prior into room [ROOM NUMBER]. Resident #6 said the ceiling had leaked on the floor. During an observation on 12/06/2023 at 12:59 p.m., observed room [ROOM NUMBER] located on Hall 1 of the facility. Observed the door was closed and when opened, the room had an odor that was musty and the air felt wet, humid, and damp. Entered room [ROOM NUMBER] and observed water damage on the ceiling approximately in the middle of the ceiling in an area that was approximately 5 feet by 5 feet. Observed the ceiling sagged in the middle and was discolored. Observed the water damaged area consisted of water-stained circles that were tan in color and darker brown around the edges of the circles and overlapped each other. Observed a large oblong area approximately 10 inches in length, 5 inches in width, that was dark green in color and black around the edge on the window side of the large water damaged area of the ceiling. Viewed a large 55-gallon trash can under the damaged ceiling and wet towels on the floor. During an interview on 12/06/2023 at 2:33 p.m., Resident #7 said she moved out of her room approximately a year prior because the ceiling had leaked. During an interview on 12/06/2023 at 2:55 p.m., RN C said she had been at the facility for 14 months. RN C said the ceiling in the facility leaked every time the area received rain. RN C said the ceiling would leak in several different places throughout the facility. RN C said room [ROOM NUMBER] on Hall 4 had major water damage and the ceiling fell in approximately two months prior. During an interview on 12/06/2023 at 3:30 p.m., the Maintenance Supervisor said he had been employed at the facility since June 2023. The Maintenance Supervisor said the ceiling in room [ROOM NUMBER] caved in from rain and leaking in late August 2023 or early September 2023. The Maintenance Supervisor said contractors had come out prior to the ceiling collapse to work on the dry wall and ceiling because the ceiling had been leaking before the major damage had occurred. The Maintenance Supervisor said the plan for repairs was to have contractors from a larger city come to facility and make the repairs. The Maintenance Supervisor said the issue was the corporation put the building on the back burner because the facility was small. The Maintenance Supervisor said the process for work orders and repairs in the facility was for staff to write the issue in the work order binder located at the nurses' station. The Maintenance Supervisor said he checked the book each day and prioritized the tasks to work on the most immediate needs first. The Maintenance Supervisor said the issues with ceiling leaking was a long-standing issue and he addressed this week by week. During an interview on 12/07/2023 at 9:15 a.m., LVN E said she had been at the facility for 2 ½ years. She said the ceiling in the facility had leaked in many places since she had started working. LVN E said the facility had the roof patched on several occasions but not repaired or replaced. LVN E said the roof contained large air conditioner units located on the roof that were not used that were heavy. LVN E said when the area received rain again, the roof would leak. During an interview on 12/07/2023 at 10:46 a.m., the Administrator said the facility did not have a formal policy for work orders but utilized a binder notebook that was kept at the nurses' station and container work order forms. The Administrator said the staff documented the repair need or issue and the form remained in the binder. The Administrator said the maintenance supervisor reviewed the binder daily and would prioritize the repairs based on urgency. The Administrator said the staff would notify the maintenance supervisor. The Administrator said she checked the binder randomly to ensure the work orders were completed and the maintenance supervisor signed off when the repair was completed. The Administrator said staff are informed of the maintenance binder when hired during orientation or if they report an issue to administration. The Administrator said administration staff will direct other staff to document in the maintenance binder. During an interview on 12/07/2023 at 11:42 a.m., The Administrator said the facility had a flat roof that caused water to travel and several different areas of the areas of the roof would leak when the area received rain. The Administrator said over the summer, shingles were replaced over the lobby and the pitched roof area. The Administrator said prior to the summer, the roof over the therapy hall was repaired. The Administrator said room [ROOM NUMBER] was not repaired because the facility was waiting on the roofers to determine where the water traveled from on the roof. The Administrator said the contractors would treat the areas that were water damaged for mold or mildew. The Administrator said the facility had not sprayed any type of chemicals in room [ROOM NUMBER] or room [ROOM NUMBER]. Record review of the facility's policy, Resident Rights, dated 02/23/2016, revealed the resident had the right to a safe environment including a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely. Record review of the facility's admission form signed by the resident and/or responsible person at admission into the facility, Statement of Resident Rights, not dated, revealed the resident had the right to a safe, decent, and clean conditions. Record review of the Maintenance Binder revealed a three-ringer notebook that held several copies of a form labeled Maintenance Work Request Form. Review revealed the form contained three (3) work request on one (1) page and had space to add the date, the location, description of the work required, who made the request, and who completed the request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for two (Resident #18 and #21) of 5 residents reviewed for unnecessary medications. Resident #18 was prescribed the antipsychotic Haloperidol for anxiety or restlessness. Resident #18 was prescribed the antipsychotic Haloperidol and the anti-anxiety Lorazepam as needed for