**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 2 CNAs (CNA C) reviewed for CNA certification. The facility failed to ensure CNA C's certification was current before allowing her to care for residents. CNA C worked in the facility providing resident care, on a full-time basis, with an expired certification for the months of February and [DATE]. This failure could place residents who received care from CNA C in medical jeopardy, which could lead to the decreased physical, mental, and psychosocial well-being of each resident. Findings included: On [DATE] record review of employee records revealed CNA C's certification expired on [DATE]. An interview with the BOM/HR on [DATE] at 3:27PM revealed she was not aware CNA C's certification had expired. She stated she thought it was the responsibility of CNA C, not herself, to ensure the certification was up to date. CNA C had been on bereavement leave since [DATE] and was not interviewed. An interview on [DATE] at 3:30PM with the Admn., the DON, the ADON, and the BOM/HR revealed the DON was not aware CNA C's certification had expired. The DON stated the last day CNA C worked on the floor was [DATE] due to a death in the family. It was noted at that time, CNA C had been working for 2-months prior to [DATE] with an expired certification. The BOM/HR asked the DON if it was her responsibility to keep up with CNA certifications. The Admn stated it was both the responsibility of the DON and the BOM/HR, along with the employee to ensure all certifications were up to date. The Admn. stated the BOM/HR should have had a system for reviewing employee folders or files to ensure all HR paperwork was up to date. The DON should have had the dates of her employees' certifications and licenses in an electronic file on her computer where it was reviewed monthly. The Admin., the ADON, and the BOM/HR could not identify a negative outcome of having an uncertified CNA caring for residents. The DON stated CNA C had been a CNA for an exceptionally long time and she was competent in her skillset but could not give a negative outcome of CNA C providing care to residents with an expired certification. An interview with the Administrator on [DATE] at 5:27PM reflected monthly in-service trainings did not count as competency training in the aforementioned subjects, due to the fact that monthly in-services did not have a pre- or post-test and had no measure of staff competency but were informational and meant as a refresher course to keep vital information at the forefront of staff decision-making and resident care. There was no facility policy for the review of employee files by the BOM/HR or for the oversight of certificates by the DON.

Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 4 out of 5 employees (LVN A, CNA B, CNA C and PTA) reviewed for required training. The facility failed to ensure staff were properly trained in Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures and Dementia for 4 of 5 employees (LVN A, CNA B, CNA C, and the PTA) reviewed for training at hire and annually. This failure could place residents at risk of receiving care from individuals who did not have the knowledge and skills to properly provide safety from adverse events or other resident life and health complications. Findings included: Record review of employee records for LVN A reflected LVN A was hired at the facility on 03/18/2022 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 09/24/2023. Record review of employee records for CNA B reflected CNA B was hired at the facility on 06/09/2023 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 02/24/2024. Record review of employee records for CNA C reflected CNA C was hired at the facility on 02/28/2023 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 02/28/2024. Record review of employee records for the PTA reflected the PTA was hired at the facility on an unknown date and had not received any training through the facility, on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since hire. An interview with the BOM/HR on 04/15/2025 at 3:27PM reflected she was unaware LVN A, CNA's B and C, and the PTA were not up to date on their trainings. She stated she had spoken with the corporate office about trainings being provided to the facility staff, but nothing had been done at the corporate level. She stated she had asked the corporate office about the required instructional material of trainings, not the timing of trainings. The BOM/HR stated the PTA did not have trainings for Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, HIV, Restrains, Emergency Procedures, and Dementia on file with the facility because she assumed the PTA had done them through her contracted company. The BOM/HR had not asked the company for verification of the trainings for the PTA prior to hire and was unable to provide the telephone number for the contracted company, so the trainings for the PTA could have been verified. The BOM/HR stated LVN A, CNA B and CNA C should have been trained on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia care through the facility, and could not explain why their training records were not up to date. The BOM/HR stated these trainings were done when an individual was hired and again annually. She stated the negative outcome of caring for residents without training could have been residents received incorrect or incomplete care by the untrained individual. Record Review of undated facility policy for required training reflected the following: There are certain in-service training courses that are required by State such as Blood Borne Pathogens, Restraints, Abuse and Neglect, Slip and Fall, Emergency Preparedness and Resident Rights upon hire and will vary by position and therefore some employees may be required to complete a minimum of courses while others will have a greater amount of training to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #43) of 15 residents reviewed for accuracy of assessments. The facility failed to indicate antipsychotic medication and hospice care on Resident #43's MDS assessment. This failure could place residents at risk of not receiving necessary care and/or services. Findings Included: Record review of Resident #43's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, generalized anxiety disorder (inability to control constant worrying), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and intermittent explosive disorder (repeated sudden outbursts of anger). Resident #43's Primary Payer was Hospice Medicaid. Record review of Resident #43's admission MDS with ARD of 08/28/24 and completion date of 08/29/24 revealed the following: Section C: Resident #43 had a BIMS score of 13 which indicated intact cognition. Section E: Resident #43 experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality) and displayed verbal behaviors directed toward others and other behaviors not directed toward others. These behaviors significantly interfered with his care. He rejected care and wandered 1-3 days during the 7-day lookback period. Section N: Resident #43 was not noted to be receiving antipsychotic medication. Question NO450.A of the MDS asked, Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA (Omnibus Budget Reconciliation Act) assessment, whichever is more recent? This question was answered, No - Antipsychotics were not received. Section O: The instructions for Section O stated, Check all of the following treatments, procedures, and programs that were performed on admission, while a resident, and at discharge. The box for hospice was not checked which indicated Resident #43 was not receiving hospice services while a resident. The box for None of the Above was checked indicating Resident #43 was not receiving hospice services while a resident. Record review of Resident #43's care plan initiated 08/19/24 revealed the following focus area initiated on 08/19/24, I am on [name of hospice] hospice, under the care of [name of physician]. Another focus area initiated on 08/29/24 stated, I use antipsychotic medications and listed the name of the medication as well as his diagnosis of intermittent explosive disorder as the reason for the medication. Record review of Resident #43's active orders dated 10/29/24 revealed the following: An order with start date of 08/19/24 to monitor Resident #43 for antipsychotic medication side effects. An order with start date of 08/16/24 to admit Resident #43 to hospice. An order with start date of 08/17/24 for Ariprazole oral tablet 15 MG (Ariprazole) Give 1 tablet by mouth one time a day related to INTERMITTENT EXPLOSIVE DISORDER. Record review of Resident #43's medication administration for August of 2024 revealed he received Ariprazole every day from 08/17/24-08/31/24. During an observation and interview on 10/29/24 at 10:24 AM Resident #43 was seated in his w/c in his room. He stated he was pleased with the care and services he received through hospice. An interview was attempted with MDS LVN on 10/30/24 at 08:17 AM by telephone. She did not answer the call. During an interview on 10/30/24 at 08:24 AM ADON stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN looked at resident charts to determine what medication and care they were receiving before completing the MDS. ADON stated MDS-LVN also gathered information regarding residents during the staff morning meeting. She stated an inaccurate MDS would negatively affect the rates the facility was paid to provide treatment to the resident. She stated that would negatively impact a resident because the facility would not have the funds needed to care correctly for the resident. During an interview on 10/30/24 at 08:31 AM ADM-IT stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN used the RAI as her policy when completing the assessments. ADM-IT stated MDS-LVN runs the medication list to find out what medications a resident is receiving before completing the MDS. She stated she did not think an inaccurate MDS would negatively affect a resident's care because nursing would still take care of the resident as needed. During an interview on 10/30/24 at 08:37 AM ADM stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN reads doctor's orders to assist in MDS completion. ADM stated an inaccurate MDS might result in the resident not receiving proper care plus I don't get the proper money. During an interview on 10/30/24 at 08:50 AM DON stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN looked in resident charts to find which cares and medications they were receiving. She stated an inaccurate MDS could negative impact a resident's care because the plan of care might be incorrect. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . Section N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of . select medications were received by the resident. In addition, two medication sections have been added. The first is an Antipsychotic Medication Review. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period . Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . Section O SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, None of the above. Hospice care Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

