**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to a dependent Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident, and Resident's bed, were soaked in a brown halo of partially dried old urine from 10:00 A.M. until 1:40 PM. Resident #123 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation. During the 1:40 PM interview, Resident #123 verbalized that she was uncomfortable and need to have her brief changed as she was Wet head to toe. The Resident was noted to have her body and bed smell strongly of urine, and in fact the entire room had a pervasive odor of urine, feces, and body odor. The Resident wore socks which were meant to be white, however, had brown stains on them which were dried on. The Resident stated that there just were not enough staff to take care of Residents, and this situation happened to her often. The Resident's bed had a brown halo of partially dried strong-smelling urine around her body from her knees to her mid back. Her mattress was soaked as well with a permanent divot in the area directly under her bottom that did not spring back into place when she rolled off of it onto her side. A pervasive smell of urine and feces permeated the room and the entire unit. ADL care records were reviewed for Resident #123 and revealed that the Resident was totally dependent on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed on 8-29-25 during survey and found to be soiled from 10:00 A.M. until 1:40 PM. in a soiled bed with soiled linens. The Resident was never seen out of bed during daytime hours for the entire survey. On 8-29-25 during an end of day meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns. Furthermore they were made aware that Residents were not being bathed and given hygiene timely, nor as often as needed, as this was the observation on days during the survey with Residents being soiled with dirty linens and clothing. On 9-3-25, prior to the survey exit the Director of Nursing informed surveyors that Resident #123 was now receiving needed care every 2 hours, and stated they had nothing further to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident received her medications in March, April, and May 2025 Late, and in some cases hours after they were scheduled to be given. Resident #123 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation. During the 1:40 PM interview, Resident #123 verbalized that she received her medications late on occasion, and sometimes hours later than they were scheduled to be given. The Resident was laying in bed and noted to have her body and bed smell strongly of urine, and in fact the entire room had a pervasive odor of urine, feces, and body odor. The Resident wore socks which were meant to be white, however, had brown stains on them which were dried on. The Resident stated that there just were not enough staff to take care of Residents, and this situation happened to her often. ADL care records were reviewed for Resident #123 and revealed that the Resident was totally dependent on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed on 8-29-25 during survey and found to be soiled from 10:00 A.M. until 1:40 PM. in a soiled bed with soiled linens. The Resident was never seen out of bed during daytime hours for the entire survey. The Resident's Medication administration record was reviewed with time stamps for the time medications were administered for 3 months, in March. April, and May of 2025. The records revealed that medications were being administered later than they were ordered to be administered. The examples follow below. March 2025 - 3-25-25, Carbidopa/levodopa ordered for 1:00 P.m., given at 2:31 P.m. April 2025 - 4-25-25, Carboxymethylcellulose-glycerin eye drops, multivitamin, docusate sodium, Carbidopa/levodopa, Meloxicam, amlodipine, Sitagliptin phosphate, house supplement drink, ordered for 9:00 A.m., given at 11:00 A.m. May 2025 - 5-25-25, Carbidopa/levodopa ordered for 5:00P.m., given at 7:42 P.m., Ascorbic acid, ferrous sulfate, Carboxymethylcellulose-glycerin eye drops, melatonin, tizanidine, Carbidopa/levodopa, doxepin, atorvastatin, oxycodone, mirtazapine, and gabapentin all ordered for 9:00 P.m., and not given until the next morning on 5-26-25 at 8:15 A.m., (11 hours late). Review of the Facility Medication Administration policy indicated medication administration would be completed according to the doctor's orders. The Resident's care plan was reviewed and indicated medications would be administered according to the doctor's orders. On 8-29-25 during an end of day meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns. On 9-3-25, prior to the survey exit, the Director of Nursing informed surveyors that Resident #123 was now receiving needed care every 2 hours, and medications timely. They further stated they had nothing further to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff and resident interviews, the facility staff failed to ensure the residents' right to a safe, clean, comfortable, homelike environment for the entire facility and for Residents #128, #103, and #109 in a survey sample of 21 Residents.The following observations were made during the survey period: On 8/27/25 at 10:30 AM and 8/29/25 at 9:00 Am there was a strong urine odor in hallway past the lobby. On 8/27 through 8/29/25 flies were observed throughout the facility in resident rooms and in the hallways.On 8/29/25 at 9:00am observed breakfast trays being served with plastic utensils. An interview was conducted at approximately 9:10 AM with the Dietary Manager Employee #3 who stated due to callouts they opted to use plastic ware to save time on dish washing.8/27/25 through 8/29/25 observed wall mounted hand sanitizer units either missing or loose on the wall. Missing tiles in hallways or in resident rooms 12, 34; baseboard pulled away from the wall in room [ROOM NUMBER] near window and wall appeared to have a blackish gray residue. Mattresses in room [ROOM NUMBER]A were noted to be heavily stained, room [ROOM NUMBER]A mattress crackled appearance. On 8/29/25 at approximately 9:00 AM observed staff serving breakfast. The tray for Resident #128 was observed to have two (2) corners damaged. The corners were noted to be very sharp. An interview with LPN #1 and C.N.A #3 was conducted, and they were asked what they should do when they observe a tray with sharp edges, and both replied they should pull the tray and report it to the Dietary Manager for replacement. LPN #1 delivered the breakfast tray to Resident #128 and pulled the tray. An interview with the Dietary Manager Employee #3 conducted at approximately 9:10 AM to ask him about the damaged tray and he stated he was not aware of any damaged trays but if the staff observed any, they should bring them back to the kitchen.Resident # 128 was admitted to the facility on [DATE] with diagnosis including but not limited to hypertension, obstructive sleep apnea, heart failure, peripheral vascular disease, chronic kidney disease stage 3, major depressive disorder and chronic obstructive pulmonary disease.Resident #128's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 7/1/2025. Resident #128 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 15 out of 15 which means the resident is cognitive intact in daily decision making. Resident #128 was coded in Section GG0130 Self Care as 0.5 Eating ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and or liquid once the meal is placed before the resident as requiring set-up or clean-up assessment.On 8/29/25 at approximately 9:05 AM observed Resident #128 eating breakfast, noting plate and cup were on overbed table, no tray and when asked where his tray was, he stated they took it back to the kitchen because it was broken at the corners. We get that sometimes.On 8/27/25 at 2:35 PM water was observed on the floor as you entered room [ROOM NUMBER]A Resident #103's room, a bath basin was observed on the floor under the sink full of water. On 8/28/25 at 9:31 AM, a bath basin was observed on the floor under the sink with approximately one (1) inch of water in the basin. On 8/29/25 at approximately 9:45 AM a bath basin was observed under the sink with approximately one (1) inch of water in the basin. Resident #103 was admitted to the facility on [DATE] with diagnosis including but not limited to human immunodeficiency virus, hypertension, seizures, chronic obstructive pulmonary disease, Adrenocortical insufficiency, pancreatitis, fibromyalgia, psychoactive substance abuse and major depressive disorder. Resident #103's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 6/18/2025. Resident #3 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 15 out of 15 which means the resident has been cognitively intact with daily decision making. On 8/27/25 at 2:35 PM an interview was conducted with Resident #103 regarding had she had issues with her sink leaking and she replied yes, I thought they had fixed it. On 8/28/25 at 9:35 AM, a further interview with Resident #103 on had anyone come in to check on the leaking sink and she said they had emptied the pan. On 8/29/25, when interviewing Resident #103 about her sink she stated, they haven't fixed that thing yet? On 8/28/25 at approximately 10:15 AM, observed a footboard leaning against the wall in room [ROOM NUMBER]D. Resident #109 was admitted to the facility on [DATE] with diagnosis including but not limited to the following human immunodeficiency virus, hypertension, anxiety, traumatic subdural hemorrhage without loss of consciousness, Type 2 diabetes mellitus, long term use of insulin, alcohol abuse, psychosis, major depressive disorder cerebral infarction, vascular dementia, neurocognitive disorder with [NAME] Bodies and obstructive pulmonary disorder.Resident #109's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 7/7/2025. Resident #109 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 11 out of 15 which means the resident has moderate cognitive impairment in daily decision making.On 8/28/25 at approximately 10:15 AM, an interview was conducted with Resident # 109 who stated it belonged to his roommate. The roommate's bed was observed without a footboard attached. Resident #128 could not recall how long it had been there.On 8/29/25 at 12:28 PM during end of day debriefing these findings were reviewed with the Administrator, Director of Nursing, Regional Director Clinical Services and Divisional Regional Director of Clinical Services. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an safe replacement for failing closet doors and insect pest prevention and control program concerns for 1 Resident (Resident #124) in a survey sample of 28 Residents. The findings included: For Resident #124 the facility staff failed to provide safe clothing and storage closets in a Resident's room which resulted in a door falling from the closet onto a Resident while she sat in her wheelchair causing an abrasion to her face. Further the facility did not treat an infestation of cockroaches in the failing closet. Resident #124 was admitted to the facility on [DATE] from the hospital. The Resident had a diagnosis history of a stroke with left side weakness, hypertension, chronic heart disease, and was unable to stand alone. The Resident's most recent MDS (an assessment) on 8-20-25 revealed a brief interview for mental status (BIMS) score of 15 out of a possible 15 points indicating no cognitive impairment. On 8-29-25 while completing observations for a Resident neighbor of Resident #124, the surveyor was moving out into the hall facing Resident #124's room and saw an upper closet door fall and strike Resident #124 while seated in her wheelchair by the closet, on the right side of her face causing 3 abrasions on her cheek and just below her right eye. The wooden upper doors to the wall closet were approximately 24 inches by 24 inches square, and approximately 1 inch thick. There were 2 upper doors that opened in opposite directions from the middle and were located between 6 and 7 feet above the floor requiring a standing posture while reaching up to access. The closet had 4 doors in total and the 2 lower doors concealed an area to hang clothing and were much larger. The Resident was not accessing the lower hanging portion of the closet when the door fell. Resident #124 cried out Help the door just hit me. She was visibly shaken and trembling as the surveyor ran to her. A staff CNA (Certified Nursing Assistant) #4 ran into the room followed by LPN (licensed Practical Nurse) #2. An assessment was completed, and the Resident denied pain, and denied being seriously hurt, stating it just scared me. No bruising or swelling was noted; however, Resident #124 was sent out to the hospital out of an abundance of caution for a CT (computed tomography) and x-rays of her face to reveal any hidden serious injuries or fractures. The Resident returned the same day revealing only soft tissue abrasions and no serious injury or fractures. The closet was examined and found to have no screws in the 2 door hinges of the door that fell, no screws in the wall of the door that fell and none on the floor, indicating the door had not been fastened with the required screws at all. The screws in the opposite upper door were only screwed in 1/2 way, with 3 screws required for each of the 2 hinges on each door and having only 2 screws in each hinge of the second door. CNA #4 removed the fallen door from the room, and the housekeeping director, unit manager, and Corporate Registered Nurse entered the room. The closet was opened and inspected, and as the larger lower doors were opened cockroaches darted into the closet and cracks in the wall around the closet observed by everyone in attendance with surprised gasps coming from all involved. The closet wooden structure was separated and chipped and peeling with saw dust like disintegration noted from the failing particle board construction. The ceiling above the closet showed water staining and damage on ceiling tiles and metal grid work that the fiber ceiling tiles rested in. This observation revealed water damage affecting the particle board closet structure causing disintegration coming from condensation dripping from above. It was known by the facility that the Air conditioning chiller and other parts of the heating and air system in the building had been inoperable, and facility staff assured surveyors that the problem was currently under planning for repair or replacement. Portable air conditioning units were staged and in active use throughout the building. Closet replacements and repairs in other Resident rooms were also ongoing during the survey as other units were in need of replacement. The facility knew or should have known that the closets were a hazard, and did not act quickly enough to mitigate the hazard resulting in a minor injury requiring only first aid to Resident #124. Teams were then dispatched to identify any other doors that could fall for immediate repair or removal. The housekeeping and maintenance directors notified the pest control contractor who responded immediately to treat the cockroach infestation in Resident #124's room. On 8-29-25 at the end of day debrief, the Administrator, Corporate RN, and DON were notified of the above findings. They stated there was no further evidence to present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation the facility staff failed to maintain an effective pest control program for 3 out of 3 units,. 1. For the facility, on 8/27/25 at 10:30 AM and 8/29/25 at 9:00 Am there was a strong urine odor in hallway past the lobby. 2. For the facility, on 8/27 through 8/29/25 flies were observed throughout the facility in resident rooms and in the hallways. 3. For the facility, on 8/29/25 at 9:00am observed breakfast trays being served with plastic utensils. An interview was conducted at approximately 9:10 AM with the Dietary Manager Employee #3 who stated due to callouts they opted to use plastic ware to save time on dish washing. 4. For the facility, on 8/27/25 through 8/29/25 observed wall mounted hand sanitizer units either missing or loose on the wall. Missing tiles in hallways or in resident rooms 12, 34; baseboard pulled away from the wall in room [ROOM NUMBER] near window and wall appeared to have a blackish gray residue. Mattresses in room [ROOM NUMBER]A were noted to be heavily stained, room [ROOM NUMBER]A mattress crackled appearance. 5. On 8/29/25 at approximately 9:00 AM observed staff serving breakfast. The tray for Resident #128 was observed to have two (2) corners damaged. The corners were noted to be very sharp. An interview with LPN #1 and C.N.A #3 was conducted, and they were asked what they should do when they observe a tray with sharp edges, and both replied they should pull the tray and report it to the Dietary Manager for replacement. LPN #1 delivered the breakfast tray to Resident #128 and pulled the tray. An interview with the Dietary Manager Employee #3 conducted at approximately 9:10 AM to ask him about the damaged tray and he stated he was not aware of any damaged trays but if the staff observed any, they should bring them back to the kitchen. Resident # 128 was admitted to the facility on [DATE] with diagnosis including but not limited to hypertension, obstructive sleep apnea, heart failure, peripheral vascular disease, chronic kidney disease stage 3, major depressive disorder and chronic obstructive pulmonary disease. Resident #128's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 7/1/2025. Resident #128 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 15 out of 15 which means the resident is cognitive intact in daily decision making. Resident #128 was coded in Section GG0130 Self Care as 0.5 Eating ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and or liquid once the meal is placed before the resident as requiring set-up or clean-up assessment. On 8/29/25 at approximately 9:05 AM observed Resident #128 eating breakfast, noting plate and cup were on overbed table, no tray and when asked where his tray was, he stated they took it back to the kitchen because it was broken at the corners. We get that sometimes. 6. On 8/27/25 at 2:35 PM water was observed on the floor as you entered room [ROOM NUMBER]A Resident6 #103's room. A bath basin was observed on the floor under the sink full of water. On 8/28/25 at 9:31 AM, a bath basin was observed on the floor under the sink with approximately one (1) inch of water in the basin. On 8/29/25 at approximately 9:45 AM a bath basin was observed under the sink with approximately one (1) inch of water in the basin. Resident #103 was admitted to the facility on [DATE] with diagnosis including but not limited to human immunodeficiency virus, hypertension, seizures, chronic obstructive pulmonary disease, Adrenocortical insufficiency, pancreatitis, fibromyalgia, psychoactive substance abuse and major depressive disorder. Resident #103 ‘s most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 6/18/2025. Resident #103 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 15 out of 15 which means the resident has is cognitively intact with daily decision making. On 8/27/25 at 2:35 PM an interview was conducted with Resident #103 regarding had she had issues with her sink leaking and she replied yes, I thought they had fixed it. On 8/28/25 at 9:35 AM, a further interview with Resident #103 on had anyone come in to check on the leaking sink and she said they had emptied the pan. On 8/29/25, when interviewing Resident #103 about her sink she stated, they haven't fixed that thing yet? 7. On 8/28/25 at approximately 10:15 AM, observed a footboard leaning against the wall in room [ROOM NUMBER]D. Resident #109 was admitted to the facility on [DATE] with diagnosis including but not limited to the following human immunodeficiency virus, hypertension, anxiety, traumatic subdural hemorrhage without loss of consciousness, Type 2 diabetes mellitus, long term use of insulin, alcohol abuse, psychosis, major depressive disorder cerebral infarction, vascular dementia, neurocognitive disorder with [NAME] Bodies and obstructive pulmonary disorder.Resident #109 ‘s most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 7/7/2025. Resident #109 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 11 out of 15 which means the resident has moderate cognitive impairment in daily decision making.On 8/28/25 at approximately 10:15 AM, an interview was conducted with Resident 109 who stated it belonged to his roommate. The roommate's bed was observed without a footboard attached. Resident #128 could not recall how long it had been there.On 8/29/25 at 12:28 PM during end of day debriefing these findings were reviewed with the Administrator, Director of Nursing, Regional Director Clinical Services and Divisional Regional Director of Clinical Services. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #41 was originally admitted to the facility [DATE]. The resident's current diagnoses included blindness, chronic back pain and migraines. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #41's cognitive abilities for daily decision making were intact. Resident #41's had a care plan problem with a revision date of [DATE] which stated he had an ADL self-care performance deficit related to blindness, and chronic health conditions. The goal stated the resident would maintain his current level of functioning through the review date, [DATE]. The interventions included requires minimal assistance with bathing/showers, and requires set up/supervision with dressing. On [DATE] at 12:21 PM Licensed Practical Nurse (LPN) O asked that the surveyor move away from grab bars along the wall leading to the service hall where maintenance and and environmental services are located. LPN O stated that the resident travels along the hallway to the shower room. Resident #41 was observed leaving his room, heading towards the nurse's station and turn the wheel chair towards the service hall using the wall grab bars as a guide. LPN O stated this was the resident's normal method of getting to the shower and she did not appear to understand his attire was not appropriate for being outside of his room. As Resident #41 was observed traveling to the shower room, he was observed with a short hospital gown on, which stopped midway his thighs and his entire back was visible, for the hospital gown ties were not tied. On [DATE] at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure the right to a dignified existence for two (2) Residents ( #151, and #41) in a survey sample of 57 Residents. The findings included: 1. For Resident # 151, the facility staff failed to ensure the resident was treated with dignity and respect after she expired. They did not ensure Resident # 151 was prepared for viewing if the family wanted visitation. Resident # 151 was admitted to the facility on [DATE], hospitalized on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Diabetes,Cerebral Infarction, Gastrointestinal hemorrhage, Chronic Kidney Disease, Hypertension, Congestive Heart Failure, Respiratory Heart Failure and history of Polysubstance Abuse. Resident #151's MDS (Minimum Data Set) coded as an admission Assessment with an ARD (Assessment Reference Date) of [DATE] coded Resident #151 as having a BIMS (Brief Interview of Mental Status) score of 14/15 indicating no cognitive impairment. Resident #151 was coded as requiring assistance with Activities of Daily Living. Review of the clinical record was conducted on [DATE]-[DATE]. On [DATE] at approximately 3:00 p.m., four (4) staff members were observed pushing a bed in the hallway. The bed was in a low position and the staff were trying to maneuver the bed around the doorway. They appeared to be struggling to push the bed. At first glance, it appeared that the staff members were pushing an unoccupied bed. Upon further observation, it was noted that a resident was in the bed. There was a gray colored blanket completely covering the resident. The entire body including the head and face were wrapped in the blanket. The staff members were having difficulty steering the bed. The staff members pushed the bed with Resident # 151 in it into an empty room at the end of the hallway close to the lobby area. There were residents near the Nurses station and at the other end of the hallway on the Central Unit. The staff members walked back down the hall toward the nursing station, talking amongst themselves. They stated one of the wheels on the bed was locked. The roommate of Resident # 151 was sitting at the corner of the hallway near the nurses station. One of the staff members stopped and talked to the roommate of Resident # 151. One of the staff members who identified herself as Registered Nurse B was asked if that was a resident in the bed who had expired. Registered Nurse-B replied yes and identified the resident as Resident # 151. Registered Nurse-B did not say anything else and walked toward the nurses station. She did not offer any explanation of why Resident # 151 was completely wrapped in the blanket, was moved to another room and the bed was pushed in the room in a cater cornered position. A review of the clinical record revealed that Resident # 151 expired on [DATE]. Resident # 151 had a Do Not Resuscitate Order. The Director of Nursing pronounced the death at 10:20 a.m. There was progress note dated [DATE] at 10:30 written by the Director of Nursing which stated Resident was provided postmortem care by aides at this time resident was observed with no chest rise or fall no noted stimulation to tactile or verbal stimuli. Resident pronounced at 1020. Three surveyors opened the door to the room where Resident # 151 had been taken. The bed was pushed cater cornered in the room close to the door. The blanket was still completely covering the entire body of Resident # 151. The blanket was wrapped around the resident's head. When the blanket was lowered to uncover the face, it was observed that Resident # 151's mouth was open, lips appeared dry, and hair was tousled. It did not appear that post mortem care had been provided. Resident # 151's mouth was open, lips appeared dry and hair was not combed. On [DATE] at 10 a.m., an interview was conducted with the Director of Nursing and two Corporate Nurse Consultants. The Director of Nursing stated the facility staff was trying to move the deceased resident into another room. The Director of Nursing stated she came to the room to pronounce the resident and observed the staff providing post mortem care. She stated the expectation was for post mortem care to be provided to residents when they expire. When asked if it was expected for the staff to completely wrap the resident in a blanket, transport them to another room and place cater cornered in the room, the Director of Nursing replied no. The room where Resident # 151 was transported had been empty and had a bed and other extra supplies stored in there. She was not placed behind a curtain nor in a manner that would have been presentable for the family to view. The Corporate Nurse Consultant (Employee C) stated it was not expected for residents who expired to be pushed into an unoccupied room where another bed and other supplies were stored. She stated that it is a dignity issue. On [DATE] during the end of day debriefing, the Administrator, Director Nursing, [NAME] President of Operations and Corporate Nurse Consultants (Employee C and D) were informed of the findings. They stated it was important to ensure residents were treated with dignity and respect. A copy of the postmortem care policy was requested. Review of the facility's policy and procedure on Post Mortem care entitled Nursing Care and Services, Effective [DATE] from Mosby's Textbook for Long-Term Care Assistants by [NAME] and [NAME] and [NAME], page 616, Chapter 6, End of Life Care revealed the following excerpt: Postmortem care is done to maintain a good appearance of the body. Discoloration and skin damage are prevented. Valuables and personal items are gathered for the family. The right to privacy and the right to be treated with dignity and respect apply after death. On [DATE] at approximately 10:45 a.m., an interview was conducted with Certified Nursing Assistant-G who stated the staff members were transporting the deceased resident to another room while waiting for the family to come view the body. Certified Nursing Assistant-G stated he worked for the Agency. On [DATE] during the end of day debriefing, the Administrator, Director Nursing, [NAME] President of Operations and Corporate Nurse Consultants were informed of the findings. They stated it was important to ensure residents were treated with dignity and respect. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Resident (Resident # 56) in a survey sample of 57 Residents. For Resident # 56, the facility staff failed to provide a bed that was an adequate size for someone 74 inches tall. The findings included: Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 56 required extensive assistance on staff for activities of daily living. Review of the clinical record was conducted 4/16/2025-4/28/2025. On 4/16/2025 at 2:42 p.m., Resident # 56 was observed lying in bed with his legs bent at the knee and feet touching the footboard. Resident # 56 stated he was over 6 feet tall. He stated the bed was too short for him. On 4/17/2025 at 10:27 a.m., Resident # 56 was observed sitting up in bed, knees bent, and feet touching the footboard. On 4/18/2025 at 2:10 p.m., Resident # 56 was observed lying in bed. His feet were touching the footboard and his knees were bent. Review of the Care plan revealed no documentation of concerns about the size or length of Resident # 56's bed. Review of the Progress Notes revealed no documentation of concerns about the size of Resident # 56's bed. On 4/22/2025 at 11:10 a.m., an interview was conducted with the Licensed Practical Nurse-P who stated residents should have beds that fit them. Licensed Practical Nurse-P stated it was important for many reasons including comfort and proper positioning. During the end of day debriefing on 4/25/2025, the Facility Administrator, two Regional Nurse Consultants (Employees C and D) and the Director of Nursing were informed of the findings that Resident # 56's bed was too short for him. They stated the size or length of the bed should accommodate the needs of residents. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to promote self determination through support of choice for one (1) Resident (Resident # 75) in a survey sample of 57 Residents. The findings included: For Resident # 75, the facility staff failed to provide a cup of coffee in the mornings prior to breakfast being served as per her choice. Resident # 75 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Diabetes, Seizure Disorder, Hypertension and Stroke. The most recent Minimum Data Set (MDS) assessment was an Annual assessment with an assessment reference date (ARD) of 3/19/2025. Resident # 75 was coded with a Brief Interview of Mental Status score 15 out of 15 indicating no cognitive impairment. Resident # 75 required assistance for activities of daily living. Review of the clinical record was conducted 4/16/2025-4/28/2025. On 04/24/25 at 11:06 a.m.- Resident # 75 stated she wanted coffee in the mornings but cannot get any until breakfast is served. Resident # 75 stated we can't get coffee until breakfast but I would like a cup before breakfast. They all know I like my coffee. She then stated, I have to buy it from the store if I want it early in the morning. On 4/23/2025 at 8:51 a.m., Resident # 75 was observed standing in her room near the door to her room. She stated she was waiting for the breakfast trays to come to the floor. Resident # 75 stated she wanted some coffee. When asked if she could get coffee prior to the trays being served, she stated no. We have to wait until the trays come. Resident # 75 also stated that the staff know I love my coffee. She stated the only way she can get coffee prior to breakfast being served is if she buys it. When asked what that meant, she stated she would have to ask the staff to go out to a store to buy some for her. Resident # 75 was observed walking back and forth to the door of her room and later in the hallway asking dietary staff members what time they were going to deliver the breakfast trays to the unit where she resided. Resident # 75's room was located on the East wing perpendicular to the hall where the door to the kitchen was located. Resident # 75 could stand in the doorway to her room and see the carts being transported out of the kitchen. On 4/23/2025 at 9 a.m., observed Resident # 75 walking in the hall and questioning staff members if the dietary cart was going to be delivered soon. On 4/23/2025 at 9:18 a.m., observed the dietary staff delivering the trays for the East unit where Resident # 75 resided, The nursing staff delivered the tray to Resident # 75 at 9:21 a.m. Resident # 75 immediately started preparing her coffee. She stated she loved coffee. On 4/24/2025 at 3:03 p.m., an interview was conducted with the Dietary Manager who stated she would discuss the request for coffee prior to breakfast with Resident # 75 and the facility staff. During the end of day debriefing on 4/24/2025, the Administrator, Director Nursing, [NAME] President of Operations and Corporate Nurse Consultants were informed of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse at the hands of Residents, and staff members. The facility further failed to report the abuse to the state agency accurately and timely, failed to fully investigate the abuse, failed to protect new victims from abuse, and further failed to implement their abuse and neglect policies for multiple known Residents who were abused, (Residents #167, Male 1, Male 2, and Female 1, #77, #50, and #56) in a survey sample size of 57 residents. The findings included: 1. The facility failures described above resulted in the willful abuse of Resident #167 and 3 other Resident victims who collectively were abused by Resident #86 on 5 occasions, (one Resident twice). Resident #167 (victim 1) was admitted to the facility on [DATE]. Diagnoses included: Motor vehicle accident with traumatic brain injury, vertebral fractures, dissection if the carotid artery, tracheostomy with status post ventilator support, seizures, atrial fibrillation, dysphagia with gastrostomy tube for feeding, weakness, and diabetes type 2. Resident #167's most recent Minimum Data Set with an Assessment Reference Date of 4-9-25 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 3 out of a possible 15 points which indicates severe cognitive impairment. The Resident was dependent on staff members for all activities of daily living including hygiene and bathing. The Resident had no aberrant behaviors documented. Resident #86 (abuser) was admitted to the facility on [DATE]. Diagnoses included : Chronic obstructive pulmonary disease (COPD) and was a current smoker, HIV, chronic Hepatitis C, homelessness, chronic pain syndrome, alcoholic hepatitis with current alcohol consumption, anxiety, schizophrenia, bipolar disorder, mood disorder, malnutrition, and diabetes type 2. Resident #86's most recent Minimum Data Set with an Assessment Reference Date of 3-12-25 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident was documented as no change in mental status, and no physical or verbal behaviors directed at others even though he had 3 occurrences of abuse toward others prior to this (3-12-25) assessment in which police reports were made. The Resident required set up help for most activities of daily living with only minimal assistance from one staff member for bathing. The document was not signed as completed until 4-17-25 during survey as data entry errors were noted, and the Resident had no aberrant behaviors documented, even though 5 abuses (two others occurred on 3-19-25, and 4-3-25) were known to have taken placed as perpetrated by this Resident by this date (4-17-25). The 3 other Resident's abused by Resident #86 were one female (abuse female 1) who refused to be mentioned in the sample for fear of retaliation, and 2 males. The first male (abuse male 1) who was abused twice refused to be mentioned in the sample for fear of retaliation, and a second male (abuse male 2) who was discharged and could not be located for interview. While on continued tour of the facility from 4-14-25 through 4-28-25 Resident #86 was interviewed multiple times, and found to be hiding half smoked cigarettes in his room, and the room smelled of burnt tobacco. The Resident admitted that he and his room mate had been caught smoking in their room that very week. The window sill by Resident #86's bed was full of the following: Two (2) half eaten Styrofoam box containers of take out food sandwiches which were covered in black and green mold, a clear plastic take out food container with moisture condensation on the closed lid with half eaten black pizza inside. Room temperature opened milk in a pint carton box which looked like cottage cheese, a name brand red plastic zip lock bag of green molded Swiss cheese, cups of cereal soggy and room temperature with milk in them, and assorted other food items too numerous to mention all spoiled and being saved by the Resident. Upon entering Resident #86 was found on his room mate's side of the room looking inside the room mate's things. This was discovered as his side of the room was approached and he said hey! that's my stuff leave it alone or I'll mess you up! The facility Administration was asked for all allegations of abuse involving Resident #86 to include; investigations, reports to the state agency, and all staff statements for surveyor review. Five document packages were received. Those documents included initial reports to state agencies, and 5 day follow up reports as required by regulation. 4 of the 5 packages also included fax copies showing each report successfully sent to each state agency. No investigations, no witness or staff statements, no planning to curb behaviors nor protect other Residents from abuse were included. When the Administrative staff were asked for those, they stated that this was all that could be found as the former administrator had recently resigned and they could not find any other information. The 5 instances of actually reported abuses perpetrated by Resident #86 are described below in chronological order; 1. 5-14-24 - (abuse male 2) - was rolling down the hallway in his wheel chair and as he passed Resident #86's door he was hit by Resident #86 on the right side of his neck. Resident #86 stated he would not hit this man again, and additional rounding was done, and the matter was closed according to the 5 day follow up report. No description of rounding was given. No initial report to the state agency could ever be found. 2. 6-12-24 - (abuse male 1) - first occurrence was going down the hallway in his wheel chair as he passed Resident #86's door he was hit by Resident #86 for no reason with a reacher (defined as a grabber device on a long handle). The facility had no five day follow up report faxed to the state agency, however, the initial report lists on the 6-12-24 documents unfounded for abuse. 3. 11-12-24 - (abuse male 1) - second occurrence - while abuse male 1 (name) tried to go round Resident #86 who was sitting in the front of the hall, abuse male 1 bumped the wheel chair of Resident #86 and hit Resident #86's arm who then struck abuse male 1 in the face. No report to the state agency was made until 3 days after this second occurrence, which was a five day follow up, with no decision to substantiate abuse ever made via the 5 day follow up report, and no initial report was ever made. 4. 3-19-25 - (sexual abuse female 1) - Resident stated she was standing in her door and Resident #86 was in the hallway in front of her door sitting in his wheel chair and reached up and touched her breast. She wanted to press charges and police were called, and the allegation was substantiated. The police arrived and arrested the Resident for an outstanding warrant in an unrelated matter. The Resident was incarcerated from 3-19-25 until his return on 3-25-25. The Resident had a history of incarceration and marked all of his clothing items with his inmate number. 5. 4-3-25 - (abuse Resident #167) - 9 days after Resident #86 returned from incarceration, Resident #167 was admitted (4-3-25) as his room mate, and the same day was assaulted by Resident #86. Resident #75 was in the hallway walking past the room shared by Resident #167, and #86, and stated she heard Resident #86 yelling at Resident #167 and she heard Resident #86 hit Resident #167 making him fall. Staff immediately entered the room as they were in the hallway and heard the altercation as well, and found Resident #167 on the floor on Resident #86's side of the room. No 5 day follow up report was submitted to the state agency until six days later, on 4-11-25 (late), and stated that no abuse occurred (unsubstantiated). Resident #75, with a Bims score of 15 out of 15 possible points, and her own responsible party was found to be an excellent historian. She was interviewed on 4-17-25 and stated that was exactly what happened and she felt sorry for Resident #167. She stated that everyone knew Resident #86 was violent and they had to avoid him, however, she stated that Resident #167 had just arrived and had no idea his room mate was dangerous. She stated Resident #86 said after the incident to the nurse in the room, he's ok, I didn't really hit him hard or hurt him bad, and he don't want to move rooms. She further stated that staff did move Resident #167, and that was good, because he is so gentle and has a bad head injury from a car wreck and can't protect himself. Staff stated that her recollection was correct. In review of all 5 ongoing allegations of abuse made by 4 different Residents about Resident #86 none were substantiated by the facility, even though there was overwhelming evidence to support it. Only when police became involved was the allegation substantiated for abuse and resulted in the Resident being arrested for an unrelated outstanding warrant, which resulted in his incarceration from 3-19-25 to 3-25-25, when he returned to the facility. The care plan for Resident #86 was reviewed and revealed only one entry focus for behaviors in his 13 month stay. That follows below; Focus - created 3-7-24, initiated 4-9-25, revised 4-16-25. The Resident has behaviors. refused assessment, refused vital signs, cursing/yelling at staff, physical aggression towards others, doing own wound care, props leg on any item while sitting, refused skin assessments, inappropriately touching others, wants to store personal items on window ledge. Goal - The resident's behaviors will not cause them or other residents distress through the review period. Interventions - follow by created date; 3-7-24 - Physician review of medication as needed, administer medications as ordered, assure Resident they are safe if they become distressed. 5-14-24 (first known abuse on others) 5-14-24 - 1:1 until seen by provider, assign staff members that are familiar or preferred by the resident when possible, diversional activities of interest as needed, provide snacks and drinks that the resident prefers if they become distressed, psyche services referral as needed, take resident to a quiet place if they become overstimulated, redirect resident and other residents from each others personal space as noted to prevent verbal/physical interactions (stopped on 5-17-24) according to progress notes 11-12-24 - education provided to ask for assistance from staff with another resident as needed to avoid verbal and physical altercations. 3-19-25 - resident encouraged to avoid touching others and respecting their personal space. 4-6-25 - 1:1 until seen by provider, 15 minute checks remainder of shift following (stopped in 48 hours) according to progress notes. Physician and nursing progress notes were reviewed and revealed further multiple incidents of serious allegations of abuse not reported nor investigated. Those follow below in chronological order: 3-7-24 - 1 day after admission, verbally aggressive to staff. 4-19-24 - Smoking at front door of facility refuse to agree to rules. 5-6-24 - [NAME] into street/main highway in wheel chair refusing to return to building stated he was rolling straight to hell because he had no money for cigarettes and snacks. 5-14-24 - Hit another Resident in the neck for no reason. 6-12-24 - Allegations of antagonizing other residents. 7-19-24 - Cursing and yelling at staff, told he could be discharged , he stated he didn't give a damn and rolled away. 7-22-24 - Smoking at front door of building throwing cigarettes on ground, cursing and yelling at staff. 7-23-24 - In hallway making derogatory remarks do not like gay people or want them near me. 7-25-24 - Smoking at front door of building and counseled again. 7-31-24 - Ripped smoking signage off the courtyard, stating he will smoke wherever he wants to. 8-5-24 - Counseled again in regard to smoking and using fire proof ash trays. 8-7-24 - Physician reported significant aggressive behavior with increased paranoia and mood dysregulation, and staff stated he does better when he does not have significant interactions with others. 9-2-24 - Resident smelled of alcohol during medication administration. 9-5-24 - Counseled not to share cigarettes with others, and no smoking inside the facility. 9-18-24 - Counseled for Resident to Resident incident of intentionally hitting the leg of a Resident. 10-22-24 - Counseled for leaving facility at night without telling staff. Given a reflective device for chair. 11-12-24 - Hit another Resident. 11-13-24 - Counseled for aggressive incident with another Resident. 12-1-24 - Resident had knife in the pocket of his wheel chair for protection staff looked and found scissors. 12-2-24 - 9:30 AM argument with room mate blocking room mate from leaving the room trying to punch room mate stated I wish he would die. Resident's room mate helped out of room. 12-2-24 - 11:00 AM stealing room mates personal items, threatened room mate with scissors. 12-2-24 - 1:00 PM drinking alcohol in front of building, cursed at nurse who confiscated it and lashed out punching and charging in wheel chair at nurse 12-2-24 - 3:30 PM punching and kicking staff, room mate removed from room after Resident #86 threatened to stab him. Full Vodka bottles found and confiscated. 12-3-24 - Resident smells of alcohol/slurred speech. 12-14-24 - Resident riding down street in traffic, resident stated he was going to the store and refused to turn around and refused to get out of the road. 12-15-24 - Resident room changed due to behaviors, Resident unhappy about room change. 12-15-24 - Resident had altercation aggressive screaming with new room mate. 12-18-24 - Resident threw medication at staff. 1-17-25 - Resident in possession of and sharing alcohol, Resident angry, cursing and using derogatory language to staff. 1-21-25 - Arguing with another Resident in hallway. 1-23-25 - Asking other residents for money, said he got cigarettes for them and they owed it to him. 2-1-25 - Verbal altercation with room mate as Resident #86 angry when his room mate moved his own personal items away from Res #86, and #86 threatened room mate with his reacher. 2-26-25 - Wants to move because he doesn't like his room mate. 3-19-25 - Police called after incident with another Resident. Police removed resident who returned on 3-25-25 after incarceration. 3-30-25 - Resident taking things from medication cart, caught by staff said he would not do it again. 10 minutes later found doing it again. 4-3-25 - Initiated physical aggression on room mate. 4-3-25 - Resident room moved again. Nursing staff on the unit where Resident #86 was housed were interviewed and stated they remembered Resident #86, and his aggressive behaviors, however, those working during survey interviews were not present during all of the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day. During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was involved with Resident #86 on 18 documented occasions in 13 months. Those instances follow patterns of behaviors exhibited by the Resident including; smoking in disallowed public spaces, smoking in his room, buying cigarettes for other Residents, drinking alcohol in the facility obtained by traveling to a local convenience store independently in his wheel chair using a busy highway to buy it, and giving it to other Residents. Resident #86 was counseled repeatedly due to aggressive acts perpetrated on other Residents, had room changes because of violence against other Residents, theft of other Residents belongings, attempting to get money from other Residents, threatening to stab a room mate with scissors, and assaulting staff. Only on 2 occasions was added supervision used, and the two occasions were a year apart. The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections. Residents reported abuse and were told no abuse occurred (unfounded/unsubstantiated) on multiple occasions before staff observed the abuse and moved Resident #86. Resident #86 was only supervised on 2 occasions (5-14-24, and 4-6-25) a year apart, then allowed to independently move around the entire facility inside, and outside without supervision or oversight, and placed with Residents who were not protected and were abused during that year. Resident #86 was known to have room changes on 3 occasions, and each time he abused again and went to a new area without supervision to abuse. Many of the incidents listed above as documented, were or should have been, allegations of abuse, however, they were not initially reported to the state agency, not investigated, not followed up with a five day report, were reported late, or never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any ongoing added staff supervision for Resident #86 to prevent the continuing known abuse from occurring. On 4-20-25 at approximately 5:00 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer. 4. For Resident # 56, the facility staff failed to protect from physical abuse by another resident (Resident # 322). Resident # 322 hit Resident # 56 in the right eye and caused a contusion and evaluation at the hospital. Resident # 56 was a [AGE] year-old readmitted to the facility on [DATE] with diagnoses that included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 322 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses that included but were not limited to: metabolic encephalopathy, cirrhosis of the liver, heart failure and altered mental status. The most recent Minimum Data Set (MDS) assessment was a Discharge Assessment with an assessment reference date (ARD) of 3/28/2025. Resident # 322 was coded with a Brief Interview of Mental Status score of 12 out of 15 indicating moderate cognitive impairment. The resident was in the facility for only 9 days and not long enough to complete an admission Assessment. Review of the clinical records was conducted 4/16/2025-4/28/2025. Review of the Progress Notes for Resident # 56 revealed that on 3/22/2025, Resident # 322 hit Resident # 56 in the eye. The note stated that Resident # 56 was was possibly assaulted by his new roommate. Residents have a swollen right eye. POA (Power of Attorney) called no answer/ left message for a return call. Resident have been moved to west wing transferred to another unit in the facility. The next note written on 3/23/2025 at 1:14 a.m. stated that Resident # 56 was sent to the hospital's ER (Emergency Room) for evaluation. The note read: Nursing observations, evaluation, and recommendations are: Resident observed with intermittent confusion. Resident observed with swelling to right eye. Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER for further eval and treatment Further review of the clinical record revealed that Resident # 56 returned to the facility on 3/23/2025 at 9:30 a.m. when the following note stated: Resident returned from ER for evaluation and treatment s/p assaulted by another resident. Multiple X-rays were taken at ER with no abnormalities reported. Contusion remains to right eye. No complaints of visual disturbances voiced. All scheduled pain medications accepted as scheduled. No complaints of pain or discomfort. Will continue to monitor. The swelling of the right eye continued for several days. On 3/26/2025, Resident # 56 was seen by the eye doctor, and new orders were written for for Prednisolone Acetate Ophthalmic Suspension TID (three times a day) to right eye for 14 Days then twice a day for 14 Days for redness to right eye. Review of Resident # 322's record revealed the following documentation from the Psychiatric nurse practitioner dated 3/26/2025: Patient is a [AGE] year-old male requested by this facility for management of aggressive behavior that has been present since 3/23/2025. Patient has been taking Abilify, trazodone, melatonin before his admission to the facility on 3/19/2025. Patient had significant agitation and psychiatry was consulted in the hospital and recommended Abilify for mood stabilization and psychosis management and recommended Haldol 7.5 mg as needed for breakthrough agitation. The note also stated: Per medical record patient recently punched another male resident in the face on 3/23/2025. His aggression was so severe that it caused the other resident to need to go to the hospital for evaluation. Staff reports patient having significant irritability however has not been noted to attack any of the staff. Today when this provider saw patient he was quite irritable and sneered at this provider. He reported 'I am a private person. He did not provide his specific mood however he appeared quite irritable and hostile in the interview. This provider asked how he was adjusting to the facility and he stated that being at the facility 'sucks.' He reported his clothing and shoes being stolen at the facility and states he is ready to go home. Staff is not reported any missing clothing from patient. Patient also stated grandiose statements and he was carrying a load of log books on his lap. The note stated: Resident # 322 stated he was on his way to law school and had only 4 more classes left before he became a lawyer. He denied feeling anxious and excessively worried. He denied having conflicts with staff or other residents. However, when this provider initiated conversation on the physical altercation he had with another male resident he became significantly agitated and repeatedly stating 'who reported this to you!' Patient became increasingly agitated and verbally aggressive with threatening behaviors and this provider decided to end the interview due to safety reasons. Patient refused to answer further interview questions. Cognitive functioning did not appear to have significant increased confusion in the encounter. No suicidal or violent ideations voiced. He denies having retaliatory ideations towards peer. No reported or observed adverse psychotropic medication side effects and patient has been noted to be psychotropic medication adherent. Under Recommendations was written: Patient with significant aggressive behaviors with high risk of violence as demonstrated by assaulting patient on 3/23/2025. Abilify does not appear to be fully effective in stabilizing mood or reducing psychosis because patient continues to have grandiose and paranoid delusions. Patient has end-stage renal disease and Haldol may be the best mode of psychosis management which may also reduce patient's aggression. Will augment Abilify with Haldol for psychosis agitation and mood disorder mood dysregulation and impulsive aggression. Haldol is currently being utilized to keep patient in the facility and reduce risk of further violence. Patient currently does not have violent ideations towards other resident at this time who is currently on another unit for safety. The Psychiatric Nurse Practitioner's note also stated there should be followed up in 1-3 weeks. It stated: If pt is to be discharged from facility before this provider is able to re-assess response of psychiatric medication intervention, please follow up with personal outside-facility provider for continued treatment evaluation and psychiatric medication management. On 4/25/2025 at 2:10 p.m., an interview was conducted with Licensed # Practical Nurse-B who stated Resident # 322 hit Resident # 56 at the change of the shifts. Licensed Practical Nurse-B stated Resident # 56 informed the police and facility staff that Resident # 322 hit him. She stated that Resident # 322 was discharged from the facility on 3/28/2025. Licensed Practical Nurse-B stated Resident # 322 had a history of extreme agitation prior to being admitted to the facility. On 4/25/2025 at 4 p.m., an interview was conducted with the Director of Nursing who stated Resident # 322 no longer resided in the facility. He was discharged home. She stated that all of the appropriate agencies were informed of the resident-to-resident altercation. The Director of Nursing stated the staff immediately separated the two residents and that Resident # 56 moved to another unit. Review of the facility's documentation revealed that Resident # 56 yelled out to the nurse that Resident # 322 had punched him in the face. Resident # 56 reported that Resident # 322 punched him after accusing him of stealing his clothes. Resident # 56 denied having any of Resident # 322's clothes. After the incident, the police were notified and completed a report. The doctor and responsible parties for both residents were notified. The facility staff notified all of the appropriate agencies of the altercation. Resident # 322 was placed on 1:1 care for the remainder of the shift. Resident # 56 requested a room change and was moved to another room. Resident # 322 was discharged from the facility on 3/28/2025. Resident # 56 remained upset about being assaulted by his roommate. He told the surveyor it messed me up. On 4/24/2025 at 1:45 a.m., an interview was conducted with Certified Nursing Assistant-C who stated they watch the residents and the way they interact with each other. Certified Nursing Assistant-C stated she would report any issues to the charge nurse or Director of Nursing. On 4/25/2025 at 2:20 p.m., an interview was conducted with License Practical Nurse-H who stated the staff monitor residents for any signs of aggression or agitation. Licensed Practical Nurse-H stated if residents do have any altercations, they would immediately be separated and protected from further abuse. During the end of day debriefing on 4/25/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings. Based on the note from the Psychiatric Nurse Practitioner, the facility administration was aware of Resident # 322's significant agitation and need for a Psychiatric consult to in the hospital prior to admission to the facility. During that hospitalization, the Psychiatrist recommended Resident 322 to start taking medications. The medication, Abilify, was prescribed for mood stabilization and psychosis management and another drug, Haldol, was recommended as needed for breakthrough agitation. The facility failed to protect Resident # 56 from abuse by Resident # 322, who was known to have significant agitation and psychosis. Resident # 56 remained upset about being hit in the eye by his roommate (Resident # 322.) No further information was provided. 