greater than 14 consecutive days without the review of the prescribing doctor. Resident #21 was prescribed an anti-anxiety/antipsychotic medication diazepam/ Haloperidol gel for treatment of agitation, and the antipsychotic quetiapine for dementia. Resident #21 was prescribed an as-needed antipsychotic for more than 14 consecutive days without the review of the prescribing doctor. This failure puts residents at risk of medication adverse effects because of being administered unnecessary antipsychotic medications. Findings include: Review of Resident #18's admission Record dated 7/12/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including chronic heart failure. Review of Resident #18's admission MDS assessment dated [DATE] revealed: He scored a 13 of 15 on his mental status exam (indicating he was cognitively intact) with no signs or symptoms of delirium. He had no potential indicators of psychosis He did not receive the anti-psychotic or anti-anxiety medication in the 7 days prior to the assessment. Resident #18 did receive hospice services. Review of Resident #18's Order Summary Report, dated 7/12/23, revealed: Order dated 6/9/23 Haloperidol 2mg/ml every six hours as needed for anxiety/ restlessness. Order dated 6/9/23 for Lorazepam 1 mg every four hours as needed for anxiety/ restlessness Review of Resident #21's admission Record, dated 7/12/23, revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease, depression, anxiety, arthritis, and abnormal weight loss. Review of Resident #21's quarterly MDS Assessment, dated 5/10/23, revealed: He scored a 7 of 15 on his mental status exam He had delusions He received scheduled and as needed pain medications Triggering medications included an antipsychotic for 4 of 7 days, and an anti-anxiety medication for 4 of 7 days: and an opiate for 7 of 7 days. Resident #21 was on hospice services. Review of Resident #21's Care plan, last revised on 6/2/23, revealed no care plan for the delusions. The facility's care plan for psychotropic medications interventions only addressed monitoring for antidepressant side effects. Review of Resident #21's Order Summary Report, dated 7/12/23 revealed: Order dated 4/24/23 Diazepam/ Haloperidol 2/2 mg/ml. Apply 1 ml to inside of wrist as needed for agitation related to anxiety disorder. Order dated 7/2/23 Diazepam Suspension 10mg/ml give 1 ml by mouth every 1 hour as needed for anxiety. Order dated 6/19/23 Quetiapine Fumarate 100mg by mouth at bedtime for dementia. Order dated 7/6/23 Quetiapine Fumarate 50mg by mouth in the morning for dementia. Interview on 07/13/23 at 8:58 AM, the DON stated the facility expectation on psychoactive medications was the medications to be kept low and to try to get the resident off and/or reduce the medication. The DON said the facility tried to reevaluate the medications every month. The DON stated the facility had triggered care areas to included psychoactive medications in general, a lack of decrease, and the number of residents on them. The DON stated most of the resident did not have an adequate diagnosis because of the doctor. The DON said 'agitation' was not an appropriate diagnosis for the use of an anti-psychotic, but the doctor ordered it. The DON said 'restlessness' was also not an acceptable diagnosis for antipsychotic use. The DON said the residents who were on an antipsychotic had diagnoses that could indicate a need for them but were not indicated as a diagnosis. The DON said the facility usually questioned a diagnosis of dementia with an antipsychotic. The DON explained the facility had to walk a fine line with the doctors because they were resistant to the pharmacy recommendations. The DON said the medical director was an old school doctor and was not receptive to feedback. Interview on 7/13/23 at 2:25 PM, the Corporate RN Consultant stated Hospice agencies would frequently give an inappropriate diagnosis for psychotropic medications. The RN Consultant stated the only inappropriate diagnosis she found were Resident #18 and #21. The RN Consultant stated she was not sure why restlessness were given as the diagnosis because each resident had another diagnosis that would support the use of the anti-psychotic. The RN Consultant stated the way she read the regulation was that there was a stop date on all as-needed medications after 14 days no matter what and after that the physician needed to come and reassess the resident. She stated terminal anxiety would work because the benefits would outweigh the risks. The RN Consultant said that a Haloperidol prescription should always be a 14-day prescription. The RN Consultant stated when the unnecessary psychotropic medication regulation came out, she did extensive education on it with the facilities. The RN Consultant stated she thought it came out in 2018, but then the Covid Health Crisis happened, and everything became about Covid control. The RN Consultant stated the findings were not a surprise because she (the RN Consultant) had been telling the facility regulation on this would happen. The RN Consultant stated the expectation was to get as needed medication a discontinue date for short duration and that there be a diagnosis that supports the medication. The RN Consultant stated she had a discussion with the hospice provider that day (7/13/23). The RN Consultant stated she did not know what happened since the facility had several layers to prevent this from happening. The RN Consultant said the front-line nurses needed to be educated about what was an appropriate diagnosis, then the ADON was supposed to pull orders each morning to see if the diagnosis was appropriate and that monitoring for side effects and behaviors were in place. The RN Consultant stated the facility's pharmacist also looked at diagnosis monthly and they (the pharmacist) should catch the inappropriate diagnosis. The RN Consultant reiterated we have several layers that should have caught the inaccurate diagnosis. The RN Consultant admitted in the Nursing Facility, this ADON had not been validating the orders correctly. The RN