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 and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA B) of 5 staff observed for resident care. -CNA B did not perform the proper process, wash her hands, change gloves, or place a residents brief properly while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 10/29/24 at 10:59 AM of incontinent care performed by CNA B, CNA B cleaned the resident's rectal area first removing several wipes covered with BM, changed her gloves, used ABHR, placed new gloves, sprayed the resident's rectal area with moisture wipe, then wiped his rectal area with two more wipes. CNA B then picked up the new brief with her contaminated gloves and placed it under the residents. The resident was then rolled to his back. CNA B wiped the resident's penis with one wipe then pulled the new brief in place with her contaminated gloves and secured it. CNA B then removed her contaminated gloves and used ABHR. During an interview on 10/29/24 at 11:34 AM CNA B verified that she did remove her gloves and use ABHR then spray the resident's rectal area with moisture wipe, then use two more wipes to clean his rectal area, and then placed his new brief without removing her gloves or washing her hands. CNA B reported that she should have changed her gloves and washed her hands before putting on the clean brief. CNA B reported that if there had been any sign of feces on her gloves she would have had a problem but she did not see anything on her gloves, so she did not feel that not changing her gloves was an issue. CNA B did verify that she cleaned the resident's rectal area first before cleaning his peri area, that due to the residents having pooped she needed to clean his rectal area first. CNA B reported that she understood and had been instructed that a resident who had a BM was supposed to have that cleaned first before cleaning the peri area. CNA B stated, If you clean the back first when it's got poop you have that cleaned and then you won't get the front dirty. CNA B verified that the DON was the current infection control instructor and that she had been instructed on handwashing and glove changes. During an interview on 10/30/24 at 09:00 AM the DON with the ADON present reported that she expects her staff to complete all incontinent care with cleaning the peri area first then the rectal area before placing the new brief. The DON said this was done to prevent bacteria from the rectal area getting in the urethra and causing a UTI/infection. The DON reported that she also expected that infections could develop with glove changes and handwashing that are not done correctly because bacteria could be introduced. The DON expects glove changes/handwashing and/or sanitizer use frequently, anytime a staff member goes from dirty to clean, and before placing any new supplies such as briefs. The DON reported that if this process was not followed then a resident would be placed at risk for infection due to bacteria that would be on the dirty gloves that could be passed to the hands. The DON verified that she did teach staff on infection control, handwashing, and glove changes and that all direct care staff were instructed on the proper process for incontinent care and when to change gloves and use handwashing or ABHR/sanitizer. Record review of the facility provided policy titled Handwashing/Hand Hygiene revised October 2023, revealed the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene f. before moving from work on a soiled body site to a clean body site on the same resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 3 (Resident #2, Resident #26, and Resident #39) of 15 residents reviewed for accidents and hazards. The facility failed to perform quarterly safe smoking assessments on Resident #2, Resident #26, and Resident #39. These failures could place residents at risk of burns and/or injury. Findings Included: Record review of Resident #2's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury with loss of consciousness of unspecified duration (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull), lack of coordination, unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body caused by involuntary contraction of the muscles and associated especially with brain disorders such as epilepsy), and parkinsonism (conditions that affect the ability to move and live independently). Record review of Resident #2's Quarterly MDS completed on 08/21/24 revealed the following: Section B: Resident #2's vision was impaired. Section C: Resident #2 had a BIMS score of 15, which indicated intact cognition. Section E: Resident #2 experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality) and displayed behavioral symptoms directed toward others as well as himself. Section GG: Resident #2 had impairment to upper extremities on one side. He required supervision or touching assistance for eating, bathing, lower body dressing, transfers and bed mobility. He required set up or clean up assistance for oral hygiene, personal hygiene, upper body dressing, footwear (removal and application), and walking. He was independent in toileting. Record review of Resident #2's care plan completed on 09/09/24 revealed he was a smoker and required supervision while smoking due to a lack of coordination and impaired cognition. Record review of Resident #2's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 05/04/2019 10/10/2020 05/11/2021 08/11/2021 11/10/2021 07/03/2023 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #2 from 07/03/23 to 10/29/24. Record review of Resident #2's safe smoking assessment dated [DATE] revealed he required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. Record review of Resident # 26's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a serious mental health disease that causes altered perception of reality), bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), muscle weakness, syncope (dizziness) and collapse, and lack of coordination. Record review of Resident #26's quarterly MDS completed on 10/08/24 revealed the following: Section C: Resident #26 had a BIMS score of 3 which indicated severely impaired cognition. Section E: Resident #26 rejected care and wandered 1-3 days of the 7-day look back period. Section GG: Resident #26 had lower extremity impairment on one side and used a w/c. He required supervision or touching assistance across all ADLs except taking off and putting on footwear and personal hygiene where he required partial/moderate assistance. Record review of Resident #26's care plan completed on 09/10/24 revealed he was at risk for injury while smoking due to poor safety awareness and cognitive impairment. Resident #26 required supervision while smoking. Record review of Resident #26's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 11/17/2022 02/27/2023 07/03/2023 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #26 from 07/03/23 to 10/29/24. Record review of Resident #26's safe smoking assessment dated [DATE] revealed he had cognitive loss, required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. Record review of Resident #39's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, apraxia (difficulty in performing daily tasks), lack of coordination, dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, ataxia (poor muscle control causing clumsy movements), and need for assistance with personal care. Record review of Resident #39's quarterly MDS completed on 09/12/24 revealed the following: Section C: Resident #39 had a BIMS score of 12 which indicated moderate cognitive impairment. Section E: Resident #39 rejected care 1-3 days during the 7-day look back period. Section GG: Resident #39 required supervision or touching assistance across all ADLs. Record review of Resident #39's care plan completed on 09/11/24 revealed he was at risk for injury while smoking related to a lack of coordination. He required supervision while smoking. Record review of Resident #39's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 04/13/2023 07/03/2023 10/03/2023 01/03/2024 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #39 from 01/03/24 to 10/29/24. Record review of Resident #39's safe smoking assessment dated [DATE] revealed he required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. During an interview on 10/30/24 at 08:28 AM ADON stated DON was responsible for completing safe smoking assessments. She said the assessments were to be completed quarterly on each resident who smoked. She said the safe smoking assessments were stored under the assessment tab in the resident's EHR. ADON stated the assessments were not done quarterly because one safe smoking assessment form was retired and the new one failed to trigger in the system when it was due. She stated a possible negative outcome of not assessing residents for safe smoking on a quarterly basis was the facility would not know if the resident needed special equipment to smoke and the residents might burn themselves. During an interview on 10/30/24 at 08:35 AM ADM-IT stated all charge nurses were responsible for completing safe smoking assessments quarterly on all smoking residents. She said the assessments were kept under the assessment tab in the EHR. ADM-IT said a possible negative outcome of not assessing residents for safe smoking quarterly was, We are a nursing home, and the residents will decline eventually, they could be burned, or they could eat their cigarette. During an interview on 10/30/24 at 08:39 AM ADM stated charge nurses were responsible for completing safe smoking assessments. She said the assessments were supposed to be done quarterly and were kept under the assessments tab in the resident's EHR. She said if assessments were not completed quarterly residents could be unsafe to smoke due to disease progression. During an interview on 10/30/24 at 08:54 AM DON stated the nurses were responsible to complete safe smoking assessments and she and ADON were responsible to ensure the assessments were completed. She stated safe smoking assessments were not done for a period of time because corporate made a new one (safe smoking assessment) and it did not trigger to be done. DON stated safe smoking assessments were to be completed quarterly and were kept in the assessments tab in the resident's EHR. She said a possible negative outcome of not completing safe smoking assessments quarterly was residents might require enhanced supervision or not be able to smoke anymore and the facility would not know. Record review of facility policy titled Smoking Policy and dated 01/15/2021 revealed the following: . A smoking safety evaluation will be completed for all residents who smoke on admission change of condition, and quarterly. Record review of facility policy titled Smoking Policy-Residents and dated 2001 revealed the following: This facility has established and maintains safe resident smoking practices. 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to maintain an effective pest control program so that the facility is free of pests for one of one facility reviewed for environment for 3 out of 3 days. -The facility failed to prevent an infestation of flies and gnats based on observations at varied times over a 3-day period from 10-28-2024 to 10-30-2024. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: During an observation of room [ROOM NUMBER] on 10/28/24 at 09:45 AM with no resident present, observed was a partially eaten tray of food in the room on a bedside table with a meal ticket dated Supper: Sunday 10-27-2024 with Salisbury steak, garlic mash potatoes, and green beans listed on the meal ticket with the noted corresponding food partially eaten on the tray. Also noted were multiple flies and gnats on the tray, curtain, wall, and bed. During an observation and interview on 10/28/24 at 10:00 AM revealed Resident #2 was in his room laying on top of his bed. The resident was observed attempting to keep flies off his person. Five flies were observed to be either on him or his bed. The resident reported that the flies were a problem and verified that they were an issue when he eats. During an observation on 10/28/24 at 10:31 AM revealed four flies were noted on the PPE station outside of room [ROOM NUMBER], one fly on the hallway wall and one fly on the hallway floor. During an observation and interview on 10/28/24 at 10:33 AM revealed Resident #10 was observed in his room lying on top of his bed dressed in sweats and a t-shirt. Noted were several flies on his person and bed and he verified that the flies were an issue especially when he eats. During an interview on 10/28/24 at 11:58 AM LVN A verified that she found the resident tray in room [ROOM NUMBER] Bed B this am and removed it (at 10:07 AM observed by the surveyor). LVN A reported that she was aware that a tray left in a resident's room from the previous evening was an issue and stated, I'm sure you (this surveyor) saw the number of flies that were on that tray. LVN A reported that all trays should be removed from the resident's room within one hour of completing a meal. During the noon meal observation on 10/28/24 the following was revealed: 10/28/24 12:10 PM 2 flies on a table with two residents present. 10/28/24 12:12 PM Resident attempts to shoo fly from his coffee cup. 10/28/24 12:12 PM 5 flies on a table with three residents present. 10/28/24 12:23 PM A resident attempts to shoo a fly from his coffee cup. 10/28/24 12:26 PM A fly landed on a resident's food. 10/28/24 12:27 PM A fly landed on rim of a resident's coffee cup. 10/28/24 12:30 PM A fly landed on a resident's fork. During an observation on 10/28/24 at 02:21 PM revealed Resident #27 was in his bed sleeping on top of his covers. Observed were 5 flies on the resident while sleeping. The resident was observed changing positions several times. During an observation on 10/29/24 at 08:45 AM five flies were noted on the Resident #27's bed. The Resident was not present. During an observation and interview on 10/29/24 at 02:03 PM revealed wound care was performed for Resident #10 who was in his room sitting at the side of his bed. Noted were multiple flies in the room. Before the care started the resident made a statement that something needed to be done about the flies. LVN A reported that she would report the issue to the maintenance supervisor. During an interview on 10/28/24 at 03:03 PM the DON reported that a tray being left out was an issue and that all trays should be picked up within one hour of the meal being completed. The DON reported that it could result in an infestation such as the flies that were noted with this incident. The DON reported that she did not know why the staff did not pick up the tray for this resident the previous evening. The DON verified that staff were supposed to complete rounds every two hours. The DON reported that the Resident in room [ROOM NUMBER] could talk but that he will not make sense with his conversations, he will not remember anything, and he will become verbally aggressive if someone tries to talk to him for any length of time. During an interview on 10/29/24 at 08:48 AM and 08:59 AM this surveyor attempted to interview Resident #22 (the resident assigned to room [ROOM NUMBER]) and he did not respond to introduction or questions. He just starred at this surveyor and then started to become agitated. During an interview on 10/29/24 at 10:30 AM in a resident council meeting 19 of 20 anonymous residents stated the flies in the building bother them. There were loud exclamations and groans following the answer. One of the residents spoke up and said, They drive me crazy flying around my face and my ears all the time. During an interview on 10/29/24 at 02:14 PM LVN A reported that the situation with the flies was horrible mostly due to the resident's behavioral issues especially with urinating and defecating everywhere to include the outside courtyard. LVN A reported that the facility has tried multitude different approaches to deal with the flies and could not get the situation under control. LVN A reported that the flies could cause issues with infections such as with a wound. During an interview on 10/29/24 at 02:49 PM the Maintenance Supervisor reported that the facility has had a second pest control fly service completed outside of the usual monthly pest control service, that he spays with permethrin twice weekly; and he sweeps, and power washes the patio twice weekly due to the resident's constant urination and defecation. He stated the facility was looking into getting and automatic closing door for the patio due to the resident will not close the doors to keep out the flies. He stated the facility has added 12 fly lights, and he has automatic fly sprayers around the facility with food grade spray to address the issue. During an interview on 10/29/24 at 03:16 PM the DON reported that the flies were definitely and issue but that they did not know what they could do that they have not done already. The DON reported they have purchased $3000 dollars' worth of fly lights to increase the current fly lights, they have increased housekeeping hours to hopefully address the incontinence issues, and they were currently pricing the replacement cost of the back patio doors with automatic doors. The DON reported that flies could cause an issue with infection. During an interview on 10/30/24 at 08:31 AM the Administrator reported that all meal trays delivered to resident rooms should be delivered as soon and the kitchen gets them ready, they should be covered, and they should be picked up 1 hour after the meal is completed. The Administrator reported that a meal tray left in the resident's room could result in issues such as flies and bugs. Record review of the facility provided Pest Control Statements revealed the facility received pest control service on the following dates: 8-16-2024 9-25-2024 10-23-2024 Record review of the facility provided policy titled Statement of Resident Rights undated, revealed the following: You have the right to: 1. all care necessary for you to have the highest possible level of health, 2. safe, decent, and clean conditions, Record review of the facility provided policy titled Quality of Life-Homelike Environment undated, revealed the following: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment . 2. The facility staff and management shall maximize . a. Clean, sanitary, and orderly environment. Record review of the facility provided policy titled Food Preparation and Service revised November 2021, revealed the following: Food Distribution and Service: 12. Food that has been served to resident without temperature controls (e.g. trays, snacks, etc.) will be discarded if not eaten withing two hours.

Based on observation, interview, 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 food service safety. The facility failed to label and date food in the refrigerator, freezer, and pantry. The facility failed to keep food in the refrigerator and freezer sealed. The facility failed to maintain cleanliness in the pantry. The facility failed to store all food at least 6 inches off the floor in the pantry. These failures could put residents at risk of food and pest borne illnesses. Findings Included: An observation of refrigerator 1 on 10/28/24 at 09:12 AM revealed the following: 1 clear plastic bag open to air containing what appeared to be lunch meat with no label or date. 1 square, opaque, plastic tub with a green lid containing what appeared to be jelly with no label or date. 1 box containing 6 sealed plastic bags of what appeared to be guacamole with brown spots throughout and a date printed on the plastic of 02/03/24. 1 square, opaque, plastic tub with a green lid containing what appeared to be slices of cheese with no label or date. 1 resealable plastic bag containing what appeared to be pasta and marinara sauce with no label and a date of 10/26. 1 bag of shredded mozzarella cheese in original packaging inside resealable plastic bag with no date and green specks throughout. 1 bag of shredded Parmesan cheese in original packaging inside resealable plastic bag with no date. 1 box of cream cheese, one third full with no date. 1 plastic tub with lid full of stacked sandwiches with no label and no date. An observation of refrigerator 2 on 10/28/24 at 09:21 AM revealed the following 1 square, opaque, plastic tub with green lid of jalapeno slices labeled and dated 10/04-10/19. 1 tray with small plastic cups with what appeared to be butter in each one. Covered with plastic wrap. No label or date. 1 opaque, plastic pitcher with red lid containing reddish liquid about 1/4 inch in bottom and some stuck to sides of pitcher with no label or date. 1 square, opaque, plastic tub with green lid full of whitish substance with no label and no date. 1 large metal bowl covered with plastic wrap full of orange substance with no label no and date. An observation of Freezer 1 on 10/28/24 at 09:26 AM revealed the following: 1 box of egg patties open to air. An observation of the pantry on 10/28/24 at 09:27 AM revealed the following: A 5-pound tub of peanut butter with peanut butter smeared all around the outside of the lid and along the bottom edge of the tub in places. 1 5-gallon tub of what appeared to be corn flakes cereal 1/4 full with no label and no date. 1 5-gallon tub of what appeared to be bran flake and raisin cereal 1/3 full with no label and no date. 1 5-gallon tub of what appeared to be crispy rice cereal 3/4 full with no label and no date open to air. 1 5-gallon tub of what appeared to be O-shaped cereal 1/2 full with no label and no date. 1 5-pound buttermilk biscuit mix in bag with no date. 1 bag of powered sugar half full inside a resealable plastic bag with no date. 1/3 loaf of bread with best by date of 10/23. 1 and 3/4 bags of hamburger buns with best by date of 10/24. 1 shelf full of loaves of bread and bags of large tortillas 3 off the floor. 