2. For Resident #77 the facility staff failed to keep the Resident free from abuse and neglect. Resident # 77 was admitted to the facility on [DATE] with diagnosis that included chronic embolism and thrombosis, mood disorder, insomnia, dysphasia, muscle, wasting and atrophy, chronic obstructive, pulmonary disease, polyneuropathy, major depressive disorder, chronic kidney disease, fibromyalgia, chronic diastolic heart, failure, hypertension, chronic pain syndrome, and generalized anxiety disorder. Resident # 77's most recent MDS (Minimum Data Set) dated, 4/23/25, scored Resident #77 as having a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating mild cognitive impairment. Resident #77 was also coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living) care except for feeding. On the afternoon of 4/23/25 Resident #77 was interviewed, and she stated that some of the CNA's are rude and rough when providing care. When asked to elaborate she stated that she had a problem with two CNA's and the facility stopped having them care for her. She stated this made the issue worse because now she felt they would just come into the room, turn off the light and tell her they would get someone else to come in but then they never would come. She also stated that now that 2 of the CNA's were upset with her Now they all are. She stated that 2 CNA's came in her room to give her care and brought witness and they Snatched, the blankets, out from under me and lifted my leg to provide care but then they just dropped it back on the bed. When asked if she was injured, she stated that she was not. She further stated, It just made me feel like they just don't care. When asked if she reported the incident, she stated that she told the DON a few days ago. She stated that she waited 12 hours to have incontinent care provided. She stated that she was not changed the entire night shift from 7 p.m. - until 7 a.m. She stated they (the CNAs) sit outside her room and laugh and talk and come in and shut the call light off but never get anyone to come in. When asked how she felt she stated that she felt Helpless, like who is going to protect me? I am bed bound, I cannot get up or defend myself if I have to. Like I am supposed to accept whatever care they choose to provide. On 4/23/25 at approximately 4:00 p.m., an interview was conducted with the DON who stated that she was aware of the incident and had advised staff to always have someone else in the room to observe when providing care for Resident #77. She stated that she told the resident it was for her as well as the staff. The DON stated that having someone else observed care would safeguard the resident as well as provide the staff with a witness to care provided. When asked if this was considered an allegation of abuse and/or neglect, she stated that it should be. The facility reported the allegation of abuse to the OLC, APS, Ombudsman, and the local authorities on 4/23/25. A review of the clinical record revealed the following excerpt from the physicians progress note: 4/23/25 9:30 p.m. -Nursing request for assessment of newly reported bilateral buttocks MASD, skin intact with blanchable redness. Recommend continuing with zinc oxide cream and frequent brief changes to reduce incontinence associated skin breakdown. Facility to manage, provider can reassess if worsening or new area of skin breakdown. A review of the Policy entitled Abuse, Neglect, and Misappropriation effective date, 10/17/23, revealed the following excer[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse at the hands of Residents, and staff members. The facility further failed to report the abuse to the state agency accurately and timely, failed to fully investigate the abuse, failed to protect new victims from abuse, and further failed to implement their abuse and neglect policies for multiple known Residents who were abused. (Residents #167, Male 1, Male 2, and Female 1, and #77) in a survey sample size of 57 residents. The findings included: 1. The facility failures described above resulted in the willful abuse of Resident #167 and 3 other Resident victims who collectively were abused by Resident #86 on 5 occasions, (one Resident twice). Resident #167 (victim 1) was admitted to the facility on [DATE]. Diagnoses included: Motor vehicle accident with traumatic brain injury, vertebral fractures, dissection if the carotid artery, tracheostomy with status post ventilator support, seizures, atrial fibrillation, dysphagia with gastrostomy tube for feeding, weakness, and diabetes type 2. Resident #167's most recent Minimum Data Set with an Assessment Reference Date of 4-9-25 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 3 out of a possible 15 points which indicates severe cognitive impairment. The Resident was dependent on staff members for all activities of daily living including hygiene and bathing. The Resident had no aberrant behaviors documented. Resident #86 (abuser) was admitted to the facility on [DATE]. Diagnoses included : Chronic obstructive pulmonary disease (COPD) and was a current smoker, HIV, chronic Hepatitis C, homelessness, chronic pain syndrome, alcoholic hepatitis with current alcohol consumption, anxiety, schizophrenia, bipolar disorder, mood disorder, malnutrition, and diabetes type 2. Resident #86's most recent Minimum Data Set with an Assessment Reference Date of 3-12-25 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident was documented as no change in mental status, and no physical or verbal behaviors directed at others even though he had 3 occurrences of abuse toward others prior to this (3-12-25) assessment in which police reports were made. The Resident required set up help for most activities of daily living with only minimal assistance from one staff member for bathing. The document was not signed as completed until 4-17-25 during survey as data entry errors were noted, and the Resident had no aberrant behaviors documented, even though 5 abuses (two others occurred on 3-19-25, and 4-3-25) were known to have taken placed as perpetrated by this Resident by this date (4-17-25). The 3 other Resident's abused by Resident #86 were one female (abuse female 1) who refused to be mentioned in the sample for fear of retaliation, and 2 males. The first male (abuse male 1) who was abused twice refused to be mentioned in the sample for fear of retaliation, and a second male (abuse male 2) who was discharged and could not be located for interview. While on continued tour of the facility from 4-14-25 through 4-28-25 Resident #86 was interviewed multiple times, and found to be hiding half smoked cigarettes in his room, and the room smelled of burnt tobacco. The Resident admitted that he and his room mate had been caught smoking in their room that very week. The window sill by Resident #86's bed was full of the following; Two (2) half eaten Styrofoam box containers of take out food sandwiches which were covered in black and green mold, a clear plastic take out food container with moisture condensation on the closed lid with half eaten black pizza inside. Room temperature opened milk in a pint carton box which looked like cottage cheese, a name brand red plastic zip lock bag of green molded Swiss cheese, cups of cereal soggy and room temperature with milk in them, and assorted other food items too numerous to mention all spoiled and being saved by the Resident. Upon entering Resident #86 was found on his room mate's side of the room looking inside the room mate's things. This was discovered as his side of the room was approached and he said hey! that's my stuff leave it alone or I'll mess you up! The facility Administration was asked for all allegations of abuse involving Resident #86 to include; investigations, reports to the state agency, and all staff statements for surveyor review. Five document packages were received. Those documents included initial reports to state agencies, and 5 day follow up reports as required by regulation. 4 of the 5 packages also included fax copies showing each report successfully sent to each state agency. No investigations, no witness or staff statements, no planning to curb behaviors nor protect other Residents from abuse were included. When the Administrative staff were asked for those, they stated that this was all that could be found as the former administrator had recently resigned and they could not find any other information. The 5 instances of actually reported abuses perpetrated by Resident #86 are described below in chronological order; 1. 5-14-24 - (abuse male 2) - was rolling down the hallway in his wheel chair and as he passed Resident #86's door he was hit by Resident #86 on the right side of his neck. Resident #86 stated he would not hit this man again, and additional rounding was done, and the matter was closed according to the 5 day follow up report. No description of rounding was given. No initial report to the state agency could ever be found. 2. 6-12-24 - (abuse male 1) - first occurrence was going down the hallway in his wheel chair as he passed Resident #86's door he was hit by Resident #86 for no reason with a reacher (defined as a grabber device on a long handle). The facility had no five day follow up report faxed to the state agency, however, the initial report lists on the 6-12-24 documents unfounded for abuse. 3. 11-12-24 - (abuse male 1) - second occurrence - while abuse male 1 (name) tried to go round Resident #86 who was sitting in the front of the hall, abuse male 1 bumped the wheel chair of Resident #86 and hit Resident #86's arm who then struck abuse male 1 in the face. No report to the state agency was made until 3 days after this second occurrence, which was a five day follow up, with no decision to substantiate abuse ever made via the 5 day follow up report, and no initial report was ever made. 4. 3-19-25 - (sexual abuse female 1) - Resident stated she was standing in her door and Resident #86 was in the hallway in front of her door sitting in his wheel chair and reached up and touched her breast. She wanted to press charges and police were called, and the allegation was substantiated. The police arrived and arrested the Resident for an outstanding warrant in an unrelated matter. The Resident was incarcerated from 3-19-25 until his return on 3-25-25. The Resident had a history of incarceration and marked all of his clothing items with his inmate number. 5. 4-3-25 - (abuse Resident #167) - 9 days after Resident #86 returned from incarceration, Resident #167 was admitted (4-3-25) as his room mate, and the same day was assaulted by Resident #86. Resident #75 was in the hallway walking past the room shared by Resident #167, and #86, and stated she heard Resident #86 yelling at Resident #167 and she heard Resident #86 hit Resident #167 making him fall. Staff immediately entered the room as they were in the hallway and heard the altercation as well, and found Resident #167 on the floor on Resident #86's side of the room. No 5 day follow up report was submitted to the state agency until six days later, on 4-11-25 (late), and stated that no abuse occurred (unsubstantiated). Resident #75, with a Bims score of 15 out of 15 possible points, and her own responsible party was found to be an excellent historian. She was interviewed on 4-17-25 and stated that was exactly what happened and she felt sorry for Resident #167. She stated that everyone knew Resident #86 was violent and they had to avoid him, however, she stated that Resident #167 had just arrived and had no idea his room mate was dangerous. She stated Resident #86 said after the incident to the nurse in the room, he's ok, I didn't really hit him hard or hurt him bad, and he don't want to move rooms. She further stated that staff did move Resident #167, and that was good, because he is so gentle and has a bad head injury from a car wreck and can't protect himself. Staff stated that her recollection was correct. In review of all 5 ongoing allegations of abuse made by 4 different Residents about Resident #86 none were substantiated by the facility, even though there was overwhelming evidence to support it. Only when police became involved was the allegation substantiated for abuse and resulted in the Resident being arrested for an unrelated outstanding warrant, which resulted in his incarceration from 3-19-25 to 3-25-25, when he returned to the facility. The care plan for Resident #86 was reviewed and revealed only one entry focus for behaviors in his 13 month stay. That follows below; Focus - created 3-7-24, initiated 4-9-25, revised 4-16-25. The Resident has behaviors. refused assessment, refused vital signs, cursing/yelling at staff, physical aggression towards others, doing own wound care, props leg on any item while sitting, refused skin assessments, inappropriately touching others, wants to store personal items on window ledge. Goal - The resident's behaviors will not cause them or other residents distress through the review period. Interventions - follow by created date; 3-7-24 - Physician review of medication as needed, administer medications as ordered, assure Resident they are safe if they become distressed. 5-14-24 (first known abuse on others) 5-14-24 - 1:1 until seen by provider, assign staff members that are familiar or preferred by the resident when possible, diversional activities of interest as needed, provide snacks and drinks that the resident prefers if they become distressed, psyche services referral as needed, take resident to a quiet place if they become overstimulated, redirect resident and other residents from each others personal space as noted to prevent verbal/physical interactions (stopped on 5-17-24) according to progress notes 11-12-24 - education provided to ask for assistance from staff with another resident as needed to avoid verbal and physical altercations. 3-19-25 - resident encouraged to avoid touching others and respecting their personal space. 4-6-25 - 1:1 until seen by provider, 15 minute checks remainder of shift following (stopped in 48 hours) according to progress notes. Physician and nursing progress notes were reviewed and revealed further multiple incidents of serious allegations of abuse not reported nor investigated. Those follow below in chronological order: 3-7-24 - 1 day after admission, verbally aggressive to staff. 4-19-24 - Smoking at front door of facility refuse to agree to rules. 5-6-24 - [NAME] into street/main highway in wheel chair refusing to return to building stated he was rolling straight to hell because he had no money for cigarettes and snacks. 5-14-24 - Hit another Resident in the neck for no reason. 6-12-24 - Allegations of antagonizing other residents. 7-19-24 - Cursing and yelling at staff, told he could be discharged , he stated he didn't give a damn and rolled away. 7-22-24 - Smoking at front door of building throwing cigarettes on ground, cursing and yelling at staff. 7-23-24 - In hallway making derogatory remarks do not like gay people or want them near me. 7-25-24 - Smoking at front door of building and counseled again. 7-31-24 - Ripped smoking signage off the courtyard, stating he will smoke wherever he wants to. 8-5-24 - Counseled again in regard to smoking and using fire proof ash trays. 8-7-24 - Physician reported significant aggressive behavior with increased paranoia and mood dysregulation, and staff stated he does better when he does not have significant interactions with others. 9-2-24 - Resident smelled of alcohol during medication administration. 9-5-24 - Counseled not to share cigarettes with others, and no smoking inside the facility. 9-18-24 - Counseled for Resident to Resident incident of intentionally hitting the leg of a Resident. 10-22-24 - Counseled for leaving facility at night without telling staff. Given a reflective device for chair. 11-12-24 - Hit another Resident. 11-13-24 - Counseled for aggressive incident with another Resident. 12-1-24 - Resident had knife in the pocket of his wheel chair for protection staff looked and found scissors. 12-2-24 - 9:30 AM argument with room mate blocking room mate from leaving the room trying to punch room mate stated I wish he would die. Resident's room mate helped out of room. 12-2-24 - 11:00 AM stealing room mates personal items, threatened room mate with scissors. 12-2-24 - 1:00 PM drinking alcohol in front of building, cursed at nurse who confiscated it and lashed out punching and charging in wheel chair at nurse 12-2-24 - 3:30 PM punching and kicking staff, room mate removed from room after Resident #86 threatened to stab him. Full Vodka bottles found and confiscated. 12-3-24 - Resident smells of alcohol/slurred speech. 12-14-24 - Resident riding down street in traffic, resident stated he was going to the store and refused to turn around and refused to get out of the road. 12-15-24 - Resident room changed due to behaviors, Resident unhappy about room change. 12-15-24 - Resident had altercation aggressive screaming with new room mate. 12-18-24 - Resident threw medication at staff. 1-17-25 - Resident in possession of and sharing alcohol, Resident angry, cursing and using derogatory language to staff. 1-21-25 - Arguing with another Resident in hallway. 1-23-25 - Asking other residents for money, said he got cigarettes for them and they owed it to him. 2-1-25 - Verbal altercation with room mate as Resident #86 angry when his room mate moved his own personal items away from Res #86, and #86 threatened room mate with his reacher. 2-26-25 - Wants to move because he doesn't like his room mate. 3-19-25 - Police called after incident with another Resident. Police removed resident who returned on 3-25-25 after incarceration. 3-30-25 - Resident taking things from medication cart, caught by staff said he would not do it again. 10 minutes later found doing it again. 4-3-25 - Initiated physical aggression on room mate. 4-3-25 - Resident room moved again. Nursing staff on the unit where Resident #86 was housed were interviewed and stated they remembered Resident #86, and his aggressive behaviors, however, those working during survey interviews were not present during all of the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day. During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was involved with Resident #86 on 18 documented occasions in 13 months. Those instances follow patterns of behaviors exhibited by the Resident including; smoking in disallowed public spaces, smoking in his room, buying cigarettes for other Residents, drinking alcohol in the facility obtained by traveling to a local convenience store independently in his wheel chair using a busy highway to buy it, and giving it to other Residents. Resident #86 was counseled repeatedly due to aggressive acts perpetrated on other Residents, had room changes because of violence against other Residents, theft of other Residents belongings, attempting to get money from other Residents, threatening to stab a room mate with scissors, and assaulting staff. Only on 2 occasions was added supervision used, and the two occasions were a year apart. The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections. Residents reported abuse and were told no abuse occurred (unfounded/unsubstantiated) on multiple occasions before staff observed the abuse and moved Resident #86. Resident #86 was only supervised on 2 occasions (5-14-24, and 4-6-25) a year apart, then allowed to independently move around the entire facility inside, and outside without supervision or oversight, and placed with Residents who were not protected and were abused during that year. Resident #86 was known to have room changes on 3 occasions, and each time he abused again and went to a new area without supervision to abuse. Many of the incidents listed above as documented, were or should have been, allegations of abuse, however, they were not initially reported to the state agency, not investigated, not followed up with a five day report, were reported late, or never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any ongoing added staff supervision for Resident #86 to prevent the continuing known abuse from occurring. On 4-20-25 at approximately 5:00 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review and facility documentation, the facility staff failed to implement the abuse policy and report an allegation of abuse for one (1) resident (Resident #77) in a survey sample of 57 Residents. The findings included: For Resident #77 the facility staff failed to report and investigate allegations of abuse in a timely manner. Resident # 77 was admitted to the facility on [DATE] with diagnosis that included chronic embolism and thrombosis, mood disorder, insomnia, dysphasia, muscle, wasting and atrophy, chronic obstructive, pulmonary disease, polyneuropathy, major depressive disorder, chronic kidney disease, fibromyalgia, chronic diastolic heart, failure, hypertension, chronic pain syndrome, and generalized anxiety disorder. Resident # 77's most recent MDS (Minimum Data Set) dated, 4/23/25, scored Resident #77 as having a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating mild cognitive impairment. Resident #77 was also coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living) care except for feeding. On the afternoon of 4/23/25 Resident #77 was interviewed, and she stated that some of the CNA's are rude and rough when providing care. When asked to elaborate she stated that she had a problem with two CNA's and the facility stopped having them care for her. She stated this made the issue worse because now she felt they would just come into the room, turn off the light and tell her they would get someone else to come in but then they never would come. She also stated that now that 2 of the CNA's were upset with her Now they all are She stated that 2 CNA's came in her room to give her care and brought witness and they Snatched, the blankets, out from under me and lifted my leg to provide care but then they just dropped it back on the bed. When asked if she was injured, she stated that she was not. She further stated, It just made me feel like they just don't care. When asked if she reported the incident, she stated that she told the DON a few days ago. She stated that she waited 12 hours to have her incontinent care provided. She stated that she was not changed the entire night shift from 7 p.m. - until 7 a.m. She stated they (the CNAs) sit outside her room and laugh and talk and come in and shut the call light off but never get anyone to come in. When asked how she felt she stated that she felt Helpless, like who is going to protect me? I am bed bound, I cannot get up or defend myself if I have to. Like I am supposed to accept whatever care they choose to provide. On 4/23/25 at approximately 4:00 p.m. An interview was conducted with the DON who stated that she was aware of the incident and had advised staff to always have someone else in the room to observe when providing care for Resident #77. She stated that she told the Resident it was for her as well as the staff. The DON stated that having someone else observed care would safeguard the Resident as well as provide the staff with a witness to care provided. When asked if this was considered an allegation of abuse and/or neglect, she stated that it should be. The facility reported the allegation of abuse to the OLC, APS, Ombudsman, and the local authorities on 4/23/25. A review of the clinical record revealed the following excerpt from the physicians progress note: 4/23/25 9:30 p.m. -Nursing request for assessment of newly reported bilateral buttocks MASD, skin intact with blanchable redness. Recommend continuing with zinc oxide cream and frequent brief changes to reduce incontinence associated skin breakdown. Facility to manage, provider can reassess if worsening or new area of skin breakdown. A review of the Policy entitled Abuse, Neglect, and Misappropriation effective date, 10/17/23, revealed the following excerpts: Page 1. Policy: there is zero tolerance for mistreatment abuse, neglect, misappropriation of property or any crime that is against the patient of a healthcare and rehabilitation center. Procedures: 1. Patients of the center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment, involuntary seclusion, including abuse from facilitated or enabled through the use of technology, and free from chemical and physical restraints, except in an emergency and or as authorized by a physician. 4. All employees are responsible for immediately (no later than two hours after an allegation is made if the incident involves abuse or bodily injury, no later than 24 hours if the incident does not involve abuse or bodily injury) reporting to the administrator, or in the absence, the Director of nursing, or their immediate supervisor and any, and all suspected witnesses incident of the patient abuse, neglect, theft, exploitation, and or mist treatment of a patient as well as any reasonable succession of a crime against the patient. 