Consultant said she did not know why the pharmacist did not catch the diagnosis. The RN Consultant stated the hospice provider was also supposed to do a monthly review of the medications. The RN Consultant stated she had to do some educating on the care plans because the staff believed that if there was a care plan to cover mood or behaviors it would also cover the medication and that was not the expectation. Review of the facility's policy and procedure on Psychotropic Medication, reviewed 1/8/21, revealed: It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary psychotropic drugs. Procedures: Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. PRN orders for Psychotropic drugs are limited to 14 days, except if the prescribing practitioner documents appropriate diagnosis and rationale to continue beyond 14 days. Then he/she must document the rationale in the resident's medical record and writes a new PRN prescription every 14 days after the resident has been evaluated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 6 of 32 residents (Resident #7, Resident #18, Resident #20, Resident #21, Resident #23, and Resident #28) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #7 prior to administering Nortriptyline, an anti-depressant medication used to treat depression (disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #18 prior to administering Haloperidol, an anti-psychotic medication used to treat certain mental disorders (schizophrenia, schizoaffective disorder) and Lorazepam, a sedative used to treat seizure disorders. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #20 prior to administering Diazepam, a sedative and anxiolytic used to treat anxiety, muscle spasms and seizures. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #21 prior to administering Buspirone, an anxiolytic medication used to treat anxiety (disorder characterized by intense, excessive, and persistent worry and fear about everyday situations). The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #23 prior to administering Lorazepam, a sedative used to treat seizure disorders. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #28 prior to administering Diazepam, a sedative and anxiolytic used to treat anxiety, muscle spasms and seizures. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include: Record review of Resident #7's face sheet revealed admission date of 05/30/2017 with diagnoses of Type 2 Diabetes Mellitus, depressive disorder, dementia and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety and fear, strong enough to interfere with ones' daily activities). He was [AGE] years of age. Record review of Resident #7's quarterly MDS, dated [DATE], indicated he had a BIMS score of 14, which indicated he was not cognitively impaired. The MDS also indicated Resident #7 was diagnosed with anxiety and depression. Record review of Resident #7's care plan, dated 06/12/2023 indicated, in part: Focus: Resident uses psychotropic medications related to anxiety and depression. Goal: The resident will remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the next 90 days. Intervention: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #7's medication profile dated 04/13/2022 indicated in part: Nortriptyline 5mg, give one capsule by mouth at bedtime related to depressive disorder. Record review of Resident #7's clinical records revealed no consent on file. Record review of Resident #18's face sheet revealed admission date of 06/09/2023 with diagnoses of Type 2 Diabetes Mellitus, end stage heart disease and chronic kidney disease. He was [AGE] years of age. Record review of Resident #18's admission MDS, dated [DATE], indicated he had a BIMS score of 13, which indicated he was not cognitively impaired. The MDS also indicated Resident #18 was diagnosed with Type 2 Diabetes Mellitus, end stage heart disease and chronic kidney disease. Record review of Resident #18's care plan, dated 06/20/2023 indicated, in part: Focus: Resident has impaired respiratory status and is at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. Goal: Resident will have no reports of unrelieved shortness of breath through the next review date. Intervention: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Monitor for shortness of breath, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions. Notify physician if interventions are not effective. Record review of Resident #18's medication profile dated 06/09//2023 indicated in part: Haloperidol 2mg/ml, give 0.5ml by mouth every 6 hours as needed for nausea/anxiety/restlessness. Lorazepam 1mg tablet by mouth, every 4 hours, as needed for nausea/anxiety/restlessness. Record review of Resident #18's clinical records revealed no consent on file. Record review of Resident #20's face sheet revealed admission date of 10/14/22 with diagnoses of Chronic Obstructive Pulmonary Disorder (a group of lung diseases that block airflow and make it difficult to breathe), Post Traumatic Stress Disorder PTSD (difficulty recovering after experiencing terrifying event), Major depressive disorder (persistent feeling of sadness and loss of interest that interferes in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety and fear, strong enough to interfere with ones' daily activities). She was [AGE] years of age. Record review of Resident #20's quarterly MDS, dated [DATE], indicated she had a BIMS score of 15, which indicated she was not cognitively impaired. The MDS also indicated Resident #20 was diagnosed with anxiety disorder, post-traumatic stress disorder (PTSD) and depression. Record review of Resident #20's care plan, dated 02/06/2023 indicated, in part: Focus: Resident mood problem related to disease process, PTSD. Goal: The resident will have improved mood state (happier, calmer appearance, less signs/symptoms of depression, anxiety or sadness) through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #20's medication profile dated 05/02/2023 indicated in part: Diazepam 2 mg, give one tablet by mouth twice a day related to anxiety. Record review of Resident #20's clinical records revealed no consent on file. Record review of Record review of Resident #21's face sheet revealed admission date of 02/11/2023 with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety and fear, strong enough to interfere with ones' daily activities), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). He was [AGE] years of age. Record review of Resident #21's quarterly MDS, dated [DATE], indicated he had a BIMS score of 07, which indicated he was severely cognitively impaired. The MDS also indicated Resident #21 was diagnosed with anxiety disorder and depression. Record review of Resident #21's care plan, dated 05/19/2023 indicated, in part: Focus: Resident uses psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression, generalized anxiety disorder Goal: Resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic drug use during the next 90 days. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #21's medication profile dated 06/19/2023 indicated in part: Buspirone HCL 10mg, give one tablet by mouth three times a day related to anxiety. Record review of Resident #21's clinical records revealed no consent on file. Record review of Resident #23's face sheet revealed admission date of 03/16/2022 with diagnoses of intellectual disability ( disability that affects the acquisition of knowledge), obsessive compulsive disorder (unreasonable thoughts and fears that lead to compulsive behaviors), major depressive disorder (persistent feeling of sadness and loss of interest that interferes in daily life) , anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety and fear, strong enough to interfere with ones' daily activities). She was [AGE] years of age. Record review of Resident #23's quarterly MDS, dated [DATE], indicated he had a BIMS score of 05, which indicated she was severely cognitively impaired. The MDS also indicated Resident #23 was diagnosed with anxiety disorder and depression. Record review of Resident #23's care plan, dated 05/30/2023 indicated, in part: Focus: uses psychotropic medications (antidepressants, antipsychotics, anxiolytics) related to intellectual disabilities, chronic behaviors such as kleptomania. Goal: The resident will maintain the highest level of function possible, will not experience a decrease in functional abilities and will have side effects and interactions kept to a minimum related to psychotropic drug use during the next 90 days. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #23's medication profile dated 06/01/2023 indicated in part: Lorazepam 1 mg, give one tablet by mouth every 4 hours, as needed for anxiety. Record review of Resident #23's clinical records revealed no consent on file. Record review of Record review of Resident #28's face sheet revealed admission date of 06/13/2022 with diagnoses of senile degeneration of brain (loss of intellectual ability associated with age), Alzheimer's disease, depression, dementia (loss of intellectual functioning, impairment of memory and abstract thinking) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety and fear, strong enough to interfere with ones' daily activities). He was [AGE] years of age. Record review of Resident #28's quarterly MDS, dated [DATE], indicated he had a BIMS score of 01, which indicated he was severely cognitively impaired. The MDS also indicated Resident #28 was diagnosed diagnoses of senile degeneration of brain, Alzheimer's disease, depression, dementia, and anxiety disorder. Record review of Resident #28's care plan, dated 06/25/2023 indicated, in part: Focus: Resident uses psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression, anxiety, and senile degeneration of the brain. Goal: The resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic drug use during the next 90 days. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #28's medication profile dated 02/07/2023 indicated in part: Diazepam gel 10mg/ml, apply to wrist topically every 4 hours as needed for anxiety. Record review of Resident #28's clinical records revealed no consent on file. During an interview and record review on 07/12/23 at 11:55 AM, the ADON stated that consents for the mentioned residents (Resident #7, Resident #18, Resident #20, Resident #21, Resident #23, and Resident #28) were not in the paper charts or the computer charts. The ADON stated that it is her responsibility to ensure that consents are obtained and scanned into the resident charts. The ADON stated that she audits charts and missed these missing consents. The ADON stated that she will get consents immediately. During an interview and record review on 07/12/23 at 4:15 PM, Regional Nurse Consultant stated that she does chart audits every 6 months, the last audit was completed 3 months ago. Regional nurse consultant stated that she is unsure why those consents were missed and will be doing a full audit to fix the problem. Staff nurses are responsible for getting the consents signed, and the ADON ensures that the consents are scanned into the resident chart. Record review of the facility's policy revised 01/08/2021, titled Psychotropic Medications indicated, in part: Policy: It is the facility's policy that each resident drug regimen is free from unnecessary drugs, including psychotropic drugs. Procedure: Informed consent will be obtained prior to administration; consents will be obtained as per state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 15 residents (Residents #18 #19, #21 and #29) reviewed for care plans in that: Resident #18 did not have a care plan to address his diuretic use. Resident #19 did not have a care plan for needs related to Parkinson's Disease (progressive disease of nervous system causing tremors, muscle stiffness, and slow imprecise movements). Resident #21 did not have a care plan to address his antipsychotic use or his antianxiety use. Resident #29 did not have a care plan to address his dietary preference of being a Vegetarian or signs and symptoms of delirium. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #18's admission Record dated 7/12/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including chronic heart failure. Review of Resident #18's admission MDS assessment dated [DATE] revealed he took a diuretic medication for 6 of 7 days prior to the assessment. Review of Resident #18's Care Plan, initiated 6/27/23, revealed no care plan for the use of diuretics. Review of Resident #19's admission Record dated 7/12/23 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's Disease. Review of Resident #19's Quarterly MDS assessment dated [DATE] revealed other neurological conditions as her primary medical condition with Parkinson's Disease identified in the Neurological section of the diagnoses. Review of Resident #19's Care Plan, last revised on 6/26/23, revealed no care plan for Parkinson's Disease. Review of Resident #21's admission Record, dated 7/12/23, revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease, depression, anxiety, arthritis, and abnormal weight loss. Review of Resident #21's quarterly MDS Assessment, dated 5/10/23, revealed: He scored a 7 of 15 on his mental status exam He had delusions He received scheduled and as needed pain medications Triggering medications included an antipsychotic for 4 of 7 days, and an anti-anxiety medication for 4 of 7 days; and an opiate for 7 of 7 days. Review of Resident #21's Care plan, last revised on 6/2/23, revealed no care plan for the delusions. The facility's care plan for psychotropic medications interventions only addressed monitoring for antidepressant side effects. Review of Resident #29's admission Record, dated 7/12/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy Bodies (a form of dementia caused by clumps of abnormal proteins that build up in the brain) and chronic pain. Review of Resident #29's quarterly MDS Assessment, dated 5/17/23 revealed He showed signs of delirium including disorganized thinking and altered level of consciousness both fluctuated. Active diagnoses Primary Medical Condition was progressive neurological conditions. The neurological section of the diagnoses indicated Resident #29 had Non-Alzheimer's Dementia and Parkinson's Disease. He weighed 128 pounds and was on a mechanically altered diet. Resident #29 received scheduled pain medication. Interview on 7/11/23 at 3:18 p.m., Resident #29 stated he was vegetarian. He stated he was sick of peanut butter and jelly sandwiches or tomato soup. Resident #29 said to address this the therapist got a menu from the kitchen for the week to include the alternatives and they would pick what was appropriate for this. He stated this was only fixed a few weeks prior 7/11/23. Review of Resident #29's Care Plan, last revised on 5/26/23, revealed no care plan for delirium; no care plan for being vegetarian, no care plan for the mechanically altered diet, and no care plan for his pain. Interview on 7/13/23 at 11:28 AM, the DON said she expected care plans to address specific diagnoses and what needs to happen from there, physician or specific providers, or what the facility expected to accomplish with that resident. She stated she expected ADL status, things the facility could do to improve the resident and what needs to happen for them which mean meant daily xyz care and communicated ADLs provided. The DON stated the ADON did care plans more than anyone else. The DON stated the ADON would review care plans. The DON said herself and the ADON shared an office so they would talk about what the resident needed and what needed to be on the care plan. The DON stated for Resident #29 she expected to see his hospice, getting up in his chair (therapy), lack of activities, ADLs, his lack of movement once he was in his chair and his supports only being a couple of neighbors who would come check on him. She said because of that Resident #29 needed a little extra listening and attention from the staff. The DON stated if there was an expectation for a pain care plan was a good question and a facility could not over care plan for a resident. Interview on 7/13/23 at 11:41 AM, the ADON stated she did the base line care plan and would initiate care plans in the computer after completing the MDS but someone else was responsible for doing the care plan. The ADON said things that needed to be included on the care plan were ADLs, behaviors, psychotropic medications, code status, anticoagulants, diagnoses and go from there. The ADON stated she would go through the resident's chart including notes and if something happened to that resident, she (the ADON) would add it to the care plan like falls. The ADON described Resident #29 as vegetarian, had no family, was on hospice, did not like the food, rarely watched TV, and he was usually pretty with it. The ADON stated she would expect to see a care plan for Resident #29 being vegetarian; the ADON explained the DM would usually do the diet expectations but the facility's last 2 DM's were less than stellar and did not do the care plans. The ADON stated she expected to care plan his occasional confusion. The ADON said she did not if Resident #29 was on scheduled pain would expect a care plan on pain medication if he was. The ADON said Resident #18 should have a care plan for diuretic use. should have detail on cath. The ADON stated Resident #19 should definitely have a care plan for her Parkinson's. Interview on 7/13/23 at 12:11 PM, the Regional DM stated she would make sure that the care plans got updated. The DM stated the dietary department was responsible for updating care plans. Interview on 07/13/23 at 03:31 PM, the MDS Coordinator stated she initiated the care plan and nursing and whoever was able to make the changes that needed to be made. She stated dietary care plans were supposed to be done by the DM, but the facility did not have one so she did not know who would be responsible for it. Review of the facility's policy and procedure on Care Plans, revised 5/6/16, revealed: It is the intent of the [corporation] to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments completion. Purpose: the purpose of this guide is to ensure