1 grocery bag containing 12 individual serving size resealable plastic bags containing what appeared to be animal crackers with no label and no date. 1 5-gallon tub 1/4 full of what appears to be flour with no label and no date 1 resealable gallon-size plastic bag full of what appears to be vanilla wafers with no label and no date. 1 large sealed bag of what appeared to be vanilla wafers with no label and no date. An observation of Freezer 2 on 10/28/24 at 09:36 AM revealed the following: 1 large bag of what appeared to be tater tots with no label and no date. 1 bag of lumpy whitish substance that appeared to be melted into a solid block on one end with no label and no date. 1 bag of what appeared to be biscuit dough with no label and no date. 1 bag of what appeared to be chicken nuggets with no label and no date. An observation of Freezer 3 on 10/28/24 at 09:40 AM revealed the following: 2 resealable bags of what appeared to be raw chicken with no label and no date. During an interview on 10/28/24 at 09:10 AM DM stated she started her job as DM and had zero training. She stated she had her food manager license but had not received dietary management training. She stated the kitchen had been too short-staffed for her to be trained since she started as DM. She stated she had just recently been able to have days off. During an interview on 10/30/2024 at 08:26 AM ADON stated a possible negative outcome of undated, unlabeled food in the kitchen was residents could get some kind of illness or bacteria. She said a possible negative outcome for residents of food in the freezer being left open to air was residents not having a good, decent, proper meal to eat. During an interview on 10/30/2024 at 08:33 AM ADM-IT stated improperly labeled and dated food in the kitchen could result in residents having food poisoning. She stated food open to air in the freezer was just gross and residents might notice the taste of freezer burn or might not eat the food due to dryness and that could result in weight loss. She stated kitchen staff were responsible for ensuring food was labeled and dated and stored correctly. During an interview on 10/30/2024 at 08:39 AM ADM stated food that was not labelled and dated correctly could result in residents being served something that does not need to be served. During an interview on 10/30/2024 at 08:52 AM DON stated food that was not labelled and dated correctly could make residents sick. During an interview on 10/30/24 at 09:17 AM DM stated she dated food when it came into the kitchen. She stated, I just found out I am supposed to date it when it gets opened. She stated she learned that information during a mock survey. DM stated leftovers were dated by all kitchen staff with two dates, they day they go into the refrigerator and three days later, which is when they are to be thrown away. DM stated food in the refrigerator and in the freezer was to be sealed, no open to air. She stated food in the pantry should not be accessible to pests and the containers should be cleaned if they get dirty. DM stated all staff were responsible for labelling and dating food in the kitchen. She stated she trained her staff regularly one-on-one. DM stated if food was not labelled and dated correctly in the refrigerator or the pantry people can get sick. She stated peanut butter on the outside of the container in the pantry could result in pests. DM stated she did not know food had to be stored at least 6 inches off the floor. Record review of facility policy titled Refrigerators and Freezers and dated 2001 revealed the following: . This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 'Use by' dates will be completed with expiration dates. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Record review of facility policy titled Food Receiving and Storage and dated 2001 revealed the following: . Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 5. Non-refrigerated foods, . will be stored in a designated 'dry storage' unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) . 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). 11. Wrappers of frozen foods must stay intact until thawing. Record review of US Food and Drug Administration Food Code dated 2022 revealed the following: . Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: . 3) At least 15 cm (6 inches) above the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure each resident had the right to formulate an advance directive for 1 (Resident #1) of 6 residents reviewed for advance directives. Resident #1 had a DNR that was signed by the physician in the wrong section and was not dated by the physician. This failure could place residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #1's face sheet dated 11-13-23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), personal history of cerebral infarction (stroke) muscle wasting and atrophy, anemia (lower than normal amount of healthy red blood cells), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident #1's face sheet noted he was DNR. Record review of Resident #1's Quarterly MDS, completed [DATE] revealed a BIMS of 9 which indicated moderately impaired cognition. Record review of Resident #1's care plan revised on [DATE] revealed the following focus area, I request a code status of DNR initiated on [DATE]. Record review of Resident #1's Order Summary Report dated [DATE] revealed an order for DNR with an order date of [DATE]. Record review of Resident #1's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order form section A revealed Resident #1's printed name, date of birth , signature, and the date [[DATE]] in the correct blanks. The portion of section E titled, Two Witnesses had the required signatures, dates [[DATE]], and printed names of two witnesses. The portion of section E titled Physician's Statement had no information on the signature, date, license #, or printed name blanks. Section F titled Directive by two physicians on behalf of the adult who is incompetent or unable to communicate and without guardian, agent, proxy . contained a signature, printed name, and license number of Resident #1's primary physician but the line for a date was left blank as were the signature, date, printed name, and license number lines for the second physician. During an interview on [DATE] at 10:17 AM LVN C stated a DNR not dated by the physician is not a DNR. When asked if she would refrain from providing CPR to a resident with a DNR that was not dated by the physician, she replied, I mean, you can't it is not a DNR. During an interview on [DATE] at 10:23 AM BOM stated a DNR that was not dated by the physician was not valid. She said a possible negative outcome of having a DNR with no date by the physician was, It would be invalid, and we would have to do CPR on him. During an observation and interview on [DATE] at 10:37 AM Resident #1 was lying in his bed with his walker next to the head of the bed. He had his eyes closed but opened them at the sound of his name. He stated he was not feeling very good due to having COVID (a severe acute respiratory syndrome). When asked if he still wanted to be DNR he looked away and closed his eyes and would not open his eyes or answer any other questions. During an interview on [DATE] at 12:35 PM BOM said of Resident #1's DNR not being dated by the physician, That could have been real bad! She held up a new copy of the DNR that was dated by the physician and said, Now I just have to go get it notarized. During an interview on [DATE] at 01:08 PM Resident #1's emergency contact was asked if she knew if Resident #1 still wanted to be DNR. She replied, Yes. I do know for sure. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER dated [DATE] revealed in part: The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. Record review of facility policy titled, Advance Directives and dated 2001 revealed in part: Advance directives will be respected in accordance with state law and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop and implement a base-line care plan with-in 48 hours for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 1 of 15 residents (Resident #14) whose care plans were reviewed. The facility failed to develop a base-line care plan with-in 48 hours of resident admitting into the facility. This failure could place all residents at risk of receiving care that does not meet the initial goals, medication interventions, services or treatments, or updated information related to re-admitting to the facility after 30 days. Findings include: Record review of Resident #14's face sheet is a 58- year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14's diagnoses included but are not limited to: schizoaffective disorder (depressive type), obsessive-compulsive disorder, anxiety, motor-neuron disease, and aphasia. Record review of Resident #14's MDS, dated [DATE], indicated a BIMS score of 99, indicating cognition could not be measured. Record review of Resident #14's MDS face sheet, undated, indicated resident was discharged on 4/13/2023 and returned to facility on 6/1/2023. Resident #14 was discharged from the facility for 48 days. Record review of Resident #14's MDS face sheet, undated, shows an MDS Entry assessment dated [DATE]. A Quarterly assessment is dated 6/14/2023. Record review of Resident #14's care plan face sheet, undated, indicated Resident #14's initial baseline/comprehensive care plan was initiated 6/28/23. In an interview on 8/31/23 at 9:46 AM, the DON stated she oversaw the care plans with the MDS coordinator. Care plans are done every Wednesday based on the MDS Nurse assessment. The DON stated baseline care plans are completed within 72 hours and a baseline care plan was not required if the resident was out of the facility for more than 30 days. The DON stated that Resident #14 was absent from the facility for more than 30 days and the baseline care plan was missing from their assessments. DON indicated a negative outcome would be a change in the resident's baseline and staff would have not noticed. In an interview on 8/31/2023 at 9:56 AM, MDS Nurse indicated an MDS assessment was opened and completed within 13 days of a resident being admitted . MDS nurse stated DON signed it and MDS nurse places their information in Section X. MDS Coordinator indicated a baseline care plan should be completed immediately once someone returns from being discharged . MDS nurse stated if the resident was out after 30 days, it would be a new baseline care plan. MDS Nurse confirmed there was not a baseline care plan located in Resident #14's chart. MDS Nurse stated that a negative outcome would be the resident does not get the proper care. Record review of facility's policy titled Care Plans, Comprehensive Person-Centered, revised in December 2016, reveals that policy does not cover timeframe dedicated to baseline care plan timeline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 2 of 15 residents (Residents #7 and #16) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to develop person-centered goals reflecting medical needs outside the facility of dialysis for Resident #16 2. Failure to develop person-centered goals reflecting psychosocial needs for activities for Resident #7. These failures could place all residents at risk of receiving care that is substandard, not individualized to the resident, or not meeting the highest practical medical and psychosocial needs. Findings included: Resident #7 Record review of Resident #7's face sheet, dated 8/30/23, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #7's diagnoses included, but not limited to, schizoaffective disorder, anxiety disorder, chronic pain, major depressive disorder, and multiple sclerosis. Record review of Resident #7's BIMS, dated 7/7/23, revealed a score of 15 indicating that the resident was cognitively intact. Record review of Resident #7's care plan, revised on 8/9/23, did not address the resident's activity needs and did not include individualized goals for the residents' psychosocial needs. Resident #16 Record review of Resident #16's face sheet, dated 8/30/2023, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident's diagnoses included but not limited to acute and chronic respiratory failure with hypoxia, type 2 diabetes, end stage renal disease, and heart failure. Record review of Resident #16's MDS, dated [DATE], indicated a BIMS score of 15 indicating that resident was cognitively intact. Record review of resident progress notes indicated that resident attended dialysis on the following days: 8/28/23, 8/23/23, 8/18/23, 8/14/23, 8/11/23, 8/9/23, 8/7/23, and 8/4/23. Record review of Resident #16's care plan, dated 7/19/23, revealed there is no goal related to resident's dialysis treatments. In an interview on 8/31/23 at 9:46 AM, the DON stated she oversaw care plans with the MDS coordinator. Care plans are done every Wednesday based on the MDS nurse assessment. In an interview on 8/31/2023 at 10:10 AM, the DON indicated a negative outcome of not having all needs care planned would be the care team does know what was going on with the residents. Record review of facility policy title Care plans, Comprehensive Person-Centered, revised December 2016, Section 8, Line B states to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Line G states to incorporate identified problem areas. Line L states to identify the professional services that are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay for 1 (Resident #60) of 2 residents reviewed for discharge summaries. A. The facility failed to ensure a Discharge Summary for Resident # 60 was completed which included a complete recapitulation of the resident's stay for a resident discharged to another facility. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents, and failure in the continuity of care for residents. The Findings included: Record review of Resident #60's electronic face sheet dated 8/31/23 indicated a [AGE] year-old male admitted on [DATE] with the following diagnoses: Alzheimer's disease, unspecified convulsions, personal history of brain injury, intermittent explosive disorder, diabetes, unspecified mood disorder, dementia, chronic kidney disease, retention of urine and psychotic disorder with delusions. A discharge MDS dated [DATE] documented a BIMS score of 5 out of 15 indicating cognition was severely impaired. A care plan dated 7/11/23 documented Resident #60 was independent in ADLs, required medications to be crushed, had a history of UTI's, had the potential for verbal aggression, physical aggression, and sexually inappropriate behaviors. Record review of Resident #60's physician progress note revealed the last note was dated 6/27/23. Nurses progress note dated 6/28/23 indicated Resident #60's family requested resident to be referred to a facility closer to family. A Nurses progress note dated 7/10/23 documented Resident #60 was accepted to another facility. A Nurses progress note on7/11/23 documented Resident #60 was discharged to another facility. Record review of Resident #60's record indicated there was no Physicians discharge summary in the record. During an interview on 8/31//2023 at 11:27 am the DON stated there was no discharge summary. The DON stated she did not know what happened to it and could not find it. The DON said resident's clinical records, including an accurate discharge summary, were supposed to be forwarded or faxed to the receiving facility in addition to verbal communication. The DON stated the facility did not send any resident paperwork with the resident. The DON stated the consequences of not having a physician discharge summary was if something happened to the resident the facility during the transfer, the facility would be responsible and the receiving facility would not have any history of his care. A policy was requested but never provided.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The facility did not have an RN in the facility on 06/3/2023, 06/04/2023, and 06/18/2023, accounting for 3 days in the last 90 days. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care. Findings include: Record review of the facility's last 90 days of time sheets for RN coverage revealed that the facility did not have an RN in the facility on 06/03/2023, 06/04/2023, and 06/18/2023. During an interview on 08/31/2023 at 11:27 AM with the DON stated she had the job posted and did not have an RN hired at that time which was why the facility was without RN coverage for 06/03/2023, 06/04/2023 . The DON stated on 06/18/2023 she did have a RN scheduled but was not sure why she did not show up. During an interview on 08/31/23 at 02:38 PM with the DON, stated a negative outcome would be for insufficient RN hours was lack of patient care. Record review of facility presented policy titled Departmental Supervision revision dated August 2006, did not address the need for RN coverage for at least 8 consecutive hours a day, 7 days a week.

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 diseases and infections for 1 of 2 biohazard/sharps containers located at facilities only nurse's station. The facility failed to ensure that residents were safe from exposed biohazard materials. This failure could place the residents at an increased risk for potentially exposing them to, injury, viral infections, secondary infections, and communicable diseases. The findings include: On 08/29/23 at 12:08 PM - an observation of biohazard/sharps container in the diabetic testing supplies was overfilled and the handle of the plunger end of a used syringe sticking out of the top of the sharps container. 08/29/23 02:04 PM- at the nurses station, observation of one biohazard/sharps container was full with the handle of the plunger end of the insulin pen sticking out of the top of the sharps container. 08/30/23 07:42 AM- Per observation of the nurse's station wash area, observed two biohazard/sharps containers with the one that was full with the handle of the plunger end of the insulin pen sticking out of the top of the sharps container. 08/30/23 09:06 AM- Per interview with the DON and the ADON stated all biohazard/sharps containers should be securely attached to the medication carts, locked, and should be disposed of when they are full. The [NAME] stated when the used syringes and biohazard/sharps reach the fill line marked on the sharps container, then the sharps container needs to empty and the container should be able to close freely. The DON reported that if a biohazard/sharps container is overfilled then staff and/or residents are placed at risk of blood borne pathogens from needle/sharps sticks. The ADON agreed with the statement DON provided above. 08/30/23 10:18 AM- interview with LVN B stated the biohazard/sharps container left on the counter in the nurses station with the hub end of a used syringe sticking out of the top was a problem due to the container being too full. LVN B stated the biohazard/sharps container being too full was not safe and a resident or staff member could get hurt from a needle stick. Record review of facility provided policy titled Medical Waste Container, Revised May 2012, indicated the following: 3. Medical waste containers used by this facility will be: a. Closable;

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms. Multiple vials of insulin left out on the counter. -The medication refrigerator was not kept at a temperature between 36 to 46 degrees. The facility's failure to ensure drugs and biologicals were stored in accordance with the currently accepted professional principles, this could place all residents receiving medication that have lost integrity to not receive their therapeutic dose. Findings included: 08/29/23 11:59 AM- Per observation of the Medication Storage Room completed with MA A. Noted the temperature monitoring of the refrigerator to be 28-30 degrees on average for the month of August. Noted multiple medications in the refrigerator with instruction no to store below freezing. Noted no expired medications. 1.08/29/23 10:46 AM- Observed LVN B prepare insulin for a resident, after LVN B left 20 bottles of resident insulin on the counter next to the sink at the nurses station out in the open. 2.08/29/23 10:51 AM - Per observation and interview with LVN B who verified that temperature log on the medication room refrigerator from 8-1-2023 from 8-29-2023 has read from 28-30 degrees. LVN B verified that she read the refrigerator temperature this am as 30 degrees. She stated freezing temperature was 32 degrees. In the refrigerator the following medications were observed: *a bottle of Lantus Insulin with instructions to store at 36-46 degrees, *a bottle of Levemir with instruction to store between 36 to 46 degrees, *an opened bottle of TB solution with instruction to store at 35 to 46 degrees, *two open bottles of Influenza Vaccine and 6 unopened bottles of Influenza Vaccine with instruction of store at 36 to 46 degrees, *Engerix-B injection with instructions to store at 36-46 degrees, *Acidophilous with instruction to store unopened container at room temperate and refrigerate after opening, *2 packages of acetaminophen suppository with instructions to store at 68-77 degrees, *4 packages of Zyprexa with instructions to store at room temperature not to exceed 86 degrees, and *3 packages of Respiridol with instructions to store at 36 to 46 degrees. LVN B stated that the refrigerator was to cold and that maybe the thermometers were not correct and needed to be replaced. LVN B stated if medications are not stored properly then they would not be effective in resident treatment and could affect their condition. Observation on 08/29/23 at 11:47 AM, 20 Resident Insulin bottles, 5 insulin pens still on the counter at the nurse's station next to the sink used by staff for handwashing. Observation on 08/29/23 at 12:08 PM, 20 Resident Insulin bottles, 5 insulin pens and insulin testing supplies at the nurse's station next to the sink. Observed 5 staff to include 2 CNA, 1 MA, and 1 Hall Monitor wash their hands at the sink in the nurse's station. Observation on 08/29/23 at 02:04 PM of the nurse's station wash area, observed 20 Resident insulin bottles and 5 insulin pens were not present Interview on 08/29/23 at 03:14 PM , DON and ADON stated they were aware of the thermometer monitoring in the refrigerator and felt that staff were reading the thermometer wrong. Staff stated the current thermometer temperature was 40 degrees but they were aware the temp was below 32 degrees since the first of the month and they could not verify that the medications were not store properly. 08/30/23 09:02 AM- Per interview with the DON and the ADON . The DON stated if medications are not stored at the recommended temperatures, then they will not be therapeutic. The DON stated if the medications in the facility refrigerator did freeze it would destroy the medication and it would not be effective; that would affect the residents care, it could affect the residents blood sugars, and their behavioral issues. ADON agreed with the statement DON had provided above. 08/30/23 09:04 AM- Per interview with the DON and the ADON, the DON reported all medications should be stored safely in a medication care safely. If the medication required refrigeration, then it should be in the refrigerator in the medication room that was locked. The DON stated the insulins that were left on the counter in the nurse's station should not have happened because a resident could access the medication which would result in issues that could affect a residents condition and the medication should have been in the medication carts or in the medication room and locked to prevent access. The ADON agreed with the statement that DON had provided. 08/30/23 10:20 AM- Per interview with LVN B stated all medication should be kept locked up to maintain resident and staff safety. LVN B stated if medications are not kept in a locked secured location, then they can be accessed by resident or staff that are not supposed to have them, that someone would steal the medication. LVN B stated it would not be safe for a resident if they were to access the mediation that was not meant for them and took that medication, that it could affect them and their condition. Record Review of a policy provided by facility, titled Nursing Policy and Procedure, dated March 2012 indicated the following: 2. Only licensed nurse the consultant pharmacist, and those lawfully authorized to administer medication (i.e., medication aides, etc.) are allowed access to medications. 11. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.