5. Any and all suspected or witnessed incidents of patient-to-patient abuse, neglect, theft, and or exploitation or the reasonable suspicion of a crime against a patient, patient center brought to the attention of the centers. The administrator will result in internal investigation, appropriate, and timely reporting to the state survey agency, and other legally designated agencies, as well as staff corrective action, suspension, and or termination as necessary. On 4/23/25 the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to investigate, prevent, and correct repeated willful abuse at the hands of Resident #86. The facility further failed to report the abuse to the state agency accurately and timely, and failed to implement their abuse and neglect policies for multiple known Residents who were abused. (Residents #167, Male 1, Male 2, and Female 1) in a survey sample size of 57 residents. The findings included: The facility failures described above resulted in the willful abuse of Resident #167 and 3 other Resident victims who collectively were abused by Resident #86 on 5 occasions, (one Resident twice). Resident #167 (victim 1) was admitted to the facility on [DATE]. Diagnoses included: Motor vehicle accident with traumatic brain injury, vertebral fractures, dissection if the carotid artery, tracheostomy with status post ventilator support, seizures, atrial fibrillation, dysphagia with gastrostomy tube for feeding, weakness, and diabetes type 2. Resident #167's most recent Minimum Data Set with an Assessment Reference Date of 4-9-25 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 3 out of a possible 15 points which indicates severe cognitive impairment. The Resident was dependent on staff members for all activities of daily living including hygiene and bathing. The Resident had no aberrant behaviors documented. Resident #86 (abuser) was admitted to the facility on [DATE]. Diagnoses included : Chronic obstructive pulmonary disease (COPD) and was a current smoker, HIV, chronic Hepatitis C, homelessness, chronic pain syndrome, alcoholic hepatitis with current alcohol consumption, anxiety, schizophrenia, bipolar disorder, mood disorder, malnutrition, and diabetes type 2. Resident #86's most recent Minimum Data Set with an Assessment Reference Date of 3-12-25 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident was documented as no change in mental status, and no physical or verbal behaviors directed at others even though he had 3 occurrences of abuse toward others prior to this (3-12-25) assessment in which police reports were made. The Resident required set up help for most activities of daily living with only minimal assistance from one staff member for bathing. The document was not signed as completed until 4-17-25 during survey as data entry errors were noted, and the Resident had no aberrant behaviors documented, even though 5 abuses (two others occurred on 3-19-25, and 4-3-25) were known to have taken placed as perpetrated by this Resident by this date (4-17-25). The 3 other Resident's abused by Resident #86 were one female (abuse female 1) who refused to be mentioned in the sample for fear of retaliation, and 2 males. The first male (abuse male 1) who was abused twice refused to be mentioned in the sample for fear of retaliation, and a second male (abuse male 2) who was discharged and could not be located for interview. While on continued tour of the facility from 4-14-25 through 4-28-25 Resident #86 was interviewed multiple times, and found to be hiding half smoked cigarettes in his room, and the room smelled of burnt tobacco. The Resident admitted that he and his room mate had been caught smoking in their room that very week. The window sill by Resident #86's bed was full of the following; Two (2) half eaten Styrofoam box containers of take out food sandwiches which were covered in black and green mold, a clear plastic take out food container with moisture condensation on the closed lid with half eaten black pizza inside. Room temperature opened milk in a pint carton box which looked like cottage cheese, a name brand red plastic zip lock bag of green molded Swiss cheese, cups of cereal soggy and room temperature with milk in them, and assorted other food items too numerous to mention all spoiled and being saved by the Resident. Upon entering Resident #86 was found on his room mate's side of the room looking inside the room mate's things. This was discovered as his side of the room was approached and he said hey! that's my stuff leave it alone or I'll mess you up! The facility Administration was asked for all allegations of abuse involving Resident #86 to include; investigations, reports to the state agency, and all staff statements for surveyor review. Five document packages were received. Those documents included initial reports to state agencies, and 5 day follow up reports as required by regulation. 4 of the 5 packages also included fax copies showing each report successfully sent to each state agency. No investigations, no witness or staff statements, no planning to curb behaviors nor protect other Residents from abuse were included. When the Administrative staff were asked for those, they stated that this was all that could be found as the former administrator had recently resigned and they could not find any other information. The 5 instances of actually reported abuses perpetrated by Resident #86 are described below in chronological order; 1. 5-14-24 - (abuse male 2) - was rolling down the hallway in his wheel chair and as he passed Resident #86's door he was hit by Resident #86 on the right side of his neck. Resident #86 stated he would not hit this man again, and additional rounding was done, and the matter was closed according to the 5 day follow up report. No description of rounding was given. No initial report to the state agency could ever be found. 2. 6-12-24 - (abuse male 1) - first occurrence was going down the hallway in his wheel chair as he passed Resident #86's door he was hit by Resident #86 for no reason with a reacher (defined as a grabber device on a long handle). The facility had no five day follow up report faxed to the state agency, however, the initial report lists on the 6-12-24 documents unfounded for abuse. 3. 11-12-24 - (abuse male 1) - second occurrence - while abuse male 1 (name) tried to go round Resident #86 who was sitting in the front of the hall, abuse male 1 bumped the wheel chair of Resident #86 and hit Resident #86's arm who then struck abuse male 1 in the face. No report to the state agency was made until 3 days after this second occurrence, which was a five day follow up, with no decision to substantiate abuse ever made via the 5 day follow up report, and no initial report was ever made. 4. 3-19-25 - (sexual abuse female 1) - Resident stated she was standing in her door and Resident #86 was in the hallway in front of her door sitting in his wheel chair and reached up and touched her breast. She wanted to press charges and police were called, and the allegation was substantiated. The police arrived and arrested the Resident for an outstanding warrant in an unrelated matter. The Resident was incarcerated from 3-19-25 until his return on 3-25-25. The Resident had a history of incarceration and marked all of his clothing items with his inmate number. 5. 4-3-25 - (abuse Resident #167) - 9 days after Resident #86 returned from incarceration, Resident #167 was admitted (4-3-25) as his room mate, and the same day was assaulted by Resident #86. Resident #75 was in the hallway walking past the room shared by Resident #167, and #86, and stated she heard Resident #86 yelling at Resident #167 and she heard Resident #86 hit Resident #167 making him fall. Staff immediately entered the room as they were in the hallway and heard the altercation as well, and found Resident #167 on the floor on Resident #86's side of the room. No 5 day follow up report was submitted to the state agency until six days later, on 4-11-25 (late), and stated that no abuse occurred (unsubstantiated). Resident #75, with a Bims score of 15 out of 15 possible points, and her own responsible party was found to be an excellent historian. She was interviewed on 4-17-25 and stated that was exactly what happened and she felt sorry for Resident #167. She stated that everyone knew Resident #86 was violent and they had to avoid him, however, she stated that Resident #167 had just arrived and had no idea his room mate was dangerous. She stated Resident #86 said after the incident to the nurse in the room, he's ok, I didn't really hit him hard or hurt him bad, and he don't want to move rooms. She further stated that staff did move Resident #167, and that was good, because he is so gentle and has a bad head injury from a car wreck and can't protect himself. Staff stated that her recollection was correct. In review of all 5 ongoing allegations of abuse made by 4 different Residents about Resident #86 none were substantiated by the facility, even though there was overwhelming evidence to support it. Only when police became involved was the allegation substantiated for abuse and resulted in the Resident being arrested for an unrelated outstanding warrant, which resulted in his incarceration from 3-19-25 to 3-25-25, when he returned to the facility. The care plan for Resident #86 was reviewed and revealed only one entry focus for behaviors in his 13 month stay. That follows below; Focus - created 3-7-24, initiated 4-9-25, revised 4-16-25. The Resident has behaviors. refused assessment, refused vital signs, cursing/yelling at staff, physical aggression towards others, doing own wound care, props leg on any item while sitting, refused skin assessments, inappropriately touching others, wants to store personal items on window ledge. Goal - The resident's behaviors will not cause them or other residents distress through the review period. Interventions - follow by created date; 3-7-24 - Physician review of medication as needed, administer medications as ordered, assure Resident they are safe if they become distressed. 5-14-24 (first known abuse on others) 5-14-24 - 1:1 until seen by provider, assign staff members that are familiar or preferred by the resident when possible, diversional activities of interest as needed, provide snacks and drinks that the resident prefers if they become distressed, psyche services referral as needed, take resident to a quiet place if they become overstimulated, redirect resident and other residents from each others personal space as noted to prevent verbal/physical interactions (stopped on 5-17-24) according to progress notes 11-12-24 - education provided to ask for assistance from staff with another resident as needed to avoid verbal and physical altercations. 3-19-25 - resident encouraged to avoid touching others and respecting their personal space. 4-6-25 - 1:1 until seen by provider, 15 minute checks remainder of shift following (stopped in 48 hours) according to progress notes. Physician and nursing progress notes were reviewed and revealed further multiple incidents of serious allegations of abuse not reported nor investigated. Those follow below in chronological order: 3-7-24 - 1 day after admission, verbally aggressive to staff. 4-19-24 - Smoking at front door of facility refuse to agree to rules. 5-6-24 - [NAME] into street/main highway in wheel chair refusing to return to building stated he was rolling straight to hell because he had no money for cigarettes and snacks. 5-14-24 - Hit another Resident in the neck for no reason. 6-12-24 - Allegations of antagonizing other residents. 7-19-24 - Cursing and yelling at staff, told he could be discharged , he stated he didn't give a damn and rolled away. 7-22-24 - Smoking at front door of building throwing cigarettes on ground, cursing and yelling at staff. 7-23-24 - In hallway making derogatory remarks do not like gay people or want them near me. 7-25-24 - Smoking at front door of building and counseled again. 7-31-24 - Ripped smoking signage off the courtyard, stating he will smoke wherever he wants to. 8-5-24 - Counseled again in regard to smoking and using fire proof ash trays. 8-7-24 - Physician reported significant aggressive behavior with increased paranoia and mood dysregulation, and staff stated he does better when he does not have significant interactions with others. 9-2-24 - Resident smelled of alcohol during medication administration. 9-5-24 - Counseled not to share cigarettes with others, and no smoking inside the facility. 9-18-24 - Counseled for Resident to Resident incident of intentionally hitting the leg of a Resident. 10-22-24 - Counseled for leaving facility at night without telling staff. Given a reflective device for chair. 11-12-24 - Hit another Resident. 11-13-24 - Counseled for aggressive incident with another Resident. 12-1-24 - Resident had knife in the pocket of his wheel chair for protection staff looked and found scissors. 12-2-24 - 9:30 AM argument with room mate blocking room mate from leaving the room trying to punch room mate stated I wish he would die. Resident's room mate helped out of room. 12-2-24 - 11:00 AM stealing room mates personal items, threatened room mate with scissors. 12-2-24 - 1:00 PM drinking alcohol in front of building, cursed at nurse who confiscated it and lashed out punching and charging in wheel chair at nurse 12-2-24 - 3:30 PM punching and kicking staff, room mate removed from room after Resident #86 threatened to stab him. Full Vodka bottles found and confiscated. 12-3-24 - Resident smells of alcohol/slurred speech. 12-14-24 - Resident riding down street in traffic, resident stated he was going to the store and refused to turn around and refused to get out of the road. 12-15-24 - Resident room changed due to behaviors, Resident unhappy about room change. 12-15-24 - Resident had altercation aggressive screaming with new room mate. 12-18-24 - Resident threw medication at staff. 1-17-25 - Resident in possession of and sharing alcohol, Resident angry, cursing and using derogatory language to staff. 1-21-25 - Arguing with another Resident in hallway. 1-23-25 - Asking other residents for money, said he got cigarettes for them and they owed it to him. 2-1-25 - Verbal altercation with room mate as Resident #86 angry when his room mate moved his own personal items away from Res #86, and #86 threatened room mate with his reacher. 2-26-25 - Wants to move because he doesn't like his room mate. 3-19-25 - Police called after incident with another Resident. Police removed resident who returned on 3-25-25 after incarceration. 3-30-25 - Resident taking things from medication cart, caught by staff said he would not do it again. 10 minutes later found doing it again. 4-3-25 - Initiated physical aggression on room mate. 4-3-25 - Resident room moved again. Nursing staff on the unit where Resident #86 was housed were interviewed and stated they remembered Resident #86, and his aggressive behaviors, however, those working during survey interviews were not present during all of the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day. During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was involved with Resident #86 on 18 documented occasions in 13 months. Those instances follow patterns of behaviors exhibited by the Resident including; smoking in disallowed public spaces, smoking in his room, buying cigarettes for other Residents, drinking alcohol in the facility obtained by traveling to a local convenience store independently in his wheel chair using a busy highway to buy it, and giving it to other Residents. Resident #86 was counseled repeatedly due to aggressive acts perpetrated on other Residents, had room changes because of violence against other Residents, theft of other Residents belongings, attempting to get money from other Residents, threatening to stab a room mate with scissors, and assaulting staff. Only on 2 occasions was added supervision used, and the two occasions were a year apart. The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections. Residents reported abuse and were told no abuse occurred (unfounded/unsubstantiated) on multiple occasions before staff observed the abuse and moved Resident #86. Resident #86 was only supervised on 2 occasions (5-14-24, and 4-6-25) a year apart, then allowed to independently move around the entire facility inside, and outside without supervision or oversight, and placed with Residents who were not protected and were abused during that year. Resident #86 was known to have room changes on 3 occasions, and each time he abused again and went to a new area without supervision to abuse. Many of the incidents listed above as documented, were or should have been, allegations of abuse, however, they were not initially reported to the state agency, not investigated, not followed up with a five day report, were reported late, or never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any ongoing added staff supervision for Resident #86 to prevent the continuing known abuse from occurring. On 4-20-25 at approximately 5:00 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 57 residents (Resident #156), in the survey sample. The findings included: Resident #156 was originally admitted to the facility 2/8/2025 and readmitted [DATE] after a right above the knee amputation (RAKA). The resident's current diagnoses included atherosclerosis, diabetes and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #156's cognitive abilities for daily decision making were intact. In MDS section GG0130. Self-Care the resident was coded as requiring supervision or touching assistance with eating, oral hygiene, rolling from left to right, sitting on side of bed to lying flat, partial/moderate assistance with lower body dressing and chair/bed-to-chair transfers, substantial/maximal assistance with toileting hygiene, shower/baths, and upper body dressing, dependent with putting on/taking off footwear, sit to stand, toilet transfers and wheeling a wheel chair. A nurse's note dated 3/5/25 at 4:28 AM stated the resident was admitted to hospital following a vascular appointment. Another nurse's note 3/5/25 at 8:19 AM stated the Responsible Party stated the resident was admitted for surgery and will be hospitalized for at least a week. The MDS assessment revealed the resident was discharged return anticipated on 3/4/25. An interview was conducted with the Social Services Director (SSD) on 4/25/25 at approximately 12:45 PM. The SSD stated there was no documentation that the Office of the State Long-Term Care Ombudsman was notified of Resident #156's 3/4/25 discharge to the hospital. The SSD stated she was not aware if notification of the State Long-Term Care Ombudsman was her responsibility with this employer. When the SSD reported back, she stated going forward she would be responsible for notifying the State Long-Term Care Ombudsman of facility initiated a transfers/discharges. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for two (2) Residents (Residents #86, and #143) in a sample of 57 residents. The Findings included: 1. For Resident #86, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed correctly prior to admission. Resident #86 was admitted on [DATE] with diagnoses including: Schizophrenia, bipolar disorder, mood disorder, and anxiety disorder. Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for anxiety, ongoing behaviors to include alcoholism, agression and nightmares, and abuse to peers. The Resident's only Passar I was completed 3-25-25, one year after his admission and it was coded incorrectly. The Resident had serious mental illness, and the document refuted that. The Resident was an abuser, and his mental illness was being treated with psychotropic medication, he was being followed by psychiatric practitioners, and he was still unstable, abusive, and his poor mental health interfered with his ability to conduct self directed activities sucessfully and safely. All of these deficits were well documented by this time. The Pasaar II should have been triggered if the Pasaar I had been completed correctly, and completed as well, however, it was never triggered nor completed. On 4-20-25 at approximately 5:00 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer. 2. For Resident #143 the facility staff failed to obtain a PASARR (Preadmission Screening and Resident Review) prior to admission on [DATE]. Resident #143 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Bipolar Disorder, Metabolic Encephalopathy, Other Psychoactive substance Abuse, and Seizures. Resident #84's most recent MDS (Minimum Data Set) was an admission Assessment, coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 out a possible 15 indicating no cognitive impairment. On 04/22/25, a review of Resident 143's clinical record was conducted. No prior to admission PASARR for mental illness or intellectual disability was found in the Electronic Health Record (EHR). The only PASARR found was dated 03/24/2024, that did not document the psychiatric diagnosis, The Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed prior to that date. On 04/24/25 an interview was conducted with the Director of Nursing (DON), who stated that the PASARR should have been done prior to admission documenting the listed diagnosis. The Administrator and Director of Nursing were informed of the findings again at the end of day meeting on 04/25/25. No further documents were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation review, the facility staff failed to develop and implement a comprehensive person-centered care plan consistent with resident needs for one (1) of 57 residents in the survey sample. The findings included: Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 56 required extensive assistance on staff for activities of daily living. Review of the clinical record was conducted 4/16/2025-4/28/2025. Resident # 56 was interviewed during tour of the facility on 4/16/2025. Resident # 56 stated he had lost a lot of weight. He stated he has had to send out for food to eat because the food in the facility tastes like garbage. Resident # 56 stated he had lost 42 pounds. Review of the Weights Summary revealed the following weights listed: 4/3/2025 14:39 166.8 Lbs Wheelchair 3/19/2025 23:26 205.0 Lbs Last weight obtained-refusal 2/8/2025 09:29 205.0 Lbs Last weight obtained-refusal 12/6/2024 12:50 205.0 Lbs Last weight obtained-refusal 11/5/2024 12:50 205.0 Lbs Last weight obtained-refusal 10/21/2024 15:30 205.0 Lbs Last weight obtained-refusal 7/10/2024 17:55 205.0 Lbs Wheelchair 6/7/2024 14:16 210.0 Lbs Wheelchair Resident # 56 had an unplanned weight loss of 39 pounds from July 2024 (weight- 205 pounds) to April 2025 (weight 166.8). A review of the clinical record revealed the following excerpts from Resident # 56's care plan: Focus: the resident is at risk for weight loss or malnutrition related to chronic disease, hx (history) non-pressure related chronic wound and hx of HTN (hypertension), wounds, decreased appetite severe malnutrition dx (diagnosis) -supplements for wound healing/nutrition 4/3 significant weight loss noted, overall decline in health status dx of GERD (gastroesophageal reflux disease), high cholesterol Date Initiated: 08/02/2023 Created on: 08/02/2023 Revision on: 04/16/2025 GOAL: the resident will have optimal nutrition and hydration status thru review period Date Initiated: 08/02/2023 Revision on: 04/16/2025 INTERVENTIONS: RD (registered dietitian) consult as needed, Diet-record meal % (percentage) intake review dietary preferences with the resident as needed snacks at bedside for easy access supplements as ordered weekly weights Date Initiated: 08/02/2023 Revision on: 04/02/2025 The Goal on the care plan was not measurable. The interventions were not implemented. There was no evidence of weekly weights being obtained nor attempted to be obtained. On 4/22/2025 at approximately 10:30 a.m., an interview was conducted with the Director of Nursing who stated the care planning process was important and should reflect the care for each resident. The Director of Nursing stated care plans should be tailored for each resident and goals should be measurable. She stated interventions should help to attain the goals for the identified concerns. During the end of day debriefing on 4/24/2024, the Executive Director (Administrator), Director of Nursing, Regional [NAME] President of Operations, and Corporate Nurse Consultants were informed of the findings. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a clinical record review and staff interviews, the facility staff failed to provide foot care for 1 of 57 residents (Resident #116), in the survey sample. The findings included: Resident #116 was admitted to the facility on [DATE] with diagnoses of but not limited to muscle weakness, major depressive disorder, left artificial hip, seizures and fibromyalgia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 03/18/25. Resident # 116's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #116 required assistance with Activities of Daily Living. On 4/16/2025 during an afternoon tour, Resident #116's was observed in bed on her back, both legs were bent laying open to either side with feet meeting in the middle bottom to bottom. Resident #116's toenails were thick, long with uneven edges. They were mostly brown in color with some yellowish areas. Resident #116 said she had seen the podiatrist before but that it had been a long time ago. She stated that she would let the Podiatrist trim and treat her toenails because they get caught in the bedcovers now and cause her pain. A review of Resident #116's progress notes did not reveal any foot or podiatry care. On 04/24/2025, at 1:40 p.m., an interview was conducted with the LPN #B who stated that Resident #116 refused to have Podiatry in the evaluate her feet and toenails in the past but that she would put her on the schedule to see Podiatry when they come to the facility next month. On 04/24/2025, an interview was conducted with the DON who stated that the facility does not have an independent Foot Care Policy, but she provided the Health Care Service Agreement for Podiatry. She went on to say that Resident #116 had been added to the Podiatry list for evaluate and treat. On 04/25/25 at approximately 6:00 PM, during the end of day meeting the Interim Administrator, DON (Director of Nursing) and two Regional Consultants were informed of the concerns. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while requiring use of an indwelling catheter for two (2) of 57 residents (Resident #124, and #50), in a survey sample of 57 Residents. The findings included: 1. Resident #124 was originally admitted to the facility 3/22/25 after an acute care hospital stay. The resident's current diagnoses multiple advanced stage pressure ulcers, a-fib and obstructive uropathy. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/25 coded the resident as resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #124's cognitive abilities for daily decision making were severely impaired. At section H0100 A - the resident was coded for requiring use of an indwelling catheter. Physician orders dated 3/23/25 stated change the Foley anchor every week and as needed every night shift every 7 days for Foley care, check the Foley anchor placement every shift, and change the Foley Catheter as needed for clinical indications such as infection, obstruction, or when the closed system is compromised. The physician's orders failed to identify the size of the catheter and bulb as well as the rationale for the indwelling catheter use. The person centered care plan dated 4/14/2025 had a problem which stated the resident requires a 14 french, 5-10 milliliter bulb Foley catheter related to pressure ulcer care. The goal stated the resident will be free from complications from catheter use thru the review period, 7/12/25. The interventions included change per physician order, provide catheter care every shift and observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify the physician as indicated. On 4/23/25 at 11:20 AM, Resident #124 was observed in bed with her right leg hanging off the bed. The catheter stat lock was observed coiled around the catheter tubing, which contained cloudy urine with much sediment. It was dated 4/21/25. On 4/24/25 at approximately 12:32 PM the resident was observed in bed again and the stat lock (a device to stabilize an indwelling catheter) was viewable coiled around the catheter tubing, it was dated 4/21/25. On 4/25/25 at 3:45 PM Licensed Practical Nurse (LPN) C was notified of the above observations. This information was obtain from the Internet on 5/8/25 - If urinary catheters are not secured appropriately, they can lead to severe trauma of a patient's urethra, potential damage to bladder neck, infection and inflammation, pain and irritation, possible bypassing, accidental dislodging of a catheter and a cleaving (condition whereby the catheter splits the penile or labial tissues). https://pubmed.ncbi.nlm.nih.gov/24335791/ On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 2. The facility staff failed to ensure a catheter urine drainage bag was clamped to prevent leakage of urine. Resident #50 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Quadriplegia, Unspecified. The significant Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/12/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #50 cognitive abilities for daily decision making were intact. Section M Skin Conditions. Coded Resident as having a stage one or greater unhealed pressure ulcers/injuries as Yes. Coded as having one stage 3 pressure ulcer. The number of these stage 3 pressure injuries present on admission/entry was coded as 0. The personal centered care plan dated 9/05/24 read that the resident requires a condom catheter. A Goal for the resident, the resident will be free from complications of catheter use. The interventions are: condom cath as ordered, observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated. The March 2025 Physician Order Summary read: condom catheter daily every shift Verbal Active 09/05/2024. On 4/17/25 at approximately 12:00 PM., a moderate amount of fluid was observed on the floor in the lobby. Visitors and staff observed walking about the lobby area. Resident #50 was observed sitting in his wheel chair in the middle of the lobby with a trail of the substance leading to his wheel chair. The substance was immediately observed to be a urine like substance coming from the resident's catheter drainage bag. A facility staff, notified by the receptionist, quickly wheeled the resident away. On 4/17/25 at approximately 12:03 PM., a brief interview was conducted with the receptionist. The receptionist said that she didn't notice urine was on the floor until someone told her. At 12:04 PM., housekeeping personnel was observed mopping up the fluids. On 4/18/25 at approximately 1:50 PM., a brief interview was conducted with Certified Nursing Assistant (CNA) F. concerning the above issue. CNA F said that once the foley bags are emptied, the valve should be clamped to keep it from leaking. On 04/24/25 at approximately 10:33 AM. a brief interview was conducted with Resident #50 concerning his drainage bag. Resident #50 said that his Certified Nurses Assistant (CNA) forgot to close the valve at the bottom of the his foley bag which caused it to leak last week. A review of a health status note dated 4/17/2025 at 2:21 PM., read: Patient was bought to his room due to foley bag leakage, pt assessed, foley bag was unclipped, clipped bag properly and moved bag to middle of wheelchair so it would not rub the wheelchair wheels, no signs of distress, will continue to monitor for safety. A review of a Health Status note dated 4/17/25 at 3:39 PM., read: Resident reassessed due to urine leak. Condom catheters are external urinary catheters that are worn like a condom. They collect urine as it drains out of your bladder and send it to a collection bag strapped to your leg. They're typically used by men who have urinary incontinence (can't control their bladder). https://www.healthline.com/health/condom-catheter On 04/28/25 at approximately 3:15 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure adequate nutrition to prevent weight loss for one (1) Resident (#56) in a survey sample of 57 Residents. The findings included: For Resident # 56, the facility staff failed to recognize signs of weight loss, resulting in 39 lb. weight loss from 07/10/2024 - 4/03/2025. Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 56 required extensive assistance on staff for activities of daily living. Review of the electronic clinical record was conducted from 4/16/2025-4/28/2025. During the tour of the facility, Resident # 56 was interviewed. He stated the food is bad. Resident # 56 stated he had lost a lot of weight. He stated he has had to send out for food to eat because the food in the facility tastes like garbage. He complained that the food is like prison food, mostly processed foods and too salty. Resident # 56 stated he had lost 42 pounds. Review of the Progress Notes revealed the following weights listed: 4/3/2025 14:39 166.8 Lbs Wheelchair 3/19/2025 23:26 205.0 Lbs Last weight obtained-refusal 2/8/2025 09:29 205.0 Lbs Last weight obtained-refusal 12/6/2024 12:50 205.0 Lbs Last weight obtained-refusal 11/5/2024 12:50 205.0 Lbs Last weight obtained-refusal 10/21/2024 15:30 205.0 Lbs Last weight obtained-refusal 7/10/2024 17:55 205.0 Lbs Wheelchair 6/7/2024 14:16 210.0 Lbs Wheelchair Review of the Physicians orders revealed the following: Regular diet- Regular texture, Thin Liquids consistency House supplement one time a day for prevention of malnutrition/wound healing 90 ml (milliliters) PO (by mouth) QD (daily) 04/02/2025 04/03/2025 Prostat SF every 12 hours for prevention of malnutrition/wound healing 30 ml PO BID (twice a day) 4/5/2025 Review of the document entitled Nutrition/Dietary Note dated 4/2/2025 signed by the Registered Dietitian revealed the following excerpts: Effective Date: 04/02/2025 13:37 Type: Nutrition/Dietary Note Note Text : Nutrition Assessment resident has refused to be weighed for several months. CBW (Current Body Weight) listed is his weight taken from July 2024. PMH (Past Medical History): Chronic wound R (right)Leg, HTN (Hypertension) , Hyperlipidemia, Depression, Meds: Metoprolol, Cholecalciferol, Omeprazole, Lipitor, MVI (multivitamin) with minerals, Iron sulfate Diet: Regular diet, Regular texture, Thin Liquids consistency, large portions Skin: pressure wounds noted increased needs d/t pressure wounds Estimated needs (IBW(Ideal Body Weight- 86 kg(kilograms): 2580-3000kcals (30-35kcals/kg); 103-172g protein (1.2-2.0g/kg); 2580-3000ml fluid (1ml/kcal) Resident reports decrease appetite and altered taste, he tells me he usually eats a good dinner but did not eat much for breakfast or dinner. He reports some things don't taste the same as the use to. He recently has developed pressure wounds and noted overall decline. He reports no chewing or swallowing difficulty and is able to feed himself. He reports enjoying sandwiches and would like to receive these more often. Will d/c large portions and add sandwich to lunch meal. He states he will try house shakes once a day, will offer QD (daily) and add prostat BID for aiding in wound healing to provide 200kcals, 30g protein daily. Recent weight shows weights are stable however, noted s/s (signs and symptoms) of muscle wasting (interosseous muscle) and fat loss (clavicle area, scapular area) nutrition dx: severe malnutrition in context of chronic illness r/t (related to) inadequate energy intake AEB (as evidenced by) severe muscle wasting and severe fat loss he orders outside food when he has money as well. Preferences updated/honored. Suggest starting weekly weights as resident will allow. RD (Registered Dietitian to f/u (follow up) as needed Review of the clinical record revealed the following excerpts from Resident # 56's care plan: Focus: the resident is at risk for weight loss or malnutrition related to chronic disease, hx (history) non-pressure related chronic wound and hx of HTN (hypertension), wounds, decreased appetite severe malnutrition dx (diagnosis) -supplements for wound healing/nutrition 4/3 significant weight loss noted, overall decline in health status dx of GERD, high cholesterol Date Initiated: 08/02/2023 Created on: 08/02/2023 Revision on: 04/16/2025 GOAL: the resident will have optimal nutrition and hydration status thru review period Date Initiated: 08/02/2023 Created on: 08/02/2023 Revision on: 04/16/2025 INTERVENTIONS: RD consult as needed Date Initiated: 08/02/2023 Created on: 08/02/2023 Diet -record meal % intake Date Initiated: 08/02/2023 Created on: 08/02/2023 ·review dietary preferences with the resident as needed Date Initiated: 08/02/2023 Created on: 08/02/2023 ·snacks at bedside for easy access Date Initiated: 08/02/2023 Created on: 08/02/2023 ·supplements as ordered Date Initiated: 08/02/2023 Created on: 08/02/2023 ·weekly weights Date Initiated: 08/02/2023 Revision on: 04/02/2025 Weekly weights were not obtained. There was documentation of refusal of weights once a month from October 2024 to December 2024. There was no documented attempt to obtain a weight in January 2025. The weight was refused in February and March 2025. The staff listed the last known weight of 205 pounds from July 2024 on each of the dates of refusal. There was no documentation of the staff addressing the resident's complaints about the food and not eating the food sent from the dietary department. There was no documentation of updated food preferences. There was no documentation of staff trying to determine the reason for the refusal to be weighed nor any attempts to weigh the resident on a different day or time. There was only one attempt to weigh each month. There also was no documentation of weekly weights after the dietitian rewrote the order on 4/3/2025. Further review of the record revealed there was no documentation that the staff was closely monitoring Resident # 56's intake of food, proper nutrients and obtaining weights as ordered. There was no documentation of other assessments, evaluations or observations to determine nutritional status or weight loss. Resident # 56 stated he lost weight because the food tastes so bad at the facility and he had to order food from restaurants regularly when he had the money. Resident # 56 stated We want food that is cooked a certain way. He stated they just give us stuff that can be heated in the oven. It's already prepared. They don't really cook food here. Resident # 56 stated he knew it was important to eat so he could get better but he could not eat the facility's food. He stated he did not have the money to buy all of his meals from a restaurant. On 4/23/2025 at 2:20 p.m., an interview was conducted with Licensed Practical Nurse-P who stated it was important for Resident # 56 to have proper nutrition to help with healing of his wounds and other medical diagnoses. She stated Resident # 56 complained about the food at the facility and would order from restaurants sometimes. On 4/25/2025 during the end of day meeting, the Administrator, Director of Nursing, Corporate Nurse Consultants were made aware of the concerns. No further information was provided.

Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure the resident received the physician ordered milliliters (ml) of oxygen for one (1) of 57 residents (Resident #271), in the survey sample. The findings included: Resident #271 was originally admitted to the facility 04/17/25 after an acute care hospital stay. The resident's current diagnoses included Acute on chronic hypoxic respiratory failure status post tracheotomy, COPD advanced age, and acute on chronic diastolic heart failure. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/27/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #271's cognitive abilities for daily decision making were intact. Resident #271 was coded in Section C1., as requiring Oxygen therapy. The baseline care plan did not address the O2 concentrator. An interview was conducted with Resident #271 on 4/22/25 at 11:18 AM. Resident #271 stated she managed her tracheotomy care in the community and she would continue caring for it in the facility. She stated she was hospitalized for pneumonia and an exacerbation of COPD and was at the facility to regain her strength. An Observation was made on 4/22/25 at approximately 11:18 AM of Resident #271's O2 concentrator delivering 6 liters of oxygen per minute. Another observation was made of Resident #271's O2 concentrator on 4/25/25 at 3:45 PM with Licensed Practical Nurse (LPN) N. The O2 concentrator was delivering 10 liters of oxygen per minute. LPN N stated she would review the resident's order for the amount of O2 the concentrator was to deliver, set the concentrator accordingly and speak with the resident of the resident of the ordered O2 delivery. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, and review of the clinical record, the facility staff failed to assess and attempt to use alternatives prior to the use of bedrails for one (1) of 57 residents (Resident #156), in the survey sample. The findings included: Resident #156 was originally admitted to the facility 2/8/2025 and readmitted [DATE] after a right above the knee amputation (RAKA). The resident's current diagnoses included atherosclerosis, diabetes and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #156's cognitive abilities for daily decision making were intact. In MDS section GG0130. Self-Care the resident was coded as requiring supervision or touching assistance with eating, oral hygiene, rolling from left to right, sitting on side of bed to lying flat, partial/moderate assistance with lower body dressing and chair/bed-to-chair transfers, substantial/maximal assistance with toileting hygiene, shower/baths, and upper body dressing, dependent with putting on/taking off footwear, sit to stand, toilet transfers and wheeling a wheel chair. Resident #156 was observed on 4/23/25 at 11:24 AM seated in a wheelchair at bedside, bilateral bedrails were attached to the bed with the bedrail closer to the door lowered. On 4/24/25 at approximately 12:35 PM the resident was observed in bed unarousable, with the head of the bed elevated to approximately 50 degrees and a meal tray before him. Bilateral bedrails were observed attached to the bed and in the up position. On 4/25/25 at 3:50 PM the resident was observed in bed as he conversed. The bed was in a high position and bilateral bedrail were in an up position. An interview was conducted with the resident on 4/25/25 at approximately 3:53 PM. The resident stated he likes having the bedrails but he could not recall requesting them or receiving information concerning risk or benefits. A review of the resident's record failed to disclose alternatives attempted prior to use of the bedrails, how the alternatives failed to meet the resident's needs and a bedrail assessment. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident received her medications in March, April, and May 2025 Late, and in some cases hours after they were scheduled to be given. Resident #123 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation. During the 1:40 PM interview, Resident #123 verbalized that she received her medications late on occasion, and sometimes hours later than they were scheduled to be given. The Resident was laying in bed and noted to have her body and bed smell strongly of urine, and in fact the entire room had a pervasive odor of urine, feces, and body odor. The Resident wore socks which were meant to be white, however, had brown stains on them which were dried on. The Resident stated that there just were not enough staff to take care of Residents, and this situation happened to her often. ADL care records were reviewed for Resident #123 and revealed that the Resident was totally dependent on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed on 8-29-25 during survey and found to be soiled from 10:00 A.M. until 1:40 PM. in a soiled bed with soiled linens. The Resident was never seen out of bed during daytime hours for the entire survey.The Resident's Medication administration record was reviewed with time stamps for the time medications were administered for 3 months, in March. April, and May of 2025. The records revealed that medications were being administered later than they were ordered to be administered. The examples follow below. March 2025 - 3-25-25, Carbidopa/levodopa ordered for 1:00 P.m., given at 2:31 P.m. April 2025 - 4-25-25, Carboxymethylcellulose-glycerin eye drops, multivitamin, docusate sodium, Carbidopa/levodopa, Meloxicam, amlodipine, Sitagliptin phosphate, house supplement drink, ordered for 9:00 A.m., given at 11:00 A.m. May 2025 - 5-25-25, Carbidopa/levodopa ordered for 5:00P.m., given at 7:42 P.m., Ascorbic acid, ferrous sulfate, Carboxymethylcellulose-glycerin eye drops, melatonin, tizanidine, Carbidopa/levodopa, doxepin, atorvastatin, oxycodone, mirtazapine, and gabapentin all ordered for 9:00 P.m., and not given until the next morning on 5-26-25 at 8:15 A.m., (11 hours late). Review of the Facility Medication Administration policy indicated medication administration would be completed according to the doctor's orders. The Resident's care plan was reviewed and indicated medications would be administered according to the doctor's orders. On 8-29-25 during an end of day meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns. On 9-3-25, prior to the survey exit, the Director of Nursing informed surveyors that Resident #123 was now receiving needed care every 2 hours, and medications timely. They further stated they had nothing further to provide.

Based on observations and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of the residents who resided at the facility were available. The findings included; On 4/24/25 at approximately 1:00 PM., a tour of the laundry room was conducted. Three industrial sized washing machines were observed. Employee U, laundry aide, said that only 2 out of the 3 washing machines were working, It's been about a year. On 4/24/25 at approximately 1:10 PM., a brief interview was conducted with the Housekeeping Director (HD)/Laundry Services Director. The HD said that he had made the administrator aware of the washing machine not working because the administrator has only been working for a few weeks. An observation of the laundry storage area (located through the HD's office) was conduted with the HD, multiple boxes were observed stacked on the floor. The HD said that they were boxes of linen. The HD was asked if he was aware that staff and residents were saying there was not enough linen on the floors, the HD said he was not informed. A document entitled Laundry Work Order was provided on 4/24/25. The document dated 4/21/25 read: Maintenance. Performed routine mantenance on 2 washers. On 4/24/25 at approximately 2:05 PM., a brief meeting was conducted with the corporate staff, the [NAME] President of Operations (VP-OPs), the Director of Nursing (DON), the Corporate Nurse, the Administrator, and the Housekeeping Director concerning the washing machine. They were informed that the Housekeeping Director didn't feel like he should inform the present administrator issues involving the laundry room having 2 out of 3 workable washing machines. According to current facility staff there were issues receiving linen and clothing in a timely manner. The Housekeeping Director mentioned that the estimated cost of repairing the inoperable washing machine could be around $5500.00, while a new washing machine would cost about $16000.00. The [NAME] President of Operations said that he was not aware of the laundry room needing a washing machine. On 04/28/25 at approximately 3:15 p.m., the above findings were shared with the Administrator, Director of Nursing (DON), Corporate Consultant and the VP of Operations.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure the resident's mattress was compatible for the bedframe for 1 of 57 residents (Resident #119), in the survey sample. The findings included: Resident #119 was originally admitted to the facility 11/12/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Low Back Pain Unspecified. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/04/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #119 cognitive abilities for daily decision making were Intact. In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial to moderate assistance with rolling from left to right, sitting to lying and lying to sitting. The person-centered care plan dated 1/13/25 read that the resident the resident prefers to stay in bed. A goal for the resident was to have their preferences honored if possible. An intervention for the resident was to review resident's preferences with them as needed. A Health Status note dated 4/16/2025 at 4:27 PM., revealed: Resident stated his mattress is broke Maintenance in to look at bed resident stated mattress lopsided causing pain ibuprofen given also get schedule tramadol ask resident if we could switch out his bed resident stated no he will get up tomorrow ask 3 times can we switch his bed resident refused adjusted legs for comfort effective. On 4/16/25 at approximately 4:00 PM., a brief interview was conducted with Resident #119 concerning his bed. Resident #119 said that he stays in constant hip pain due to his bed leaning lower at the foot of the bed on the right. Upon visual inspection, the right side of the resident's mattress (at the foot of the bed) appeared lower than the left side. Resident #119 also said that the maintenance man has been trying to fix his bed, but cannot fix it. Shortly thereafter, the maintenance staff walked into the residents' room. The maintenace staff was asked to measure the mattress on the resident's bed. The measurements were: 26 inches high on the right lower end of the mattress and 31 inches higher on the left end of the mattress at the foot of the bed. The maintenance staff said that he tried to fix the resident's bed but couldn't. Licensed Practical Nurse (LPN ) C knocked, entered the residents' room and asked him if he was ok. The resident informed her that he was in pain due to his mattress being lopsided. LPN C informed him that she would be back with pain medication. On 4/16/25 at approximately 4:15 PM., LPN C entered the room with ibuprofen. LPN C and the maintenance staff offered to replace the residents old mattress with a new one but the resident declined saying that it was too close to eating dinner and that he would wait until tomorrow for fear he's be left sitting up too long waiting to be transferred from out of his bed. On 04/28/25 at approximately 3:15 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant.

Based on resident interview, staff interview, and review of facility documentation, the facility's staff failed to act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility reported in three out of three months. The findings included: An interview was conducted on 4/17/2025 at 1 p.m. with the Activities Director who stated Resident Council meetings were conducted monthly. He stated the Council president kept minutes of each meeting. The Activities Director stated he would encourage alert and oriented residents to attend the meeting with the surveyor. On 4/18/2025 at 1 p.m., an interview was conducted with the Resident Council President who stated the residents had meetings every month. She stated she wrote the minutes for the meetings. She stated that the facility did not respond to the concerns of the group. She stated they complained every month about the food, the temperature in the facility, lack of staffing and pests in the facility. She stated there was a serious problem with those issues. The Resident Council Meeting was conducted on 4/21/2025 at 2:00 p.m. in the small dining room. Ten alert and oriented residents attended the meeting. There were representatives from all three units of the facility. During the Resident council meeting, the residents who attended complained that they did not get offered bedtime snacks and did not receive snacks on a regular basis. The attendees represented all three units. The residents stated that it was rare to receive snacks at bedtime. They all stated they would like a snack at bedtime. The residents further stated that they had witnessed the dietary staff bring snacks to the unit occasionally, and left them at the nursing station desk. Some of the residents stated they were Diabetic and did not get a snack on a regular basis. They stated the nursing staff left the snacks at the nursing desk, which allowed ambulatory residents who could get to the desk to get a snack but the residents who could not ambulate, often did not get a snack. They all stated they had observed nursing staff eating the snacks that were supposed to be given to residents. The residents complained that the foods were salty and starchy foods for each meal. They also stated the only fresh fruit allowed were bananas. They stated they are served canned fruit which tastes old. An interview was conducted with the Dietary Manager on 4/18/2025 at approximately 4:15 p.m. The Dietary Manager stated that the only bedtime snacks that were provided were for the Diabetics on the units. She stated that was what was included in the Dietary contract. The Dietary Manager stated she provided nursing staff with the snacks for Residents diagnosed with Diabetes. She stated the snacks provided were labeled with the names of the Residents with Diabetes. The nursing staff was responsible for distributing the snacks. The Dietary Manager stated she did not provide snacks for the other residents due to the contract with the facility. An interview was conducted with the facility's Activities Assistant on 4/23/2025 at 3:20 p.m. She stated that she could not submit copies of the last six months of Council minutes because only the Activities Director could do that and he was not in the office. The Activities Assistant stated she would inform the Activities Director of the request to send a copy of the Resident Council minutes for the previous 6 months to the surveyor. The minutes from January, February and March 2025 were provided to the surveyor by the Director of Nursing who stated she would contact the Activities Director to send the minutes from October to December 2024. The Director of Nursing stated the only notes she could access in the system at the time of the request were the ones for the current year 2025. She stated the Activities Director would have to access the minutes from 2024. Review of the facility documentation revealed no documentation of written responses to the concerns expressed during the Resident Council meetings. The facility's policy titled Resident's Rights, undated reads, Residents have a right to form or participate in a resident group to discuss issues and concerns about the facilities policies and operations such as resident council. On 4/24/2025 during the end of day debriefing, the findings were shared with the Executive Director (Administrator), Director of Nursing, Regional [NAME] President of Operations, and Corporate Nurse Consultants (Employees C and D). They stated it was important to respond to the grievances promptly. No additional information was provided. The requested minutes from October to December 2024 were not submitted to the surveyor prior to the completion of this report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, and a clinical record review, the facility staff failed to notify the Physician and/or Designee of refusals of care and services for two (2) of 57 residents (Resident #43 and 116), in the survey sample. The findings included: 1. The facility staff failed to notify the Psychiatric-Mental Health Nurse Practitioner (PMHNP) that Resident #43 refused his medications most days. Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. A care plan problem dated 12/23/24 stated the resident has behaviors (refuses medications, ADL care, and weights) related to dementia, and a depressive disorder. The goal read the resident's behaviors will not cause him or other resident's distress thru the review period, 5/22/25. The interventions included administer medications as ordered, and assign staff members that are familiar or preferred by the resident whenever possible. On 4/23/25 at 12:02 PM an interview was conducted with the Psychiatric-Mental Health Nurse Practitioner (PMHNP) regarding Resident #43. The PMHNP stated he was considering increasing the resident's medications he was receiving, Remeron and Exelon for dementia and depression. The PMHNP was informed that the resident was currently nonadherent with the ordered medications and had not adhered for an extended period therefore, what would warrant increasing the dosages. The PMHNP stated he had never been notified that Resident #43 was nonadherent with the ordered psychiatric medications. The PMHNP stated at 12:13 PM when the resident was visited earlier that day he was exhibiting paranoia (he believed that the staff was giving him the wrong medications) and the cognitive screening revealed significant dementia (a score of 4 out of 10). The PMHNP further stated the resident talked about holding the wheelchair foot pedals to threaten staff because they were trying to harm him. The PMHNP stated he educated the staff on methods to achieve the resident's compliance and communicated to the staff the importance of nursing services keeping him informed of the resident's adherence to the prescribed medications. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 2. Resident #116 was admitted to the facility on [DATE] with diagnoses of but not limited to muscle weakness, major depressive disorder, left artificial hip, seizures and fibromyalgia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 03/18/25. Resident # 116's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #116 required assistance with Activities of Daily Living. On 4/14/2025 during the initial tour, Resident #116's room had a strong smell of urine. The bed was soiled, the incontinent pad appeared brown in color and soaked with urine. Resident #116 stated she did not want to have her bed changed or be assisted with ADL (Activities of Daily Living) and incontinent care by the CNA (Certified Nursing Assistant) assigned. A review of a Nursing note dated 04/22/2024 revealed that Resident #116 refused ADL care and that it was reported to the physician and Residents family member. On 04/24/2025, at 1:40 p.m., an interview was conducted with the LPN #B who stated that Resident #116 refuses care often, and that her refusal had been care-planned but that the resident still refuses often. When asked if the physician was notified LPN#B stated most times the physician is notified. She went on to say that Resident #116's aunt could usually assist with getting resident #116 to allow ADL and incontinent care. On 04/24/2025, an interview was conducted with the Facility's Nurse Practioner. When asked if she was notified when Resident #116 refused care, she stated no not every time but that she is aware that Resident #116 refuses ADL and incontinent care almost daily. She went on to say that she has had Psychiatry to evaluate the resident and has added this behavior to the care plan. On 4/25/25 at approximately 6:00 PM, during the end of day meeting the Interim Administrator, DON (Director of Nursing) and two Regional Consultants were informed of the concerns. The DON stated the family member that they would contact to assist with the communicating with the resident has informed that she washes her hands with Resident #116 and the staff will be working with the Resident, physician, behavioral health and social work to develop a new plan of care. No additional information was provided.