that an interdisciplinary approach is utilized in addressing the Care Area Triggers that were generated by the completion of the Minimum Data Set in order to effectively address the Care Area Assessments and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Procedure: All comprehensive care plans will be completed utilizing the [computer software documentation program] electronic system. The facility Interdisciplinary Team members are responsible for addressing their assigned Care Area Assessments triggered by the MDS at the time of the MDS assessment. Case Mix Manager or designee will be responsible for: Delirium, psychotropic drug use, and pain. Dietary Manager or designee will be responsible for Nutritional Status. Care Plan Updates The Interdisciplinary Team will review the care plans Annually, Quarterly, and as needed to ensure all goals and approaches are appropriate. Acute Care Plans: As acute problems or changes to interventions or goals are identified as appropriate care plans will be developed or modified by a Nursing staff member. Care Plan Meetings. Review of the facility's policy and procedure on Baseline Care Plans, revised 5/13/21, revealed: Resident person-centered baseline care plans are developed and implemented for new admission and readmission residents. Fundamental Information Resident person-centered baseline care plans communicate fundamental approaches and goals for resident related clinical diagnosis, identified concerns, and as a result of the admission evaluation/assessment of each healthcare discipline. The baseline care plans are developed and implements to support effective individualized resident care that meet professional standards of quality care and services. Resident person-centered baseline care plans describe services not provided due to the resident's exercise of rights, including the right to refuse treatment. A. Desires and refusals of the resident will be documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms (indicate which med room) inspected for medication storage, for 1 of 1 treatment carts (which med cart) inspected for medication storage, and for 1 of 31 residents reviewed for pharmacy services (Residents # 29) during review of medication carts. The facility failed to ensure the Review of the medication room revealed: opened and undated vials of influenza vaccine. Review of the wound care/ treatment cart revealed: Review of the medication cart revealed: expired medications in cart This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Record review of Resident #29's admission record dated 07/13/23 indicated he was admitted to the facility on [DATE] with diagnoses which included neurologic disorder with Lewy bodies (affects chemical in brain and impairs thinking, movement, behavior, and mood), heart failure (heart does not pump blood like it should), anemia, atrial fibrillation (rapid heart rate that causes poor blood flow) and Parkinson's (disorder of central nervous system that causes tremors). He was [AGE] years of age. Record review of Resident #29's quarterly MDS, dated [DATE], indicated he had a BIMS score of 15, which indicated he was not cognitively impaired. The MDS also indicated Resident #29 was diagnosed with heart failure. Record review of Resident #29's care plan dated 05/26/2023 indicated in part: Problem: Resident has altered cardiovascular status r/t Atrial Fibrillation, and heart failure. Goal: The resident will be free from s/s of complications of cardiac problems through the review date. Intervention: Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts. Record review of Resident #29's order summary report, dated 05/20/2023, indicated in part: Aspirin 81mg tablet, Give 1 tablet by mouth in A.M. for heart failure. During an observation and record review on 07/12/23 at 10:00 AM, the medication room was observed with LVN E present. Inside the refrigerator there were three opened/undated 5ml vials of influenza vaccine with expiration dates of 6/30/23. The influenza vaccine manufacture pamphlet dated March 2022 indicated in part: Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. Observation of the wound care cart on 07/12/23 at 10:45 AM revealed: - 1 tube of aspercreme 4% lidocaine 2.5fl oz expired 2/23; -5 bottles of rapid dry 28 ml expired 2/22; -1 tube of medical grade honey gel 1.5 oz expired 2/23; -1 package of alginate wound dressing expired 5/21; -1 bottle of pain and itch spray 2.75 fl oz expired 6/22; -16 packages of honey non adherant dressing 10cmX12.5cm expired 11/19; -1 hydrocolloid dressing 6in X 6in expired 10/18; -15 packages of providone iodine swab sticks expired 9/20; -29 packages of hydrogel 4inX4in squares expired 12/21; -10 medical grade honey 2in X2in expired 6/23; and -1 box of calcium alginate dressing 12-inch rope expired 1/22. During an interview on 07/12/23 at 10:30 AM, LVN E said that all nurses were responsible for ensuring that expired medications and supplies were pulled from medication room and carts. LVN E stated that all nurses have access to the locked cabinet where expired medications are stored for destruction. LVN E stated that she is responsible for the treatment cart and was unaware that the expired wound care supplies were in the cart. LVN E stated that she will start checking for expired medications and supplies from now on. During an observation and interview on 07/12/23 at 11:00 AM, medication cart 1 of 4, revealed a bottle of Aspirin 81mg, expired 5/31/2023, prescribed to Resident #29. LVN F stated that she administered the aspirin to Resident #29 yesterday and today and failed to notice it was expired. LVN F stated that the resident was prescribed Aspirin on 5/20/23. Record review of the MAR dated 00/00/00 for Resident #29 revealed he received Aspirin from the expired bottle every day. LVN F stated that adverse effects of administering expired Aspirin is that the resident will not get the desired effect of the medication. LVN F stated that she is unsure why the failure occurred and nurses were responsible for ensuring that expired medications