Based on interview and record review, the facility failed to develop, implement, and permanently maintain and effective training program for all staff, which includes trainings on abuse, neglect, exploitation, misappropriation of resident property, and dementia management, that is appropriate and effective, as determined by staff for 12 of 15 (ADM, DON, ADON, Dietary Supervisor, Activities Director, MA B, Monitor Tech D, MA E, CNA C, Monitor Tech F, [NAME] G, and [NAME] H) employees reviewed for Abuse, Neglect, and Misappropriation training and Dementia training. The facility failed to ensure all staff were trained at time of hire and annually on Abuse, neglect, exploitation, restraints, and falls. This failure could place all residents at risk for abuse, neglect, exploitation, bodily injury, and decline in overall health. Finding include: Record review of employee record for Dietary Supervisor revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 02/28/2023 Record review of employee record for Monitor Tech D revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 08/08/2023 Record review of employee record for Monitor Tech D revealed that there were no trainings listed on an annual basis for this employee. DOH was 08/08/2023 Record review of employee record for CNA C revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 07/18/2023 Record review of employee record for [NAME] G revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 03/01/2023 Record review of employee record for [NAME] H revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 02/28/2023 Interview on 08/31/23 at 02:54 PM with BOM who verified that she is responsible for employee orientation, and trainings. Record review of Employee New Hire Packet does reveal a document for the employee to fill out upon completion of training at time of hire. No documentation provided for annual trainings. No policy provided by facility on initial or annual training for employees.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the freezer was free from dirt, debris and rust. Freezer items were not properly stored, labeled, and dated. 2. The facility failed to ensure refrigerator and pantry foods were properly stored, labeled, and dated. 3. The facility failed to ensure general cleanliness was maintained in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 8/29/23 @ 9:10 AM revealed the following: 1. (1) plastic bag of egg omelets, open to air, not in original box, with no label. 2. (1) plastic bag of frozen meat patties, open to air, not in original box with no label. Observation of the kitchen food prep area and the pantry area on 8/29/23 at 9:15 AM revealed the following: 1. A metal rolling rack holding canned foods had food splatters and dirt on the rails holding the canned goods. 2. Crumbs were observed on the front and sides of the industrial toaster and on the stainless-steel table holding the toaster. There were crumbs of food under and behind the toaster. 3. Crumbs were observed on the metal shelf above the kitchen prep table holding the spices. 4. The front and sides of the fryer had food splatters and food debris on the sides of the fryer. 5. There were food crumbs on the lower ledge of the shelves holding clean pans and dishes. 6. A half used jar of grape jelly was on the pantry shelf. The label stated to Refrigerate after opening. 7. A white plastic tub labeled powdered milk had food splatters and dirt on the lid. 8. There were individual sugar packets, cracker packages and food crumbs on the floor under the wire shelving units holding food items in the pantry area. 9. The white Insignia freezer had no handle on the outside of the freezer. The front of the freezer was sticky to the touch. Observations of the kitchen prep area, the pantry area, and the kitchen appliances on 8/30/23 at 8:30 AM revealed there were no changes in the cleanliness in the kitchen. Observations of the kitchen prep area, the pantry, and the kitchen appliances on 8/31/23 at 9:00 AM revealed there were no changes in the cleanliness in the kitchen. In an observation and interview with the DS on 8/31/23 at 8:42 AM, the DS stated she missed the grime and crumbs in the freezer and the pantry. The DM stated she was sorry she missed it and she will get it cleaned. The DS stated she expects all staff to be cleaning daily. The DS stated she does spot checks on a weekly basis. Cleaning practices are standard and should be adhered to. The DS stated she trained the staff on how to clean. The DS stated the consequences of not cleaning the kitchen thoroughly would be food borne illnesses and unsanitary surfaces which could make residents sick. The DS stated the jar of used jelly should have been refrigerated. The DS stated she would throw the opened jelly out and keep it refrigerated from now on. The DS stated the consequences of not refrigerating the jelly according to the instructions would possibly make the residents sick if consumed. She further stated residents could get sick from the food not being covered or refrigerated after being opened. Record Review of the facility policy dated October 2008, titled Sanitation documented: All kitchen areas shall be kept free of litter and rubbish All counters, shelves and equipment shall be kept clean, maintained in good repair and free from breaks corrosion open seams cracks and chipped areas that may affect their use or proper cleaning. All equipment, food contact surfaces and utensils shall be washed to remove soils Kitchen surfaces not in contact with food shall be cleaned on a regular basis. Record Review of the facility policy dated October 2017, titled Food Receiving and Storage documented: All foods in the refrigerator and freezer will be covered, labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 6 residents reviewed for abuse and/or neglect. NA A struck Resident #1 on the left arm during care with her open hand. This failure could affect residents resulting in physical or emotional harm resulting in in deterioration in their health condition, need for medical treatment, physical impairment, exacerbation of their condition, serious bodily harm, emotional distress, and feelings of isolation. Findings include: Record review of Resident #1's face sheet printed 7-10-2023 revealed a [AGE] year-old male resident admitted to the facility originally on 4-6-2022 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with thinking and how someone uses language), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), major depression(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Alzheimer's (a progressive disease that destroys memory and other important mental functions). Record review of Resident #1's clinical record revealed his last MDS was a quarterly completed 4-18-2023 listing him with a BIMS of 5 indicating he was severely cognitively impaired, and he had a functionality of requiring set-up assistance with activities. Record review of the provider investigation report for intake #427342 revealed that on 5-30-2023 the facility was notified that during an argument in the dining room on the evening shift at 09:33 PM NA A struck Resident #1 on the left upper arm with her open hand. NA A was immediately suspended. Video evidence was reviewed, verified that NA A did strike Resident #1 on the left upper arm with her open hand, and NA A was terminated. Record review of the provider investigation report revealed there were no staff witnesses to the event. Record review of NA A statement provided 5-30-2023 stated as follows: Resident #1 would not stop coming up to the nurse station with no clothes on and I was trying to get him to go bac to his room. Other residents were yelling about him being naked. When I asked him to go, he started staring at my breast and said he was going to do nasty things to them. He has groped me before and I did not want to him touching me again and I shoved his arm away from me. I did not hurt him or intent to harm him in any way. Record review of the Sheriff's Office report Case #10610 with date of event 5-30-2023 and date of report 6-4-2023 revealed the following narrative: Per statement taken from the administrator by the officer is that NA A struck the resident with her hand and the administrator reported that the resident has no visible signs of injury. Record review of Resident #1's clinical record revealed he had been discharged to a mental health facility on 7-3-2023 due to increasing sexual behaviors and wandering. Record review of the facility provided trainings revealed that NA A was trained on 4-14-2023 on the policy titled Abuse, Neglect, Exploitation General Policy. During an interview on 7-10-2923 at 10:51 AM the Administrator verified that NA A was videoed striking Resident #1 on the arm (on 5-29-2023 at 09:33 PM) and the Administrator reported the following: That another resident reported the following morning (on 5-30-2023) that he witnessed NA A hit Resident #1 late the evening before, the Administrator immediately reviewed the video footage, verified the incident did happen, immediately suspended NA A (who reported that she reacted to the residents repeatedly appearing naked at the nurses station and repeatedly staring at her breasts), and had Resident #1 assessed (who did not remember the event and did not have any injuries or ill effects from the event). The Administrator provided the video for this surveyor who verified that NA A did strike Resident #1 on the left upper right arm with her open palm and then according to the Administrator appeared to threaten to hit Resident #1 again but did not act on that threat. Resident #1 did not seem to be affected by the confrontation and did not appear to be injured. The two-nursing staff behind the nurse's station denied witnessing the event. The police were notified, have investigated, and are charging NA A. The Administrator reported that if an employee acts in a manner of threatening a resident that employee will be terminated, and that behavior could affect a resident and could result in negative affects to their care and condition. Review of the video footage on 7-10-2923 at 10:51 AM revealed NA A did strike Resident #1 on the left upper right upper arm with her open palm. During an interview on 7-10-2023 at 11:13 AM the DON verified that she had reviewed the video of the incident and that staff member NA A did strike Resident #1 on the left upper arm with the palm of her right hand, that NA A did not deny the event, and NA A reported that she was frustrated with Resident #1 continually trying to touch her breast and vagina, and the DON reported that NA A was immediately terminated for her actions. The DON reported that if a staff member is reported as acting in a manner towards a resident that is abusive or neglectful, they are immediate suspended, investigated, and if the allegation is found to be true then they are terminated. The DON reported that if a resident is treated in such a manner by a staff member it could affect the resident negatively emotionally. Record review of the facility provided policy titled Abuse, Neglect, Exploitation General Policy undated, revealed the following: Standard: This facility has developed and implemented this policy and procedure to prohibit mistreatment, neglect, and abuse of all elder and misappropriation of elder property. Abuse means any act or failure to act performed intentionally or recklessly that caused or is likely to cause harm to an elder .Facility staff will not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Record review of the facility provided policy titled, Resident Rights undated, revealed the following: Right of the Elderly. b. An elderly individual has the right to be treated with dignity and respect . 