Based on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure medications were administered according to professional standards for 1 of 57 residents (Resident #43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. A care plan problem dated 12/23/24 stated the resident has behaviors (refuses medications, ADL care, and weights) related to dementia, and a depressive disorder. The goal read the resident's behaviors will not cause him or other resident's distress thru the review period, 5/22/25. The interventions included administer medications as ordered, and assign staff members that are familiar or preferred by the resident whenever possible. An interview was conducted with Licensed Practical Nurse (LPN) H on 4/18/25 at approximately 11:48 AM regarding Resident #43's statement about his dental procedure, aftercare and ongoing monitoring. LPN H stated she ensured medications for pain were ordered and would be available for administration after the procedure. LPN H reviewed the medication administration record and stated the resident had not received any pain medication since the dental procedure and it was likely because he aggravates the nurses and always refuses his medications. LPN H stated the resident had refused all medication during the morning medication pass but she would ask Resident #43 if he wanted a pain pill to help with his mouth pain but she left without the pain medication. Upon LPN H's return to the medication cart, she stated Resident #43 said he would accept the pain medication for pain rated 7 out of 10. LPN H administered Oxycodone 10 mg to the resident at 12 noon. LPN H stated the nurse's do not pour the resident's medications prior to offering administration because the resident always refuses to accept his medications. LPN H stated they ask the resident at medication pass are you taking your medications and based on his response determines if the medications are removed from the medication cart. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. This information was obtained from the internet on 5/12/25: Steps for Oral Medication Administration When administering medications, patient safety is the top priority. Therefore, considerations must be given throughout the medication process to ensure practices are in place that promote safe medication administration. This includes confirming the medication rights when collecting, preparing, and administering medications. Before administering oral medications, the nurse should assess for contraindications that would prohibit the patient from being able to receive the medication, such as dysphagia, NG tube with gastric suctioning, NPO (nothing passed orally) status, or the inability to sit upright. After determining that oral medications may be safely administered, the nurse should verify the medication administration record (MAR) against the prescribing provider's orders. The nurse should then remove the medications from the medication cabinet, drawer, or automated dispensing cabinet, confirming the medication rights for each medication. The medications should then be prepared, confirming the rights for each medication a second time. After the medications have been prepared, the nurse is then ready to administer the medications. After confirming the rights for each medication for a third time, the nurse should assist the patient into an upright position. If the patient is unable to be placed in the upright position, a side-lying position may be used; however, the nurse should use caution to ensure the patient's ability to swallow in this position. When positioned, the nurse should offer the patient something to drink. Consideration should be given to ensure the liquid offered is not contraindicated with any of the medications the patient is taking, and that the oral intake is accounted for within the medication record. Ask the patient if they prefer to take all medications at once or if they prefer the medications to be placed in the cup one at a time. Remain with the patient to ensure all medications are swallowed before documenting the medication administration. Perform any required post-assessments (e.g., blood pressure checks or pain reassessments) and document the patient's response to the medication. (https://openstax.org/books/clinical-nursing-skills/pages/12-1-administering-oral-medications)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 2 Residents (#77, & #147) in a survey sample of 57 Residents. The findings included: 1. For Resident #77 the facility staff failed to provide 2 showers per week for Resident who is unable to provide self-care. Resident # 77 was admitted to the facility on [DATE] with diagnosis that included chronic embolism and thrombosis, mood disorder, insomnia, dysphasia, muscle, wasting and atrophy, chronic obstructive, pulmonary disease, polyneuropathy, major depressive disorder, chronic kidney disease, fibromyalgia, chronic diastolic heart, failure, hypertension, chronic pain syndrome, and generalized anxiety disorder. Resident # 77's most recent MDS (Minimum Data Set) dated, 4/23/25, scored Resident #77 as having a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating mild cognitive impairment. Resident #77 was also coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living) care except for feeding. On the afternoon of 4/23/25 an interview was conducted with Resident #77 who stated that she waited 12 hours to have her incontinence care provided. She stated that she was not changed the entire night shift from 7 p.m. - until 7 a.m. She stated they (the CNAs) sat outside her room and laughed and talked and came in and shut the call light off and told her someone would be in to change her, but no one ever came in. When asked if she reported this, she stated that she had reported it to DON. When asked how she felt she stated that she felt Helpless, like who is going to protect me? I am bed bound, I cannot get up or defend myself if I have to. Like I am supposed to accept whatever care they choose to provide. She also stated that she has not had a shower or had her hair washed in months. A review of the clinical record revealed that in the ADL (Activities of Daily Living) POC (Point of Care) documentation, Resident #77 was documented as receiving a bed bath on 17 days in the month of February 2025 and on 15 days in the month of April, however no showers are documented for either month or no record of hair washing were recorded for either month. A review of the clinical record revealed the following excerpt from the physicians progress note: 4/23/25 9:30 p.m. -Nursing request for assessment of newly reported bilateral buttocks MASD, skin intact with blanchable redness. Recommend continuing with zinc oxide cream and frequent brief changes to reduce incontinence associated skin breakdown. Facility to manage, provider can reassess if worsening or new area of skin breakdown. A review of the policy, entitled Shift responsibilities for CNA revealed the following excerpts: 1. CNA's will report to a designated unit at the beginning of a shift to obtain the shift responsibility/patient assignment as determined by a licensed nurse. 2. Obtain patient assignment at the beginning of each shift/with the nurse and nurse. Examples of general report information include, but not limited to the patient's name, room in bed, scheduled appointments, bathing needs, special healthcare needs, etc. 3. Provide pertinent patient information for the oncoming shift, such as tasks that are not completed, etc. Number four prefer to perform shift responsibilities/assignments that promote quality of care; make rounds, identify an address any immediate patient needs, promptly respond to call lights, and notify the license starts with any pertinent findings (red skin, etc.). On 4/24/25, during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For resident number 147 the facility staff failed to provide 2 showers per week for Resident who is unable to provide self-care. Resident # 147 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to severe sepsis with shock, diabetes, type two, and Enterocolitis due to C-Difficile, Pneumonitis due to inhalation of food and vomit, malignant neoplasm of oropharynx, respiratory failure with hypoxia, dementia, squamous, cell carcinoma of skin and scalp, generalized anxiety disorder, BPH, gout, mood disorder, and dysphasia. Resident #147's most recent MDS (minimum data) with an ARD parent assessment reference date of 4/9/25 coded resident # 147 as having a Bims (Brief Interview of Mental Status) score of 12 out of 15 indicating mild cognitive impairment Resident #147 requires assistance with all aspects of ADL care and requires the use of a walker/wheelchair. On 4/23/25 at 11:00 a.m. Resident #147 was observed in bed with a white t-shirt on with food stains on the shirt. Resident #147's mouth appeared to have food residue; the blankets had stains brown in color. Resident #147 was interviewed and asked when he had last had a shower, to which he responded, Not since I got here. When asked if he would like a shower, he stated that he would. A review of the clinical record revealed that although, Resident 147 was given bed baths in March and April he had not received a shower or hair washing at the time since admission. On 4/23/25 at 2:00 p.m an interview with CNA C was conducted who stated, Residents are supposed to have 2 showers per week unless they request otherwise. On the afternoon 4/23/25 an interview was conducted with LPN D who stated, CNA's are supposed to shower Residents twice a week including hair washing. If a Resident refuses the CNA should report to the nurse so that this can be documented in the clinical record. A review of the policy, entitled Shift responsibilities for CNA revealed the following excerpts: 1. CNA's will report to a designated unit at the beginning of a shift to obtain the shift responsibility/patient assignment as determined by a licensed nurse. 2. Obtain patient assignment at the beginning of each shift/with the nurse and nurse. Examples of general report information include, but not limited to the patient's name, room in bed, scheduled appointments, bathing needs, special healthcare needs, etc. 3. Provide pertinent patient information for the oncoming shift, such as tasks that are not completed, etc. Number four prefer to perform shift responsibilities/assignments that promote quality of care; make rounds, identify an address any immediate patient needs, promptly respond to call lights, and notify the license starts with any pertinent findings (red skin, etc.). On 4/23/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 57 residents (Resident 43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. The resident had a care plan problem dated 4/15/25 which stated complaints of a toothache. The goal read the residents pain will be resolve thru review period, 5/22/25. The interventions included a dental appointment and administer medications as ordered. A review of the nurse's notes revealed the resident complained of a toothache on 4/12/25 and was evaluated by a dentist of 4/14/25 with instructions to return to the dentist on 4/15/25 for dental services. The clinical record contained no documentation of what services the resident received on 4/15/25 or documentation of an assessment by the facility's staff regarding the resident's status after the dental services. On 4/18/25 at 11:35 AM an interview was conducted with Resident #43. The resident's face was noticeably edematous and he presented with a grimace and grumpiness. The resident stated he had a tooth which had broken off and required surgical removal by the dentist. He stated that his mouth was hurting and he was still spitting out blood. The resident stated the nurse's would not give him any pain medications so he was just dealing with the pain. An interview was conducted with Licensed Practical Nurse (LPN) H on 4/18/25 at approximately 11:48 AM regarding Resident #43's statement about his dental procedure, aftercare and ongoing monitoring. LPN H stated she ensured medications for pain were ordered and would be available for administration after the procedure. LPN H reviewed the medication administration record and stated the resident had not received any pain medication since the dental procedure and it was likely because he aggravates the nurses and refuses all medications. LPN H stated the resident had refused all medication during the morning medication pass but she would ask Resident #43 if he wanted a pain pill to help with his mouth pain but she left without the pain medication. Upon LPN H's return to the medication cart she stated Resident #43 said he would accept the pain medication for pain rated seven (7) out of 10. LPN H administered Oxycodone 10 mg to the resident at 12 noon. Another interview was conducted with Resident #43 on 4/18/25 at approximately 3:15 PM. The resident stated the pain continued and he was reminded to notify the nurse for they were available to assist him. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents received dialysis and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 Resident (#64) in a survey sample of 57 Residents. The findings included: For Resident #64 the facility failed to ensure proper transportation to the dialysis facility and failed to ensure ongoing communication and collaboration with the facility to ensure continuity of care. Resident #64 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to acute osteomyelitis of left ankle and foot cellulitis of left lower, limb, and stage renal disease, dialysis dependent, muscle weakness, hypertension, diabetes type two, arthrosclerosis of arteries in the bilateral legs, ischemic cardiomyopathy, and congestive heart failure. Resident #64 was alert, oriented and listed as his own Responsible Party, however he admitted to being non-compliant with the BIMS (Brief Interview of Mental Status) assessment because he felt the questions were stupid, thus, explaining the MDS scoring of 99 on his BIMS exam. Resident is non weight bearing to both legs due to wounds and diagnosis of osteomyelitis. On 4/15/25 at approximately 10 a.m. an interview was conducted with Resident #64 who stated that since his admission he has missed several dialysis appointments because they don't always send the right vehicle. When asked to elaborate he stated that he is 6'4 tall and has a high-backed wheelchair, and if they send the regular wheelchair minivan, he is too tall, and his head hits the top of the van. He stated he has to ride hunched over almost looking down and it makes him sick. When asked if he had told the facility this, he stated that he had told Everyone that would listen. When asked if he always refuses, he stated I go when they send the right vehicle. On the afternoon of 4/15/25 an interview was conducted with LPN K who stated that Resident #64 has behaviors of refusing dialysis. She stated that he likes to get his way. When asked to elaborate she stated that he wants a particular type of vehicle for transportation and won't accept anything else. On 4/16/25 an interview with the DON was conducted and she stated that Resident #64 has behaviors of refusing dialysis. When asked why he refused she stated he said the van was too small. When asked, has he always refused since admission, she stated that he has gone a few times. When asked if the same type of van is sent on the days, he accepted she stated He will not go if they send a regular mini-van or a stretcher transport. He wants the extra tall striker van. [cargo van] When asked why she stated he says he is too tall and won't fit. When asked if he was measured, she stated that he is 6' 4. When asked what type of wheelchair he has she said a high-backed wheelchair. When asked if measurements were taken of him to see if he has a valid concern, she stated they were not. A review of the clinical record revealed the following regarding missed dialysis appointments: 3/27/25 - 11:18 a.m. Spoke with resident r/t him missing his dialysis appointment yesterday 3/26/2025, resident states he did not go because they sent a stretcher transport, and he need a large wheelchair transport van. This writer discussed the importance of keeping his appointments with dialysis and his risk of fluid overload by not eating the proper nutrition. Resident states he understands the risk and states I will go if they provide the correct transportation. This writer asked why he was missing his appointments before he was admitted to the facility, he states he missed the appointment for the same reason of incorrect transportation. 3/28/25 - 11:42 a.m. -Resident refused his dialysis appointment once again this am r/t transportation issues. They sent a stretcher transport he states he needs the large wheelchair transport van. Resident have been educated on the importance of dialysis. 3/31/25 - 9:57 p.m. [Physician Note] -was notified by nursing staff that he has been refusing to go to hemodialysis. I discussed with him and asked why he was refusing. He reported that he is not going to dialysis on the stretcher and he is not going with dirty clothes. I did discuss the importance of hemodialysis. He is scheduled to receive his antibiotic for osteomyelitis during antibiotic treatment. He refused PICC line prior to hospital discharge. No signs of fluid overload noted. Continue to encourage increased compliance with HD treatments His concerns were Discussed with nursing staff. 4/9/25 - 5:05: refused to go dialysis. Van is too small. NP [Name Redacted] is aware. 4/14/25 - 3:00 p.m. -Resident was dressed and ready to go to dialysis, but the transportation did not show up. Writer tried calling [Dialysis name redacted] dialysis several times, but no one picked up. 4/16/25 [physician note] -He is seen to follow-up on hemodialysis treatment refusals. He continues to be noncompliant with hemodialysis treatment. There have been issues with transportation as well. He is scheduled to receive his antibiotic for osteomyelitis during hemodialysis treatment. 4/18/25 - 2:44 p.m. Resident transport arrived at the facility to take him to dialysis. Insurance was made aware of resident preference today prior to arriving. Resident was rolled to the front lobby to the hospital to home van. Resident immediately stated that he was not going to get in the van because he has told the building that it was not the right size and he would not fit. Resident asked if he would at least try to get on the van so that he would see if he was able fit. Resident stated that he does not care he was not being put on the van because he can't fit and would be sick riding back from dialysis on that size van . 4/19/25 - 10:27 -Resident c/o nausea, his assigned nurse offered and administered prn Zofran. Resident stated I think I'm feeling like this because I missed dialysis resident missed dialysis r/t his refusals, he was offered to go the ER on yesterday 4/18/2025 which he declined, he was offered this am to go to the ER by his assigned nurse and thus writer he declined both times. 4/19/25 - 11:51 a.m. -Received report from his assigned nurse that he is yelling out for help, this writer went to his room immediately. On arrival to his room the resident was laying in his bed with the sheet over his head, this writer asked was he ok and what did he need help with, resident responded I just need to rest that's all. This writer asked him if he would like to go out to the hospital, the resident stated no I just need to rest I'll be ok. 4/20/25 - 8:35 a.m. Monitor resident for s/s of fluid overload. (swelling, SOB, abnormal v/s) related to 3 missed dialysis every shift. 4/21/25 - 9:57 a.m. Pt refusing dialysis said he can't fit in van, the minivan sent does accommodate pt however pt stated he needs more room because he is 6'2. advised pt we can send him to ER for dialysis because he has refused 4 times, pt still refusing NP is aware no new order. On 4/22/25 - Resident #64 was interviewed, and he stated the staff measured him in his wheelchair and then they made some phone calls and got me approved to go in the big van every appointment. I feel so much better today since I had my dialysis. 4/22/25 - at 10:08 AM. Resident measured sitting in the chair from floor to head. Resident measures 54 inches. 4/22/25 - at 10:03 AM. Spoke with resident about the new transport for dialysis with request for larger van, the new company was able to accommodate, he went to his scheduled dialysis, the request for larger van was made to send for further schedule transport for dialysis, he understands the other company will no longer provide services and is in agreement, more alert today and respond. He feels better. A review of the clinical record revealed that Resident #64 had not had labs drawn at the facility and was also scheduled to receive his antibiotic IV Gentamicin at dialysis. On 4/22/25 an interview was conducted with LPN K who stated that Residents who are on dialysis have communication books that are sent to dialysis with them and the center should enter information for the facility to review, and the facility puts in the weights and vitals prior to leaving the facility to communicate with dialysis. A review of Resident #64's Communication Book for dialysis revealed that the pages were mostly blank except for vital signs. The dialysis center and facility did not check the boxes and fill in names of Meds to be given at dialysis or Meds given at dialysis. There were no copies of labs or written results of labs drawn, for facility to review, weights were not entered, nor was refusal of wts entered. On 4/23/25 at approximately 3:00 p.m. an interview was conducted with the DON who was asked if the dialysis book should be sent to the center with the resident, filled out prior to the Resident leaving the facility, any medication entered on the sheet, and weight and vital signs. When asked what is expected from the center with regards to the communication book, she stated that they expected any lab results, medications given, and any weights or vitals taken as well as any other pertinent information related to dialysis care and treatment, but it was not done. The DON state it was the expectation is for a nurse receiving the book from dialysis with no communication from them, she stated they should call the center and get an update, but it was not done. During the above interview, the DON stated the labs obtained at dialysis should be part of the clinical record, but they were not and it was the dialysis center's responsibility to administer the resident the doses of Gentamicin. When asked who is responsible for reporting medications compliance to the physician, she stated that the facility is. When asked how the facility is keeping record of this if the communication book or the MAR does not notate it and they would have to contact dialysis. The DON was then asked to obtain any labs drawn at the dialysis center. 4/24/25 11:45 AM, Surveyor F received copies of labs faxed to DON by the dialysis center. Labs were reviewed with the DON, who stated she has made the NP aware. 4/24/25 1:21 PM Note Text: Received a call from [dialysis name redacted] dialysis r/t abnormal labs hemoglobin 5.6 gave orders to send to ER. Resident was verbally informed by his assigned nurse of his results and new orders; resident is refusing to go to the ER stating I feel good there's nothing wrong with me I'm not going to the er. Resident is declining to go to the ER at this time. NP made aware. 4/24/25 7:37 P.M. Called NP in regard to potassium level, NP advised to call dialysis (Name redacted) and get results from yesterday, no answer from dialysis, NP authorized labs cbc, and cmp stats, spoke with pt he stated he will allow lab to try one time, advised if Lab can not get labs call dialysis in am to get the labs results they take. A review of the clinical record revealed that Resident #64 eventually agreed to be transported to the hospital on 4/25/25 for a blood transfusion due to low hemoglobin and returned to the facility on 4/26/25. A review of the facility policy regarding transportation revealed the following: Policy: The center will ensure transportation to medically related appointments and will be responsible for coordinating accommodations, as needed. PROCEDURE 1. The center will schedule a provider appointment when a consult recommendation is received. 2. The responsible party may be requested to contact the transportation company for completion of appropriate forms allowing patient to use transportation services. 3. Transportation services will be notified at least 24 hours before the appointment time to schedule their service, when possible. 4. If transportation is not available or cancelled, provider and the patient and/or responsible party will be notified, and the appointment will be rescheduled. A review of the policy entitled Hemodialysis dated 1/29/24 revealed the following excerpt: Policy: A licensed nurse will monitor dialysis access grafts/devices as ordered by the provider and will oversee the care of the hemodialysis patient pre and post treatment. Paragraph 2 Outpatient Hemodialysis: 1. The Dialysis Communication Form will be initiated prior to sending patient for dialysis. A dialysis center ' s designated form may be used in place of the center ' s Dialysis Communication Form. 2. Patient reports received from dialysis center will be uploaded to the medical record. On 4/29/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to ensure that a resident who exhibited behavioral health symptoms received clinically appropriate services for one (1) of 57 residents (Resident #43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. In MDS section D0150 (Mood), the resident was coded as having trouble falling or staying asleep, or sleeping too much, nearly every day, feeling down, depressed, or hopeless, nearly every day, feeling tired or having little energy, nearly every day, and experiencing trouble concentrating on things, nearly every day. In MDS section E0800. Rejection of Care the resident was coded as rejecting care 4 to 6 days each week. A care plan problem dated 12/23/24 stated the resident has behaviors (refuses medications, ADL care, and weights) related to dementia, and a depressive disorder. The goal read the resident's behaviors will not cause him or other resident's distress thru the review period, 5/22/25. The interventions included administer medications as ordered, and assign staff members that are familiar or preferred by the resident whenever possible. An interview was conducted with Resident #43 on 4/18/25 at approximately 3:15 PM. The resident stated his mouth pain continued and he was reminded to notify the nurses because they were available to help him. The resident was noticeably more agitated than he was earlier in the day and he required gentle encouragement to share his feelings. Frequently Resident #43 required reminders that the Health Department had authorized the Survey Team to ascertain care practices in the facility and his statement was valued. The resident also stated that the people who lived and worked in the facility did not like him, and they did not treat him fairly. The resident further stated he believed they were giving him the wrong medications and he did not need most of the medication they wanted him to take. The resident shared he was a retired police officer and he knew how to protect himself. On 4/22/25 at 9:35 AM the facility's staff called the police to come to the facility because the resident was agitated, swinging and threatening others with wheelchair foot pedals. The resident was surrounded by the police officers and staff and could be heard stating that God was not listening to him, because he asked to be taken out of his misery and leave this world. A review of the nurse's notes revealed the resident was nonadherent with the medication regimen and an interview with the Psychiatric-Mental Health Nurse Practitioner (PMHNP) on 4/23/25 at 12:02 PM revealed that the provider was not made aware of the medication noncompliance. The PMHNP stated the resident's cognitive screening revealed significant dementia (a score of 4 out of 10) and the resident was was exhibiting paranoia (he believed that the staff was giving him the wrong medications). A further review of the nurse's notes revealed the resident had experienced weekly confrontation with his peers and/or staff and the care plan intervention to assign staff members that were familiar or preferred by the resident whenever possible, displayed no evidence it was instituted or reevaluated. The caregivers documentation and the care plan interventions failed to include interventions for working with the resident's beliefs of not being liked or treated fairly, or receiving the wrong medications. The documenting failed to reveal care and services had resulted in improved mental and/or psychosocial functioning. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from significant medication errors for 1 Resident (#64) in a survey sample of 57 Residents. The findings included: For Resident #64 the facilty staff failed to ensure the Resident received all of his medications as ordered by the physician. Resident number 64 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to acute osteomyelitis of left ankle and foot cellulitis of left lower, limb, and stage renal disease, dialysis dependent, muscle weakness, hypertension, diabetes type two, arthrosclerosis of arteries in the bilateral legs, ischemic cardiomyopathy, and congestive heart failure. Resident #64 was alert, and oriented and listed as his own Responsible Party, however he admitted to being non compliant with the BIMS (Brief Interview of Mental Status) asessment because he felt the questions were stupid, thus, explaining the MDS scoring of 99 on his BIMS exam. Resident is non weight bearing to both legs due to wounds and diagnosis of osteomyelitis. On 4/15/25 at approximately 10 a.m. an interview was conducted with Resident #64 who stated that since his admission he has missed several dialysis appointments because transportation does not always send the right vehicle. When asked to elaborate he stated that he is 6'4 tall and has a high backed wheelchair, and if they send the regualar wheelchair mini-van he is too tall and does not fit. Clinical record review revealed that Resident #64 has missed 6 dialysis appointments. Resident #64 is ordered to recieve Gentamicin IV while at dialysis theerefore missing his dialysis has caused him to also miss 6 critical doses of antibiotics needed for his Osteomyelitis. Resident #64 also was supposed to recieve Calcium Acetate (a phosphorus binder used to lower blood phosphorus levels in dialysis patients) with each meal. The following excerpts were entered in the chart regarding the missed medications: 3/26/25 8:07 p.m. - Calcium Acetate (Phos Binder) Oral Capsule 667 MG Give 2 capsule by mouth with meals for hyperphosphatemia r/t dialysis to be given at dialysis. 3/29/25 7:13 p.m. -Writer called the Pharmacy to inquire about resident's calcium acetate oral capsule give 2 cap. with meals. Pharmacy stated this has to be provided by dialysis to give facility to give to resident. Will call Dialysis on Monday. 3/30/25 10:37 a.m. -Calcium Acetate (Phos Binder) Oral Capsule 667 MG Resident have refused dialysis since he has been here. Give 2 capsule by mouth with meals for hyperphosphatemia r/t dialysis to be sent from dialysis. 3/30/25 12:07 p.m.Calcium Acetate (Phos Binder) Oral Capsule 667 MG Give 2 capsule by mouth with meals for hyperphosphatemia r/t dialysis Dialysis will provide. 3/31/25 - Writer spoke to [name redacted] at the dialysis center today, pertaining to resident. [Name redacted] stated that resident had his gentamycin ABT at dialysis center and will find out about resident's Calcium acetate capsule and will call facility tomorrow. On 4/21/25 an interview was conducted with the DON who was asked why the Calcium Acetate was being documented as being given at dialysis, she stated there was some confusion about who was supposed to supply it. We eventually got it straight that the dialysis center supplied it to the facility to dispense with each meal. When asked who was responsible for ensuring that the Resident received all of his doses of Gentamicin she stated that the dialysis center is the one administering it. When asked who is repsonsible for reporting medications compliance to the physician, she stated that the facility is. When asked how the facility is keeping record of this if the communimcation book does not mention it and the MAR does not mention it either, she stated they would have to contact dialysis. A review of the MAR (Medication Administration Record) for March revealed that Resident #64 did not receive the Calcium Acetate from admission on [DATE] through the end of the month 3/31/25. A review of the MAR for April revealed that Resident #64 missed 19 doses in April. A review of the lab results received on 4/24/25 that were results from labs drawn at dialysis on 3/31/25 revealed that the Resident had a high phosphorus level of 5.3. A review of the MAR revealed that there was no mention of the Gentamicin IV being given at dialysis. On 4/23/25 durring the end of day meeting the Admistrator was made aware of the concerns and no further information was provided.