were pulled from the medication carts. During an interview and record review on 07/13/23 at 09:20 AM the DON stated that all staff nurses have keys to the locked medication cabinet in the medication room, where all expired and discontinued medications are to be stored for disposal. All staff nurses should be checking their medication carts, treatment carts and medication room daily for expired medications and supplies. DON stated that she and the ADON check medication carts every 1 to 2 weeks for expired medications but she had never checked for expired supplies. The DON stated that pharmacy performed monthly audits of medication room and medication carts. Record review of the monthly audits performed by the pharmacist revealed that the pharmacist found expired meds in April 2023 and June 2023 audit. The DON stated that it is ultimately her responsibility to ensure that expired medications are removed from the medication room and medication carts. The DON stated that she thinks that Resident #29 was prescribed aspirin for his heart, to thin his blood. The DON stated that since the aspirin was expired, it was not providing the desired effect for the resident. The DON stated she will implement a plan to ensure that medication carts, treatment carts and medication rooms are reviewed for expired medications and supplies. Record review of the facility's policy titled Storage of Medications revised 9/2018 indicated in part: Outdated, contaminated, or deteriorated medications are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of the amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have certified resident rooms equipped for adequate nursing care, comfort, and privacy for 4 of 53 rooms (Rooms #1A and #1B, #26A and #26B, #27A and #27B, and #55A and #55B) as evidenced by: Hall A, room [ROOM NUMBER] was certified for two Title 18 (Medicare) resident beds and was not resident ready. room [ROOM NUMBER] could not be easily transitioned into a resident ready room. room [ROOM NUMBER] was being used as the facility administrator's office and contained a desk, bookshelves, filing cabinets and a small table and chairs. room [ROOM NUMBER] had no resident furniture. Hall B, room [ROOM NUMBER] was certified for two Title 18 (Medicare) resident beds and was not resident ready. room [ROOM NUMBER] could not be easily transitioned into a resident ready room. room [ROOM NUMBER] was being used as the medical records office/storage and contained large storage shelves on three of four walls and a desk. room [ROOM NUMBER] had no resident furniture. Hall B, room [ROOM NUMBER] was certified for two Title 18 (Medicare) resident beds and was not resident ready. room [ROOM NUMBER] could not be easily transitioned into a resident ready room. room [ROOM NUMBER] was being used as the therapy office and had wall mounted desks on three of four walls. room [ROOM NUMBER] had no resident furniture. Hall D, room [ROOM NUMBER] was certified for two Title 18 (Medicare) resident beds and was not resident ready. room [ROOM NUMBER] could not be easily transitioned into a resident ready room. room [ROOM NUMBER] was being used as a nursing supply room with heavy duty shelving anchored to the walls. room [ROOM NUMBER] had no resident furniture. This failure could affect residents by placing them at risk of residing in rooms without proper furnishings and privacy. The findings include: Review of the facility-completed Form 3740 Bed Classification, completed and signed by the Administrator on 06/15/22, documented the facility identified room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] as Title 18 Medicare-Only beds for both the A and B beds in each room. Observation on 06/15/22 beginning at 1:45 PM showed: room [ROOM NUMBER] was used as an office for the Administrator. room [ROOM NUMBER] contained a desk, bookshelves, filing cabinets and a small table and chairs. room [ROOM NUMBER] contained no resident furniture, no privacy curtain tracks, and no visible call light jack. room [ROOM NUMBER] was used as the medical records office. room [ROOM NUMBER] had shelving on three of four walls and a desk as well as a door equipped with a keyed lock. room [ROOM NUMBER] contained no resident furniture, no privacy curtain tracks, and no visible call light jack. room [ROOM NUMBER] was used as the therapy staff office. room [ROOM NUMBER] contained wall mounted desks on three of four walls. room [ROOM NUMBER] contained no resident furniture, no privacy curtain tracks, and no visible call light jack. room [ROOM NUMBER] was used as a nursing supply storage room. room [ROOM NUMBER] contained heavy duty, anchored shelving on three of four walls. room [ROOM NUMBER] contained no resident furniture, no privacy curtain tracks, and no call light [NAME]. In an interview on 06/15/22 at 3:29 PM, the Administrator stated that room [ROOM NUMBER] has always been the administrator's office. Administrator stated that all the offices are classed as Title 18 Medicare-Only rooms. She stated that room [ROOM NUMBER] was used for medical records and had been switched over from another room recently, though she could not remember an exact date. The Administrator stated that Room # 27 and room [ROOM NUMBER] could be converted back to resident ready but that it would take at least a day. She stated that due to the age of the building, there was very little designated office space or storage space and resident rooms had been taken over as workspace because of that. In an interview on 06/16/22 at 11:16 AM, the Administrator stated there was no facility policy regarding bed classification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide a safe, functional and comfortable environment for residents in 4 of 4 halls (A, B, C, and D) in that: Resident rooms and other areas accessible including public hallways to the residents had broken windows; door sills that were hard to get over ; drywall damage; missing or detached baseboards; furniture that was worn to the exposed wood and/or particle board (cannot be sanitized due to porous