2. has the right to be free from abuse, neglect .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 06/27/23 at 10:10 AM revealed Resident #2 was in the dining room eating a snack with a drink present. Three flies were noted on the table. The resident was noted repeatedly attempting to keep the flies off his snack. Observation and interview on 06/27/23 at 10:28 AM in resident room [ROOM NUMBER] revealed two flies on Resident #1's bed and one fly flying around his head. Interview with Resident #1 revealed the flies kept him up at night getting in his nose and ears. He stated he tried to keep it clean in his room, but it didn't make any difference. He stated he would swat at them all the time. Resident #1 stated the flies were constantly in his room on a daily basis and they were worse the hotter it got. Observation on 06/27/23 at 10:35 AM revealed Resident #4 (room [ROOM NUMBER]) was laying in his bed under a sheet. There were six flies observed in his room. One fly landed on his pillow and one fly landed on his ankle. Observation and interview on 06/27/23 at 10:50 AM in resident room [ROOM NUMBER] revealed four flies on Resident #3's bed. Interview with Resident #3 revealed the flies bother him all day and aggravate him. Resident #3 stated the flies were constantly in his room on a daily basis and they get in his food. He stated he has a fly swatter, but it doesn't help. Observation on 06/27/23 at 11:05 AM revealed two flies were observed in resident room [ROOM NUMBER]. There was no resident present. Observation and interview on 06/27/23 at 12:28 PM revealed about seven flies in the dining room while residents ate lunch. Flies were observed on the plates and cups of five residents. Residents were observed to be swatting at flies and four flies landed on residents. Interview with Resident #3 revealed the flies were bad especially during meals. Observation and interview on 06/27/23 at 12:30 PM, Resident #5 was observed sitting at his table at lunch. His plate had a fly on it. When asked about the flies, Resident #5 stated, They get in food and will get worse when they get hotter. Observation and interview on 06/27/23 at 12:40 PM, Resident #6 was observed sitting at his table at lunch. He had flies landing in his food. Resident #6 stated, It sucks, they get in my food, and they don't do a damn thing here. During an interview on 06/28/23 at 11:45 AM, the Maintenance Supervisor stated they had a contract with {pest control company} that sprays the building monthly and prn if needed and they have automatic fly sprayers at each doorway and several in each hall. The Maintenance Supervisor stated, We are working on getting our fly lights fixed, they broke recently and {pest control company} is getting prices for us. We also have a landfill that's about a 1/4 mile from this facility that causes a problem. Observation on 06/28/23 at 01:39 PM, two flies were observed in the conference room. During an interview on 06/28/23 at 1:40 PM, the Administrator said there were always flies in the building and the residents go in and out the patio door all the time and sometimes the residents leave the door open to the patio. She stated she had instructed all staff to keep the door shut. The Administrator stated, We use a spray in our wall sprayers that is safe for residents and is supposed to kill flies. It is a wall mounted air freshener type thing on the wall in the dining room and hall. {Pest control company} comes out and sprays monthly for pests. When asked if the monthly visits include flies, the Administrator stated she assumes the pest control contract covers flies. The Administrator stated the maintenance man would have the documentation of what {pest control company} sprays for in the contract. When asked about the outcome for the residents the Administrator stated, Flies do carry disease and it is an infection problem. The Administrator stated every time someone complains about the flies, she calls {pest control company} to come out and spray again. Record review of facility provided pest control log revealed, in part, dates and treatments as follows: Treatment dates and services performed: 6-13-2023 - performed an inspection on the interior and exterior of all areas 5-6-2023 - serviced roach bait stations, multi catch traps, fly lights and glue boards 4-4-2023 - performed an inspection of all areas; recommend replacing broken outdated fly lights $250 each - 2 broken Species listed in treatment: Flies, fruit flies, crickets, mice . Record review of the facility provided pest control logs for the dates listed above revealed documentation on 06/13/23 as follows: Open actions from previous service - Fly light not working Recommendation - replace unit Status - pending Location - dining room Record review of the facility's undated policy Pest Control reflected This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 2 of 2 medication carts (hall 1 medication cart and hall 2 medications cart) reviewed for expired medications. The hall 2 medication cart contained 2 loose medication tablets and one multidose vial of insulin that was open and without an indicated open or expiration date. The hall 1 medication cart contained two multidose vials of insulin that were open and without an indicated open or expiration date. This failure could place residents at risk of drug diversion or exposure to medications and/or biologicals that are expired and/or contaminated. Findings included: During an observation and interview on 07/10/2022 at 10:22 AM, there were two loose medication tablets in the bottom of the second drawer of the hall 2 medication cart. In the third drawer of the medication cart, there was one multidose vial of Lantus (insulin glargine) that was open, had about one-fourth of its contents remaining in the vial, was labeled with a pharmacy fill date of 05/23/2022, and was labeled as belonging to Resident #21. The insulin vial was not labeled with a use by, expiration, or open date. LVN B reported that she was responsible for the hall 2 medication cart currently and that there should not be any loose medication tablets in the medication cart because those tablets would be contaminated. LVN B reported that every nurse should check their medication cart for loose medications when they come on shift and clean them up when they're dropped. LVN B reported that there were loose medication tablets in the medication cart because somebody may have dropped the pills and didn't get them out. LVN B reported that the vial of Lantus for Resident #21 was still in use but that it should not be because it's outdated. LVN B reported that she did not know when the vial had been opened and that insulin vials should be labeled with an open date because they are only good for 30 days after being opened. LVN B reported that she did not know why the vial of Lantus was not labeled with an open date and that the consequences of it missing labeling included that they (residents) could get outdated insulin which could cause them to become sick. During an observation and interview on 07/10/2022 at 10:34 AM, there were two multidose vials of insulin that were not labeled with a use by, expiration, or open date in the third drawer of the hall 1 medication cart. One of the vials was Levemir (insulin detemir), which was open, had about one-fourth of its contents remaining in the vial, was labeled with a pharmacy fill date of 12/27/2021, and was labeled as belonging to Resident #55. The other was a vial of Lantus (insulin glargine) that was open, had about three-fourths of its contents remaining in the vial, was labeled with a pharmacy fill date of 05/23/2022, and was labeled as belonging to Resident #48. LVN C reported that she was currently responsible for the hall 1 medication cart. LVN C reported that she did not know when the two vials of insulin had been opened and that they should both contain open dates on them because the amount of time they are good for once they're opened. LVN C reported that she was not sure exactly how long insulin vials are good for once they're opened. LVN C reported that she did not know if the two vials were currently in use. LVN C was asked about the potential consequences of insulin vials not containing an open or expiration date and she replied, I'm not sure of the answer. They (residents) could get sick for having outdated insulin. LVN C reported that she did not know why the vials had not been labeled with an open or expiration date. During an interview on 07/11/2022 at 2:04 PM, the ADON reported the DON was out of town and not currently at the facility. The ADON reported there should not be loose medication tablets in medication carts. The ADON reported the floor nurses are responsible for conducting weekly audits of medication carts on the night shift. The ADON reported that the potential consequences of loose medications being in medication carts included that somebody could get the wrong medication or that it may indicate that someone did not receive a medication that they should have. The ADON reported that there may have been loose tablets in the medication cart because they (staff) did not audit very well. The ADON reported all insulin vials should be dated with an open date when they are opened so everyone knows when they will expire, which is 28 days after being opened. The ADON reported that the potential consequences of not having such labeling included we could be giving insulin that is out of date. The ADON reported that she did not know why there were insulin vials in the medication carts that were not labeled with an open date. Record review of facility provided policy titled Medication Storage, dated January 2014, revealed in part: Policy It is the policy of the home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse. Procedure 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed Record review of