Based on observations and staff interviews, the facility staff failed to safely store drugs and biological in one of three medication rooms and in the Infection Preventionist refrigerator. The findings included: On 4/23/25 at 11:34 AM an observation of the medication room on the [NAME] wing was conducted with Licensed Practical Nurse (LPN) O. An expired dose of Prevnar 20 was observed in the refrigerator for a resident who was discharged . LPN O stated it was not administered because the resident discharged prior to administration. LPN O stated it should have been removed from the refrigerator and returned to the pharmacy. On 4/25/25 at 11:30 AM an observation was conducted with the Infection Preventionist of the Infection Preventionist's medication refrigerator and testing supplies. Two expired RSV test kits had an expiration date of 12/2024 and one culture test kit had and expiration date of 10/19/2023. The above test kits were stored with other testing supplies which were still appropriate for use. It was also identified that seventeen influenza vaccines had names which had been redacted and remained in the refrigerator, twenty-two COVID-19 vaccine with an expiration date of 4/7/25,were incorporated with COVID-19 vaccines still appropriate for administration. In the refrigerator was also one T-dap vaccine expired 1/8/24, and three expired Shingrix vaccines with expiration dates ranging 10/17/24 to 12/3/24. An interview was conducted with the Infection Preventionist directly after the observations and finds. The Infection Preventionist stated she accepted the position less than a week before and she had not had an opportunity to assess and plan how to manage the department therefore she was not aware of the above findings prior to the review. The Infection Preventionist stated the expired drugs and test kits were given to the Director of Nursing for proper disposal. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to ensure meals served were palatable to consume by 2 of 57 residents (Resident #55, & #41) in the survey sample. The findings included: 1. Resident #55 was originally admitted to the facility 5/25/23 and the resident was readmitted [DATE] after a hospital stay. The resident's current diagnoses included quadriplegia secondary to gunshot wound in 2017, and neuromuscular dysfunction of the bladder. The annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/24/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #55's cognitive abilities for daily decision making were intact. The resident's nutrition care plan with a revision date of 9/3/24 stated the resident often orders food from outside entities and frequently ask other residents and staff for money to make purchases. On 4/25/25 at 12:15 PM, an interview was conducted with Resident #55 regarding why she orders out so often. The resident stated she does not eat anything prepared by the facility for she has knowledge that the kitchen is roach infested and she knows the food is horrible. The resident also stated she often puts her personal food in the unit pantry and it is stolen. Resident #55 further stated on the weekends there is little dietary staff so it looks like they take left overs from various days during the week to make trays to serve. The resident stated her family provides all of her meals. On 4/25/25 at 3:05 PM an interview was conducted with the Dietary Manager (DM). The DM stated that they prepare all meals in-house and she was attempting to add new items to the cycle menu, but she did not make a great deal of changes except to offer more alternatives. The DM stated she was still consulting with the Registered Dietitian and others to serve more of the resident preferences. The DM also stated there had been problems with roaches in the kitchen but the infestation was currently under control. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 2. Resident #41 was originally admitted to the facility 9/6/22. The resident's current diagnoses included blindness, chronic back pain and migraines. The quarterly MDS assessment with an assessment reference date (ARD) of 2/11/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #41's cognitive abilities for daily decision making were intact. Resident #41's had a care plan problem with a revision date of 12/20/24 which stated the resident prefers to leave personal items in the windowsill, a preference of purchasing and eating food from outside of the facility and storing food items in their personal refrigerator. The goal stated the resident will have his preferences honored if possible thru the review period, 5/14/2025. The interventions included encourage the resident to adhere to a therapeutic diet, and not to store food items outside of recommended time frames and temperatures. Observations were made in the resident's room of many spices and food products such as oodles of noodles, crackers and canned goods which could be opened and heated in a microwave. Therefore an interview was conducted with Resident #41 on 4/22/25 at 11:29 AM. The resident stated his blood sugars gets low and he has no foods to consume like a sandwich for his bedtime snack, except a cheese sandwich, which causes him constipation. The resident also stated that there are times he is hungry because the food is often not cooked well and most of the items are processed foods, that the dietary staff only warms and plates. The resident further stated he desired fresh fruits, but other than a banana which was recently added to the menu, there is no fresh fruits, just little cups of fruits in a juice. Resident #41 stated the food just doesn't have any flavor and most people use they few dollars to order out until their funds are depleted or arrange for their family to order food and have it delivered. On 4/25/25 at 3:05 PM an interview was conducted with the Dietary Manager (DM). The DM stated that they prepare all meals in-house and she was attempting to add new items to the cycle menu, but she did not make a great deal of changes except to offer more alternatives. The DM stated she was still consulting with the Registered Dietitian and others to serve more of the resident preferences. The DM also stated there had been problems with roaches in the kitchen but the infestation was currently under control. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to maintain all mechanical and electrical equipment in safe operating condition for the facility. The findings included: The facility staff failed to ensure all kitchen equipment was in working order. On 4/15/25 at approximately 9 a.m. observations of meals being served on Styrofoam trays were made. During the inspection of the kitchen the Dietary Manager stated that the dishwasher and the oven were not working. The interview with the Dietary Manager revealed the dishwasher had not been working. When asked how long the dishwasher had been down, she stated that she would have to check the work orders, and she stated she was not sure how long the oven had been broken either. Review of facility documentation from the repair technician revealed the following: On 4/14/25 at 2:11 p.m. (after Surveyors entered on day 1 of survey) an email was sent from the maintenance director to the company responsible for repairs to both the dishwasher and oven that read: 4/14/25 at 2:11 p.m. - Please have a tech service come for repairs as soon as possible as this is a priority situation. A review of the invoices for repairs to the dishwasher and the oven read as follows: 3/26/25 - Customer complaint was unit not washing at all, found 214VAC on the T1,2 and 3 of 3CON, diagnosed as bad wash pump, putting in estimate for repair. 4/10/25 - When removing the bottom panel found roaches running throughout the entire unit, found roaches and roach excrement inside of the old motor, advising customer to get an exterminator out before replacing the unit to prevent the motor going bad again after I replace it as well as, so I don't take any roaches home, a majority of them had egg sacs attached to their body. 4/15/25 -Customer wanted me to come out today to remove the panels of the warewasher to verify if infestation had been stopped, we found together that there were a reduced number of bugs but still persistent, customer wants to reschedule to Friday to have exterminator out one more time to prevent bugs from breaking a new motor. 4/18/25 - Arrived onsite and replaced motor it was filled with roaches, after replacing the motor unit is working and functioning normally. A review of the work orders revealed that the oven had also been out of service, excerpts are as follows: 4/9/25 - Oven not heating. Troubleshoot the problem found need to replace fan motor. Blower spacer and mounting screws. Parts ordered. 4/15/25 - Received part. Removed the old blower and motor. Installed new blower and motor. Oven working at normal function. A review of the facility policy entitled Timely Repairs dated 1/22/24 revealed the following: 1. Verify identified repairs are completed within two (2) business days from the date the work order was generated in the preventative maintenance electronic record unless the repairs require the acquisition of outside resources. 2. For repairs that require the acquisition of outside resources, and/or parts that must be ordered which will delay and extend repair time past ten (10) working days, document in the preventative maintenance electronic record the parts ordered, P.O. number(s), contractor, and/or anticipated date for repairs. On 4/18/25 during the end of day survey the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Comfortable and safe temperature on the Central Unit: a. Resident #43 complained of not being comfortable because of coldness on 4/17/25. Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. On 4/17/25 at 11:35 AM an interview was conducted with Resident #43. He was observed lying on his bed complaining of a toothache and wrapped in a robe. The only linens on the resident's bed was sheets and a light bedspread. Resident #43 stated that it's was too cold and that's why he had a robe wrapped around him. The resident further stated that he is accustomed to the cold because lived in Buffalo, New York for years and the coldness was why he left Buffalo. The resident also stated he had been cold seven day out of the last seven and it was too cold in the facility for elders. The resident stated a blanket could help but a better form of heat would be better. Nurses were observed distributing blankets later in the day on 4/17/25 at approximately 1:15 PM but Resident #43 did not receive one. Also on 4/17/25 at approximately 3:20 PM the Maintenance Director stated the Corporate office instructed him not to turn the heating system back on because over the coming weekend the temperature was supposed to rise significantly. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 5. Comfortable and safe temperature on the Central Unit: Resident #45 complained of feeling cold on 4/17/25. Resident #45 was originally admitted to the facility on [DATE] and had not been discharged from the facility. The resident's diagnoses included dementia and coronary artery disease. The annual MDS with an assessment reference date (ARD) of 1/18/25 coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview coded the resident as having long term and short tem memory problems and severely impaired decision making abilities. On 4/17/25 at 11:37 AM an interview was conducted with Resident #45. Resident #45 complained of freezing and stated that was why she needed her foot covered. She further stated she had been freezing for the last 3 out of seven days. Nurses were observed distributing blankets later in the day on 4/17/25 at approximately 1:15 PM and Resident #43 received one. Also on 4/17/25 at approximately 3:20 PM the Maintenance Director stated the Corporate office instructed him not to turn the heating system back on because over the coming weekend the temperature was supposed to rise significantly. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 6. Comfortable and safe temperature on the Central Unit: Resident #85's husband stated the resident was often cold on 4/17/25. Resident #85 was originally admitted to the facility 8/22/2023. The resident's current diagnoses included adult failure to thrive, dementia and dysphagia. The significant change MDS with an assessment reference date (ARD) of 1/18/25 coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview coded the resident as having long term and short tem memory problems and moderately impaired decision making abilities. On 4/17/25 at approximately 11:39 AM Resident #85 was observed seated in her room with a blanket wrapped around her. An interview was conducted with Resident #85's husband who was seated beside her, assisting her to consume food he had brought in. The husband stated the resident is often cold therefore he keeps personal blankets on her bed. The husband stated over the last week it had been colder but he was aware that the heat had been turned off for the season. On 4/17/25 at approximately 3:20 PM the Maintenance Director stated the Corporate office instructed him not to turn the heating system back on because over the coming weekend the temperature was supposed to rise significantly. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 7. Comfortable and safe temperature on the Central Unit: Resident #38 complained about it being too cold in her room on 4/17/25. Resident #38 was originally admitted to the facility 11/20/2023. The current diagnoses included Parkinson's disease and diabetes. The quarterly MDS with an assessment reference date (ARD) of 2/20/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #38's cognitive abilities for daily decision making were intact. On 4/17/25 at 11:49 AM Resident #38 was observed in bed with 3 additional throw blankets on and wearing a burgundy wool hat. During the interview with Resident #38 she stated it was too cold and she had put on and gotten out everything out she could to keep warm and it was not helping. The resident stated the heated needed to be turned up. Nurses were observed distributing blankets later in the day on 4/17/25 at approximately 1:15 PM but Resident #43 did not receive one. Also on 4/17/25 at approximately 3:20 PM the Maintenance Director stated the Corporate office instructed him not to turn the heating system back on because over the coming weekend the temperature was supposed to rise significantly. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. Sanitary Issues: On 4/18/25 at approximately 12:04 PM, an interview was conducted with Licensed Practical Nurse (LPN) H, at the medication cart. A medium size roach was first observed crawling around on the top of the medication cart near the drawers, then as LPN H attempted to get rid of it, the roach ran across the cart near the applesauce container and then quickly beneath the towel absorbing the water from the water pitcher. LPN H removed the towel, exposing the roach and was observed swatting the roach to the floor and killing it. LPN H stated she has seen roaches before in the facility but not on the medication cart. On 4/28/25 at approximately 4:00 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. They offered no comments and voiced no concerns regarding the above information. 2. For the facility, the facility staff failed to ensure a clean and comfortable homelike environment and the [NAME] and East units. For Resident # 56 residing on [NAME] Unit, the facility staff failed to ensure ensure a clean, comfortable homelike environment due to deep scratches on the unpainted walls and the presence of roaches. Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 56 required extensive assistance on staff for activities of daily living. Review of the clinical record was conducted 4/16/2025-4/28/2025. During rounds on 4/16/2025 at 3:15 p.m., Resident # 56 was observed lying in bed and watching television. The walls were noted to have large white colored areas and deep scratches. The walls were in need of painting. When asked if there were any other problems, he stated there were a lot of roaches in the facility. Resident # 56 stated roaches were everywhere. He stated they were in the residents' rooms and in the hallways. He also stated he had seen roaches in the facility several times. Resident # 56 stated the room needed some work. On 4/17/2025 at 1:20 p.m., there were observations of debris under the Resident # 56's bed and in the corners of the room. On 4/18/2025 at approximately 11:30 a.m., an interview was conducted with the Housekeeping Director. He stated the housekeeping department was responsible for cleaning the rooms. He stated the staff did clean each room each day. The Housekeeping Director stated the facility was in the process of getting the walls painted. On 4/18/2025 at approximately 11:45 a.m., an interview was conducted with the Maintenance Director who stated the facility had a pest control contract. He stated the exterminator should be notified of persistent problems with pests. He also stated the facility was being painted in the hallways. There were observations of painters painting in the hallways on each unit. On 4/18/2025 during the end of day debriefing, the Administrator, [NAME] President of Operations, Corporate Nurse Consultant (Employee C) and Director of Nursing were informed of the findings of failure to provide a clean, comfortable, homelike environment. On 4/23/2025 at 3:15 p.m., an interview was conducted with Licensed Practical Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated some of the rooms did not look homelike. During the end of day debriefing on 4/23/2025, the Facility Administrator, two Corporate Nurse Consultants (Employees C and D) and Director of Nursing were informed of the findings. They stated the rooms should be comfortable and homelike and that some were in need of repair. No further information was provided. 3. On the East Unit, the facility staff failed to ensure a clean, comfortable homelike environment including but not limited to: foul odors, patchwork on unpainted walls and the presence of roaches. During tour of the facility on 4/16/2025, there were several observations of areas where the facility failed to ensure a clean, comfortable, homelike environment. There were odors of urine and feces noted while touring the unit. During tour of the Shower room on the East short hall, there were roaches observed in the shower stall. In the room where residents # 9 and # 75 resided, there were white patches on the walls and a hole in the plaster. The bathroom had patches on the walls. Both residents who resided in the room were alert and oriented with BIMS (Brief Interview for Mental Status) scores of 15 indicating no cognitive impairment. Both residents were interviewed on 4/16/2025 at approximately 2:30 p.m. They stated the room looked like that for a while. Resident # 75 stated there was a problem with roaches in their room and other areas in the facility. Their room was located two doors down and perpendicular to the hall to the facility's kitchen area. Throughout the days of the survey, there were observations of odors occasionally on the East Unit. The odors were more pungent in the mornings prior to 11 a.m. On 4/18/2025 at 12:30 p.m., an interview was conducted with CNA (Certified Nursing Assistant)-B who stated that sometimes roaches were observed in the facility. She also stated sometimes there were odors in the facility. She stated the nursing staff was expected to perform incontinence care every two hours and after every incontinent episode. She stated there were some residents who refused care and that contributed to the odors. She stated the staff was expected to inform the supervisor of any refusal of care and Housekeeping staff of any rooms that needed cleaning. On 4/18/2025 at 1:10 p.m., an interview was conducted with Licensed Practical Nurse-D who stated there were issues with roaches and ants in the facility. She stated sometimes there were odors also. Licensed Practical Nurse-D stated she made rounds to ensure incontinence care was being provided regularly. She stated if residents had clutter or items that might attract pests, she encouraged them to keep the items covered and clean. During the end of day debriefing on 4/23/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings. The Facility Administrator stated it was important for the facility to be clean, comfortable and homelike. No further information was provided. Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure the Residents' right to a safe, clean, comfortable homelike environment for the entire facility and seven (7) Residents (#'s56, 75, 43, 45, 85, 38, and #116) in a survey sample of 57 Residents. The findings included: 1. For the facility, the residents complained of being either too cold or too hot, the dishwasher was not working, the oven was not working, the rooms were dirty, there were strong odors of urine on all hallways, the shower rooms were dirty, and (one)1 shower needed repair. 4/15/25 10:00 a.m.- Walking on to the Central Unit there was a strong odor of urine all the way down to the shower room. Central unit shower room strong urine odor, toilet was dirty and not flushed, stains at base of toilet near floor yellow and brown. Three (3) used wash cloths on the floor, shower chair has brown stains on it. 4/15/25 10.10 a.m.- East unit shower room shower curtain has brown stains, also mold at base of curtain, shower room smells of urine, shower stalls not clean, resident clothing in room. 4/15/25 10:15 a.m.- [NAME] unit shower room shower stall at end of room is running, staff attempt but unable to turn it off. shower chair has dirty linen on it, paper towels on floor and in sink. Odor of Urine in hallways. On 4/15/25 - 11:00 a.m. an interview was conducted with the housekeeping supervisor who stated that they usually clean the shower rooms in the morning, but they didn't have a chance because the CNA's were giving showers all morning. Stated his usual deep clean day is Wednesday for shower rooms. 4/16/25 - 9:00 a.m. shower curtains had not been changed or washed with the same mold and brown stains observed on the shower curtains. This was observed by the housekeeping supervisor and Employee D; the housekeeping supervisor stated the facility does not have any new curtains to replace them with. When asked if an attempt been made to wash the curtains currently hanging and he stated that he did not know. 4/15/25 - 4/16/25 observations were made of all meals being served on styrofoam trays. On 4/26/25 at 3:00 p.m. an interview conducted with the Dietary Manager revealed the dishwasher had not been working. When asked how long the dishwasher had been down, she stated that she would have to check the work orders. Review of facility documentation from the dishwasher repair technician revealed the following: 3/26/25 - Customer complaint was unit not washing at all, found 214VAC on the T1,2 and 3 of 3CON [Motor Part numbers], diagnosed as bad wash pump, putting in estimate for repair. 4/10/25 - When removing the bottom panel found roaches running throughout the entire unit, found roaches and roach excrement inside of the old motor, advising customer to get an exterminator out before replacing the unit to prevent the motor going bad again after I replace it as well as, so I don't take any roaches home, a majority of them had egg sacs attached to their body. 4/15/25 -Customer wanted me to come out today to remove the panels of the warewasher to verify if infestation had been stopped, we found together that there were a reduced number of bugs but still persistent, customer wants to reschedule to Friday to have exterminator out one more time to prevent bugs from breaking a new motor. 4/18/25 - Arrived onsite and replaced motor it was filled with roaches, after replacing the motor unit is working and functioning normally. A review of the work orders revealed that the oven had also been out of service, excerpts are as follows: 4/9/25 - Oven not heating. Troubleshoot the problem found need to replace fan motor. Blower spacer and mounting screws. Parts ordered. 4/15/25 - Received part. Removed the old blower and motor. Installed new blower and motor. Oven working at normal function. 4/17/25 - Residents on three (3) of three (3) units complained about the temperature being cold in the facility. The overnight temperature in Henrico County was 41 degrees. The facility maintenance director escorted Surveyors E and F to each unit and the temps were as follows: Central Unit - room [ROOM NUMBER] - 65 degrees East Unit - room [ROOM NUMBER] - 65 degrees West Unit - room [ROOM NUMBER]- 68 degrees West Unit hallway 72 degrees The Maintenance Director was asked why the heat was not on he stated, This time of year in Virginia it is sometimes cold at night and hot during the day, and it is not good for the system to keep turning on and off the heat and air. He stated that this is an old system and cannot keep up with the demands of this building. The Maintenance Director also informed surveyors that the chiller they have now is from another building and is not functioning properly. The surveyors requested repair and service information for the heating and air conditioning for the past year below are excerpts from the emails between the Regional Director of Physical Plant and Corporate offices regarding the repairs: 5/21/24 - This chiller was working when it was turned off last year at [facility name redacted]. [Company name redacted] moved it for us, it was vandalized sitting in [Facility name redacted] parking lot overnight. Since it was installed a few months ago in the mechanical room, a large circulating pump has ruptured spraying all over the mechanical room. The control board is ruined and has to be built and programmed for this particular chiller . Given the issues last year with the state, I think we need to move on this asap. 4/1/25 - The chiller project at [Facility name redacted] which began in 2023, remains unresolved despite a significant financial investment. The original chiller was relocated and installed, only to find the control board was nonfunctional. We then incurred additional costs to bring in a temporary chiller while awaiting a new control board. We were told installation would proceed in the spring, but that was followed by further delays. We've now been informed that the system is still not operational and are told guidance is pending from [Company name redacted]. This has gone on for far too long. We are now at risk of the state shutting down the building if the issue is not resolved immediately. On 4/21/25 at 4 p.m. a large trash can was observed in the hallway on the [NAME] Unit. Water was dripping from the ceiling into the trash can. An interview with the Maintenance Director revealed that the temperature had gone up to 81 degrees that afternoon the a/c was turned on. The air conditioning unit was leaking, condensation from the rooftop unit. The [NAME] Unit has a separate air conditioning system, and the Maintenance Director stated the technician said there was Three and a half (3-1/2) inches of ice built up on the coils that had to melt before any repairs could be done. A review of the facility policy entitled Timely Repairs dated 1/22/24 revealed the following: 1. Verify identified repairs are completed within two (2) business days from the date the work order was generated in the preventative maintenance electronic record unless the repairs require the acquisition of outside resources. 2. For repairs that require the acquisition of outside resources, and/or parts that must be ordered which will delay and extend repair time past ten (10) working days, document in the preventative maintenance electronic record the parts ordered, P.O. number(s), contractor, and/or anticipated date for repairs. 8. For Resident #116 residing on the Central Unit, the facility staff failed to maintain a clean comfortable and homelike environment. 1. During the Survey 04/14/2025-04/28/2025, The wall behind Resident #116's bed and the wall behind the television was soiled, with what appeared to be dried dark brown liquid splashes from the middle of the wall down to the floor. 2. Ensure the Resident Room was free of pests. 3. The floor tile under Resident #116's sink is missing, and the one that was pulled up has jagged edges throughout the entire survey. Resident #116 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, muscle weakness, major depressive disorder, left artificial hip, seizures, and fibromyalgia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 03/18/25. Resident # 116's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #116 required assistance with Activities of Daily Living. On April 14, 2025, during the initial tour, Resident #116's room was devoid of any homelike decorations. The room possessed a strong smell of urine. Some of the tiles under the sink were missing, and one of the remaining tiles had jagged edges. The wall behind Resident #116's bed and the wall behind the television had what appeared to be dark brown liquid splashes to the floor. On 4/22/25, at approximately 1:00 PM, a dead mouse was observed in a sticky trap behind Resident #116's door in the room. On 04/23/25 at 12:40 p.m., an interview was conducted with the LPN #B, who stated that pests/bugs/insects should not be in residents' rooms. On 04/23/25 an interview was conducted with the DON (Director of Nursing), who stated that Angel Rounds are done every morning after the Morning Stand up and are conducted by all department heads and unit managers. She also indicated that pests, bugs, and insects should not be in residents' rooms. On 04/24/25, an interview was conducted with the housekeeping staff, who stated that resident rooms are checked, mopped, and cleaned daily, as well as when requested or needed. Review of the facility policy entitled Patient Room Inspections, implemented 05/01/2022, revealed a policy statement which included the following excerpts: 1. Identify room locations. 2. Inspect room environment including but not limited to sprinkler heads, lights, globes, privacy curtains and tracks, wallpaper, walls, floor tile, carpet, baseboards, door, door hardware, bumper stops, and frames, ceiling tiles, toilet seats, towel bars, grab bars, furniture, windows, blinds, and all electrical appliances and/or equipment including medical devices to verify items are safe and properly maintained. 6. Check for insects/pests. 11. Replace cracked or broken wall/floor tile. Re-caulk around tile and bath fixtures as necessary. Apply new grout as necessary. 17. Inspect flooring and repair as needed. On April 24, 2025, during the end-of-day meeting, the Administrator, Director of Nursing, Housekeeping, and Maintenance staff were informed of the findings regarding the failure to provide a clean, comfortable, and homelike environment. There was no additional documentation was provided.