surface); loose handrails; and cobwebs in resident rooms. These failures could affect the residents and placed them at risk of living in an unsafe and uncomfortable environment. Findings included: Observation on 6/13/22 at 11:18 AM revealed room [ROOM NUMBER] had a chipped door sill. Surveyor attempted to roll a bedside table over it and it caught. (If a bedside table could 'catch' then any other rolling device would also 'catch'. Observation on 6/15/22 beginning at 01:53 PM of Hall A revealed: room [ROOM NUMBER] - the doorsill was chipped, and the nightstands worn to the wood was not santizable. room [ROOM NUMBER] - both nightstands were worn to the exposed wood was and not sanitizable. room [ROOM NUMBER] - both nightstands were worn the exposed wood was not sanitizable. room [ROOM NUMBER] - the doorsill cracked. room [ROOM NUMBER] - the doorsill was cracked; 1 of 2 nightstands was worn to the wood and was not sanitizable and the ceiling had dark brown smears on it. The handrail between room [ROOM NUMBER] and 13 was detached from the hanger. room [ROOM NUMBER] - 1 of 2 nightstands were worn down to the exposed wood the other nightstand was worn to the exposed particle board - neither was santizable. The Hopper Room door on Hall A was scrapped and unsightly. The Shower Room on Hall A was scraped and worn to the exposed wood. Observation beginning on 06/15/22 at 2:05 PM of B hall revealed: A screw on the outside/bottom of the handrail between the offices and resident rooms was patched and sharp. The handrail between the hopper room and shower room was loose. The Administrator was shown the loose handrail and stated, oh I wasn't aware, I'll get that fixed. She stated the plan was to update the rooms as they could. She said the facility was going to concentrate the efforts on the lobby and hallway first. room [ROOM NUMBER] - the doorsill was cracked. The resident in that room was observed to use a walker. room [ROOM NUMBER]'s - the base board was coming off the wall by the door on one wall and behind the door on the other wall. The windowsill plaster was cracked. The doorsill was chipped. The resident using the room at that time was observed using a walker. room [ROOM NUMBER] - the plaster on windowsill was cracked to exposed metal. room [ROOM NUMBER] - the door was scraped, and the doorsill was cracked. The resident in the room was observed with a wheelchair. room [ROOM NUMBER] - the doorsill was cracked. The handrail between rooms [ROOM NUMBERS] was loose. room [ROOM NUMBER] - The doorsill was cracked. room [ROOM NUMBER] - The doorsill was cracked in two places; the resident was observed using a wheelchair. There was a cable cover for wires that was held up with push pins. room [ROOM NUMBER] - The doorsill was cracked, the windowsill was cracked, and the family chair was worn to the bare wood and could not be sanitized Observation beginning 06/15/22 at 02:43 PM of the C hall environment showed: The handrail by the nurse's station was loose but blocked by a facility wheelchair. The handrail by the dining room was loose and the closed door on C hall was scratched and gouged leaving the wood unsantizable. room [ROOM NUMBER] - The bed side tables was worn to bare wood, both dressers were scraped to exposed wood. There was a hole in the wall beside the B hall. The handrail outside room [ROOM NUMBER] was loose. room [ROOM NUMBER] - the window was taped shut with thick, black tape. The resident stated the window had been broke about a year. room [ROOM NUMBER] - The doorsill was cracked. room [ROOM NUMBER] - the door was scraped; the bed side table was warped and cracked; there were cobwebs behind the resident's recliner and in the closet. The dresser was worn to exposed wood and the resident confirmed it was the facility's dresser. The handrail between rooms [ROOM NUMBERS] was loose. room [ROOM NUMBER] - The B bed's bedside table was worn to exposed particle board, baseboards were coming off from the wall. The handrail between rooms [ROOM NUMBERS] was loose. The handrail between rooms [ROOM NUMBERS] was loose. room [ROOM NUMBER] - The bed side table was worn to particle board and unable to be sanitized. Observation on 06/15/22 beginning at 03:03 PM showed: The D Hall handrail across from the nurse's station was loose. room [ROOM NUMBER] - The doorsill was cracked; the fall mat was cracked leaving the fabric underneath exposed (unable to be sanititized); the windowsill plaster was cracked to exposed to the metal underneath. The handrail between the shower room and the women's bathroom was very loose. room [ROOM NUMBER]- There was a chunk of windowsill missing leaving the metal underneath exposed. The handrail outside of room [ROOM NUMBER] loose. room [ROOM NUMBER] - the paint was peeling at the ceiling above the resident beds, and there was worn, exposed wood on the dresser. room [ROOM NUMBER] - The windowsill was cracked to exposed wood and there was a crack from the floor to ceiling behind the b bed nightstand. room [ROOM NUMBER] - There was a hole in the room under the window and the dresser was worn to exposed particle board (unable to be sanitized). room [ROOM NUMBER] -The ceiling had water damage and peeling paint over the B bed. room [ROOM NUMBER] - The bed side table was missing edging and was worn to particle board (could not be sanitized). The handrail between room [ROOM NUMBER] and 50 was loose. room [ROOM NUMBER] - The windowsill had peeling paint, the dresser was chipped and worn to exposed particle board (could not be sanitized). room [ROOM NUMBER]- Had paint chipped above the bed. room [ROOM NUMBER] - The windowsill plaster was gone leaving the metal exposed, the furniture worn to exposed wood (could not be sanitized). Interview on 6/15/22 at 3:29 PM the Administrator said she was embarrassed about the glass in room [ROOM NUMBER]. She nodded her head in a yes motion about the worn out furniture Interview on 06/16/22 at 11:16 AM during the exit conference the Administrator stated they could not find a policy on homelike environment, essential equipment, or handrails.