facility provided policy titled Medication-Labels, dated December 2013, revealed in part: Policy It is the policy of this home to assure medications are properly labeled. Record review of facility provided policy titled Medications-Vials and Ampules of Injectables, dated March 2012, revealed in part: Policy It is the policy of this home that vials and ampules will be handled, stored, and discarded properly. Procedure 2. The date opened and the initials of the first person to use the vial are recorded on the multi-dose vials. Record Review of facility provided policy titled Administering Medications, dated December 2012, revealed in part: 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-done container, the date opened shall be recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. Flies, spiders, cockroaches. and a scorpion were observed in multiple areas of the facility These failures could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: During an observation on 07/10/22 at 9:15 AM, a dead scorpion was observed on the floor of the staff bathroom nearest the conference room. During an observation on 07/10/22 at 9:19 AM, 4 flies were observed in the kitchen area and 1 dead bug in the hallway outside the kitchen office. During an observation on 07/10/22 at 09:27 AM, 5 flies were observed in room [ROOM NUMBER]. No resident was present. During an observation on 07/10/22 at 09:30 AM, 8 flies were observed in room [ROOM NUMBER] on bed A and B. There was no resident present. During an observation on 07/10/22 at 09:32 AM, Resident #20 (room [ROOM NUMBER]) was laying in his bed under a blanket. There were 12 flies observed in his room. During an observation on 07/10/22 at 09:33 AM, Resident #34 was laying in bed with 5 flies on him. Upon awaking he attempted to shoo the flies. The resident stated that he did not like the flies and that they bothered him. During an observation on 07/10/22 at 09:37 AM, a fly was observed in the bathroom of room [ROOM NUMBER]. There was no resident present. During an observation on 07/10/22 at 09:38 AM, Resident #47 (room [ROOM NUMBER]) was laying on his bed under a blanket. 5 flies were observed in the room. During an observation on 07/10/22 at 09:40 AM, 8 flies were observed in the room [ROOM NUMBER]. There was no resident present. During an observation on 07/10/22 at 09:41 AM, 29 dead bugs (3 beetles, one spider, and 25 flies) were observed in the hallway between room [ROOM NUMBER] and the end of the hall exit near room [ROOM NUMBER]. During an observation on 07/10/22 at 09:54 AM, 8 flies were observed on bed A in room [ROOM NUMBER]. There was no resident present. During an observation on 07/10/22 at 10:01 AM, 10 flies were observed in room [ROOM NUMBER] on Bed A and 5 flies were observed on Bed B. There was no resident present. During an observation on 07/10/22 at 10:05 AM, 4 flies were observed in room [ROOM NUMBER] on Bed B with the Resident #47 present. During an observation on 07/10/22 at 10:14 AM, 7 flies were observed in room [ROOM NUMBER] on bed A. During an observation on 07/10/22 at 10:14 AM 4 flies were observed room [ROOM NUMBER] on Bed A and 6 flies were noted on bed B. There was no resident present. During an observation on 07/10/22 at 10:15 AM, Resident #23 was observed rolling down the hall in his wheelchair in an agitated state cursing. He continued to curse in his room. He was heard screaming, Goddamn flies! M-fing flies! During an observation on 07/10/22 at 10:49 AM, a resident in the dining room was observed eating a snack with a drink present. 3 flies were noted on the table. The resident was noted repeatedly attempting to keep the flies off his snack. During an observation on 07/10/22 at 12:05 PM, Resident #36 was observed sitting at his table at lunch. His cup had a fly on it. During an observation on 07/10/22 at 12:07 PM, a resident was sitting at his dining room table eating his meal and shooing flies. Upon approaching the table this surveyor observed a total of 5 flies on the table. A second resident present stated, How about getting rid of all these flies. When asked if the flies were a problem the second resident stated, Ya there are about 15 flies on each table. During an observation of the dining room on 07/10/22 at 12:16 PM, this surveyor observed flies on 9 of the 11 dining room tables with residents present and eating meals. During an observation on 07/10/22 at 12:23 PM, flies were observed in the bowls and on the plates of two residents. One resident at the table had 8 flies on his person and 7 on his table. During an observation on 07/10/22 at 01:42 PM, 5 flies were observed on the lobby coffee table. During an observation on 07/10/22 at 01:47 PM, a spider was observed crawling on the floor of a resident's area in room [ROOM NUMBER]. During an observation on 07/10/22 at 01:49 PM, Resident #47 was in his bed with 6 flies on him. He said the flies keep him awake when asked if they bother him. During an observation on 07/10/22 at 01:52 PM, a dead cockroach was observed in the hallway outside the ADMIN office. During an observation on 07/11/22 at 08:43 AM, 8 flies were observed on the wall in room [ROOM NUMBER] during the AM medication pass. During an observation on 07/11/22 at 03:06 PM, a dead cockroach was observed in hallway outside the ADMIN office. During an observation on 07/12/22 at 08:54 AM, 5 flies were observed in the conference room. During an observation on 07/12/22 at 08:56 AM, a surveyor was stopped in hall by Resident #1 in his wheelchair. The resident asked, You with the state? When the surveyor told him yes, he said, Y'all need to do something, there are way too many cockroaches and flies in this place, we eat that stuff with our food every day. They spray a little can of that stuff but that doesn't work, they just come back out at night and crawl all over us. During an observation on 07/12/22 at 09:17 AM, Resident #38 stopped a surveyor in the hall and asked that surveyor to take a picture of the flies under his bed. The resident said he kills the flies and puts them under his bed to see how long it will take housekeeping to sweep them up. The resident said he counted more than 100. The resident also showed surveyor several flies on his bathroom floor. The resident had a folded-up Coca-Cola box from a 12 pack that he was using as a flyswatter. The resident said housekeeping came down his hall yesterday, but they stopped cleaning at room [ROOM NUMBER] and didn't start again until room [ROOM NUMBER] so his room was skipped. During an interview on 07/11/22 at 09:33 AM, HM A stated Yes, they are horrible. HM A said the bugs and flies were a problem for the residents. HM A stated, We have the fly spray on each door but that is not working. HM A said problems which can occur from not controlling flies and bugs include, You can have flies on everything. If they have an open wound or something like that, they can be on it. During resident council meeting interview on 7/11/22 at 10:30am, five residents attending stated that they knew how to file grievances but had not done so. The five residents in attendance stated that they kill the flies with fly swatters. The five residents did not indicate that they were bothered by the flies. During an interview on 07/12/22 at 08:33 AM, the MS replied that they have fly sprayers at each doorway and several in each hall. They have a contract with {pest control company} that spays the building monthly and prn if needed. The MS stated, We try to keep our patio door in the dining room that lead to the smoking area closed and I try to educate the staff to keep them closed but the residents go in and out frequently to smoke. We have a wind machine on the patio door, but I noticed that it is making a strange noise the last couple of days, so I am going to get it fixed. We usually have 1-2 scorpions per year because they are common for this area and its summertime, but the flies are the real problem. We also have a landfill that's about a 1/4 mile from this facility that causes a problem. When asked what problems these issues could cause for the residents, the MS reported that if left unattended they can lay eggs and be severely annoying. The MS did verify that to his knowledge they have never had any fly larva in the building. During an interview on 07/12/22 at 08:39 AM, the ADON said that the issues with flies, scorpions, spiders and cockroachescomes and goes. The ADON reported she was aware that the blower above the patio doors to the smoking area had been broken. The ADON reported the patio doors are the main issue for the infestation due to the residents leaving them open, that they often urinate on the patio, and feed stray animal on the patio that led to difficulty keeping insects out of the facility. The ADON reported they have fly swatters they will give to resident who can use them properly. The ADON reported that flies and bugs can carry/cause bacteria, land on food, land on wounds, or anything like that. The ADON reported that they plan to educate/provide written training for staff on observation and prevention of insect infestation. During an interview on 07/12/22 at 08:43 AM, the ADM said the issue with flies, scorpions,s piders and cockroaches It's not an everyday thing. It's this time of year. We do have fly spray and I noticed some of them are out, so we have reordered replacements. We do have a contract with Orkin to treat every month. Our main issue is the patio doors that the residents go in and out to smoke. Staff need to pay more attention and make sure they are closed. The ADM said problems the issues with flies and bugs could cause for the resident were spider and scorpions can sting residents and scare staff and flies can cause infection problems. The administrator reported they were going to in-service staff on paying attention to the patio door for insect prevention. During an interview on 07/12/22 at 09:10 AM, the MS reported that for the facility policy for pest control they usually provide the {pest control company} contract/monthly treatments. The facility does not have a pest control policy, but they will get one written. The MS also stated that they have fly lights at each door that attracts and kills flies. The MS provided the last 3 months of Orkin treatments. Record review of facility provided pest control log revealed, in part, dates and treatments as follows: Treatment dates: 6-24-2022 5-16-2022 4-15-2022 Species listed in treatment: Cockroaches, flies, scorpions, spider . Record review of the facility provided pest control logs for the dates listed above did not reveal documentation that the pest control applicator had noted any issues with flies, cockroaches, bugs or spiders. Record review of facility incident reports revealed no documentation of pest-related injuries or bites to residents.