Based on observation, resident interview, and staff interview, the facility's staff failed to provide meals at regular times and in accordance with resident needs, preferences and requests on three out of three units. The facility staff failed to offer and provide snacks at bedtime and failed to serve meals timely. The findings included: During the Resident council meeting conducted on 4/21/2025 at 2:00 p.m., the ten alert and oriented residents who attended complained that they did not get offered bedtime snacks and did not receive snacks on a regular basis. The attendees represented all three units. The residents stated that it was rare to receive snacks at bedtime. They all stated they would like a snack at bedtime. The residents further stated that they had witnessed the dietary staff bring snacks to the unit occasionally, and left them at the nursing station desk. Some of the residents stated they were Diabetic and did not get a snack on a regular basis. They stated the nursing staff left the snacks at the nursing desk, which allowed ambulatory residents who could get to the desk to get a snack but the residents who could not ambulate, often did not get a snack. They all stated they had observed nursing staff eating the snacks that were supposed to be given to residents. The residents complained that the foods were salty and starchy foods for each meal. They also stated the only fresh fruit allowed were bananas. They stated they were served canned fruit which tastes old. An interview was conducted with the Dietary Manager (DM) on 4/18/2025 at approximately 4:15 p.m. The Dietary Manager stated that the only bedtime snacks provided were for the Diabetics on the units. She stated that was what was included in the Dietary contract. The Dietary Manager stated she provided nursing staff with the snacks for Residents diagnosed with Diabetes. She stated the snacks provided were labeled with the names of the Residents with Diabetes. The Dietary Manager stated she did not provide snacks for the other residents due to the contract with the facility. Review of Resident Council minutes for January to March 2025 revealed documentation of concerns regarding dietary. There were no observations of snacks being offered or provided to residents prior to the survey team informing the administrative staff of the concerns expressed by residents and the findings. On 4/23/2025 at 8:51 a.m., Resident # 75 was observed standing in her room near the door to her room. She stated she was waiting for the breakfast trays to come to the floor. Resident # 75 stated she wanted some coffee. When asked if she could get coffee prior to the trays being served, she stated no. We have to wait until the trays come. Resident # 75 also stated that the staff know I love my coffee. Resident # 75 stated I would have to get it myself. She stated the only way she could get coffee prior to breakfast being served was if she bought it. When asked what that meant, she stated she would have to ask the staff to go out to a Restaurant to buy some coffee for her. On 4/23/2025 at 8:55 a.m., Resident # 75 was observed in the hallway. Stated she went to the Dining Room to read the breakfast menu and was coming back to the room to tell her roommate what was on the menu. Resident # 75 was observed walking back and forth to the door of her room and later in the hallway asking dietary staff members what time they were going to deliver the breakfast trays to the unit where she resided. Resident # 75's room was located on the East wing perpendicular to the hall where the door to the kitchen was located. Resident # 75 could stand in the doorway to her room, look to the left and see the carts being transported out of the kitchen to the units. On 4/23/2025 at 9:06 a.m., observed a Certified Nursing Assistant who knocked on the kitchen door, asked about trays for the Central Unit. A dietary staff member was observed coming down the hall. He stated he just delivered trays to Central Short. Dietary staff members were observed transporting carts out of the kitchen and going to different units between 8:53 a.m. and 9:12 a.m. On 4/23/2025 at 9:18 a.m., observed the dietary staff delivering the carts for the East unit where Resident # 75 resided, The nursing staff delivered the tray to Resident # 75 at 9:21 a.m. Observations were made that other residents on East Unit long and short halls received their trays after 9:25 a.m. The nursing staff were passing the trays and setting them up for the residents as needed. On 4/23/2025 at 11:50 a.m., observed Residents eating lunch in the dining room. There were approximately 21 residents (representing all three units) in the dining room eating lunch. For the residents who resided on the East Unit and Central Unit, there had been only two-two and a half hours between the breakfast and lunch meals. Review of the facility's documentation of meal times revealed the listed times for delivery of meals were more than 14 hours between the dinner meal and breakfast. Examples included: East Long/East Short- Dinner-6 p.m.- Breakfast- 8:15 a.m. Central Long/Central Short-Dinner-5:45 p.m.- Breakfast 7:50 a.m. Another copy of the facility's meal times was presented to the survey team. That copy had typed times along with some handwritten designation of the units associated with times. Examples of more than 14 hours included but were not limited to: Dining Room-Dinner-5:35 p.m.-Breakfast-8:30 a.m. West Long-Dinner- 5:00 p.m.- Breakfast- 7:30 p.m. Central Short-Dinner- 5:50 p.m.- Breakfast-8:10 p.m. East Short-Dinner-6:35 p.m.- Breakfast-8:45 p.m. The breakfast trays were over an hour late on the East and Central Units Residents who attended the Resident Council meeting stated the facility was always short staffed and it affected everything. They stated they could not get their trays fast because there was not enough staff to pass the trays. They also stated they often order food from the outside because they get hungry. They stated they often do not like the food but have to eat it since they need food. On 4/24/2025 at approximately 10:45 a.m., an interview was conducted with the Dietary Manager. Regarding times of delivery of food carts to the units, the Dietary Manager stated she was aware that residents on the East Unit complained about the delivery times of their meals. She stated that's why sometimes I deliver meals on the East unit first instead of always doing the [NAME] Unit first. The Dietary Manager stated the dietary department was delivering the meals to the units as fast as possible. The Dietary Manager stated the dietary staff delivers the meal carts and nursing staff distribute them to the residents. On 4/25/2025 during the end of day debriefing, the findings were discussed with the Executive Director (Administrator), Director of Nursing, [NAME] President of Operations, and Regional Corporate Nurse Consultant. Some residents had lunch two hours after breakfast and then had to wait 6 or more hours for dinner. Breakfast was more than 14 hours after the dinner meal. Most residents did not receive a bedtime snack. They stated snacks should be provided to residents and that meals should be delivered on time. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation, the facility staff failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public throughout the facility. The findings included: For the facility, the staff failed to maintain comfortable ambient temperatures throughout the facility. 4/17/25 9:00 a.m. Residents on 3 of 3 units complained about the temperature being cold in the facility. Residents were observed in the hallway wrapped in blankets. The overnight temperature in the area according to the national weather service was 41 degrees. The facility maintenance director escorted Surveyors E and F to each unit and the temps were as follows: Central Unit - room [ROOM NUMBER] - 65 degrees East Unit - room [ROOM NUMBER] - 65 degrees West Unit - room [ROOM NUMBER] - 68 degrees West Unit hallway - 72 degrees The maintenance director was asked what the acceptable temperatures were for the facility, and he stated the building should be no less than 71 degrees and no more than 80 degrees. When asked why the heat was not on when the temperatures in the rooms were 65 and 68 degrees, he stated, This time of year in Virginia it is sometimes cold at night and hot during the day, and it is not good for the system to keep turning on and off the heat and air. He stated that this is an old system and cannot keep up with the demands of this building. The maintenance director also informed surveyors that the chiller they have now is from another building and is not functioning properly. The surveyors requested repair and service information for the heat and air conditioning for the past year below are excerpts from the emails between the Regional Director of Physical Plant and Corporate offices regarding the repairs: 5/21/24 - This chiller was working when it was turned off last year at [facility where it was moved from name redacted]. [Company name redacted] moved it for us, it was vandalized sitting in [Facility currently being surveyed name redacted] parking lot overnight. Since it was installed a few months ago in the mechanical room, a large circulating pump has ruptured spraying all over the mechanical room. The control board is ruined and has to be built and programmed for this particular chiller . Given the issues last year with the state, I think we need to move on this asap. 4/1/25 - The chiller project at [Facility being surveyed name redacted] which began in 2023, remains unresolved despite a significant financial investment. The original chiller was relocated and installed, only to find the control board was nonfunctional. We then incurred additional costs to bring in a temporary chiller while awaiting a new control board. We were told installation would proceed in the spring, but that was followed by further delays. We've now been informed that the system is still not operational and are told guidance is pending from [Company name redacted]. This has gone on too long. We are now at risk of the state shutting down the building if the issue is not resolved immediately. On 4/21/25 at 4 p.m., a large trash can was observed in the hallway on the [NAME] Unit. Water was dripping from the ceiling into the trash can. An interview with the maintenance director, at that time, revealed that since the temperature had gone up to 81 degrees that afternoon the a/c was turned on. He stated that the air conditioning was leaking into the building as a result of condensation from the rooftop unit. He stated that the [NAME] Unit has a separate air conditioning system, and he had a technician come out because of the condensation leaking into the building. He said that the technician said there was 3 1/2 inches of ice on the coils and the facility would have to turn off the unit and let the ice melt before any repairs could be done, and he would come back the next day after it had a chance to melt. A review of past surveys revealed that the facility thewas cited on 9/14/24 for lack of a functioning air conditioning system. By the close of survey on 4/22/25 the facility was still working on repairs to the heat and air conditioning. A review of the facility policy entitled Timely Repairs dated 1/22/24 revealed the following: 1. Verify identified repairs are completed within two (2) business days from the date the work order was generated in the preventative maintenance electronic record unless the repairs require the acquisition of outside resources. 2. For repairs that require the acquisition of outside resources, and/or parts that must be ordered which will delay and extend repair time past ten (10) working days, document in the preventative maintenance electronic record the parts ordered, P.O. number(s), contractor, and/or anticipated date for repairs. On 4/29/25 during the end of day meeting the Administrator was made aware of the findings and no futher information was provided

Based on observation, interview, and clinical record review the facility staff failed to maintain an effective pest control program for the facility. The findings included: For the facility staff failed to keep the building free from pests, namely roaches. On 4/15/25 during the initial tour of the facility the shower rooms were observed by surveyors E & F, the shower room on East Unit had a live roach crawling in the shower area. 4/15/25 - 4/16/25 observations of meals being served on styrofoam trays. The interview with the Dietary Manager revealed the dishwasher had not been working. When asked how long the dishwasher had been down, she stated that she would have to check the work orders. Review of facility documentation from the repair technician revealed the following: 3/26/25 - Customer complaint was unit not washing at all, found 214VAC on the T1,2 and 3 of 3CON, diagnosed as bad wash pump, putting in estimate for repair. 4/10/25 - When removing the bottom panel found roaches running throughout the entire unit, found roaches and roach excrement inside of the old motor, advising customer to get an exterminator out before replacing the unit to prevent the motor going bad again after I replace it as well as, so I don't take any roaches home, a majority of them had egg sacs attached to their body. 4/15/25 -Customer wanted me to come out today to remove the panels of the warewasher to verify if infestation had been stopped, we found together that there were a reduced number of bugs but still persistent, customer wants to reschedule to Friday to have exterminator out one more time to prevent bugs from breaking a new motor. 4/18/25 - Arrived onsite and replaced motor it was filled with roaches, after replacing the motor unit is working and functioning normally. During the Resident Council meeting on 4/21/25, all 10 Residents that were in attendance agreed there currently is a Problem with roaches and ants throughout the building. On 4/23/25 a review of the pest control logs revealed that although the facility has a contract with pest control services for monthly service it is not effective, in that 3 of 3 units are still complaining of pests in the building, ants roaches and mice. While in the confrence room during most days of the survey ants were observed by all survyeors in attendance. On 4/28/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility nursing staff failed to treat residents with dignity and respect for one of four residents in the survey sample and per the resident council. The findings included: On 3/12/24 at 3:45 PM an interview was conducted with Resident #2 who stated that the staff are coming into the Resident rooms without knocking, they are using ear buds and talking on the phone while providing ADL care, they are generally rude to residents. When asked if she could name anyone in particular, she stated that it in general they have a lousy attitude when working with residents. Although these behaviors were not observed during survey, the Resident Council minutes revealed the following: June 2023-Resident council minutes state poor customer service. July 2023-Aides customer service is poor. August 2023-Resident council minutes state staff playing around and too loud during bedtime hours. September 2023-Resident council meeting minutes reflect complaints of staff being on their cell phone while providing care. October 2023- 7 pm-7 am noise at night slam doors November 2023-Aides continue to be on cell phones, Aides not helping, poor customer service, attire not professional. December 2023-Aides and nurses talking loud outside of doors. January 2024-Aides and nurses are on the phone while providing care. On 2/13/24 at approximately 2:00 PM an interview was conducted with the Administrator who stated that he is aware of some customer service issues with staff and is addressing these issues with staff. During the end of day meeting the Administrator was made aware of the concerns and no further information was provided

Based on observation, interview, clinical record review, and facility documentation review, the facility staff failed to inform the resident representative, when there was a change in condition for one resident in a survey sample of four residents. The findings included: For Resident #3, the facility staff failed to inform the resident's representative of the resident's fall from bed on 2/9/24. Resident #3 had a diagnosis of dementia. The most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/12/24 coded her BIMS (Brief Interview of Mental Status) score of 0, indicating rarely or never understood. On 2/12/24 at approximately 4PM Resident #3's daughter came to the room while the Surveyor was interviewing Resident #2 (Resident #2 is the roommate of Resident #3). When Resident #3's daughter came into the room Resident #2 greeted her and said Did they tell you that your mom fell out of the bed on Friday? Resident #3's daughter said No, no one called me, when did she fall? Resident #2 stated that it was about 2 or 3 AM. She stated she was awake the curtain was closed but she heard a soft thud and realized she had fallen. She said the nurse came in pretty quickly and bandaged her elbow where it was bleeding. Resident #3's daughter searched her phone and did not see any missed calls or voicemails from the facility. She stated That's bad they did not call me. If she didn't want to bother me at 2 AM I can understand that, but she could have called me later on in the morning. 2/9/2024 - 2:08 AM -Fall Note Description of the fall/V/S/injuries if any resident observed in floor in between her bed and roommates bed laying on right side, one teddy bear under her head and one teddy in her hand, Blood on floor from skin tear to left elbow. resident responds at baseline; What interventions were in place at the time of the fall? reposition pillow and bed in lowest position What are the risk factors that could have contributed to the fall? resident turning over in bed and rolled out of bed What new interventions were implemented in response to the fall? close monitoring Was the Provider/resident and RP (responsible party) notified at the time of the fall? yes Additional Comments: Surveyor was unable to contact nurse for an interview during the survey. On 2/12/24 during the end of day meeting the Administrator was made aware of the issue and no further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise the care plan for one resident (Resident #6) of eight (8) residents in the survey sample. For Resident #6, the facility staff failed to review and revise the care plan after a significant weight loss from July 2022 to October 2022. The findings included: On 09/12/2023, a review was conducted of Resident #6's clinical record. Review revealed Resident # 6 was edentulous, had difficulty swallowing, and was prescribed a mechanically altered diet. According to the Monthly Weight Report, Resident #6 had a 20.0093% decrease in weight between July 2022 and October 2022. There were no monthly weights documented in July 2022 and August 2022. The weights from June 2022 to January 2023 were: 01/06/2023 - 96.1 lbs. 01/03/2023 - 95.2 lbs. - Wheelchair 11/21/2022 - 95.2 lbs. 10/11/2022 - 100.0 lbs. 10/06/2022 - 96.7 lbs. 07/07/2022 - 118.2 lbs. 06/28/2022 -116.0 lbs. - Mechanical Lift 05/11/2022 - 117.0 lbs. 03/10/2022 - 110.8 lbs. Further review of weights taken monthly to twice monthly from January 2021 of 125.5 lbs. to November 2021 of 124 lbs. showed weights that were stable with slight fluctuations in weight. The first weight calculated for 2022 was completed in March 2022. It was 110 lbs., which was an 11.243% difference from the November 2021 weight of 124 lbs. The Registered Dietitian's notes stated Resident #6 was seen on 07/18/2022 and the plan was to continue the mechanically altered diet due to dysphagia, and continue with staff assisting with feeding. Gradual weight gain was noted. The next Dietitian note dated 10/12/2022 documented Nutrition Weight Change Note-significant weight loss noted and resident has dementia and weight loss is expected. Decreased oral intake noted. Ensure supplements increased to three times daily. Weight loss may be unavoidable. On 09/13/2023 at 1:10 p.m., an interview was conducted with Licensed Practical Nurse C who stated the Certified Nursing Assistants were expected to report food intake to the nurses. LPN C stated the nurses review the care plans of all residents, follow the plan of care, follow the physician's orders regarding diets, weights and nutritional supplements. LPN C stated the physician should be notified to assess the residents. On 09/14/2023 at 2:45 p.m., an interview was conducted with the Director of Nursing who stated Resident # 6 had dementia and failure to thrive. The Director of Nursing stated the expectation was for the staff to assess and monitor for significant weight loss. The Director of Nursing stated she did not see any weights for August 2022 and September 2022. When asked if the nursing staff would be expected to monitor this resident closely for weight loss due to the medical diagnoses, history, decreased food intake, and prognosis, the Director of Nursing stated, Yes. The Director of Nursing agreed that a resident with a weight of 117 would look different at 96 pounds. There would be an obvious indication of a change in weight. Resident #6's care plan was reviewed. It read: Nutrition Risk R/t (related to) advanced dementia, advanced age, mechanically altered diet provided for ease of chewing/swallowing. Goal: The resident will maintain adequate nutritional status aeb (as evidenced by) no significant weight change by next review. Date Initiated: 01/06/2022 - Created on: 06/12/2018 Revision on: 10/25/2022 Interventions: · Monitor/document/report PRN any s/sx (signs or symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date Initiated: 07/18/2022 · Monthly Weights Date Initiated: 01/06/2022 · Provide adaptive equipment for feeding; divided plate. Date Initiated: 01/06/2022 · Provide and serve supplements as ordered. Date Initiated: 01/06/2022 · Provide staff supervision/assistance with feeding at meal times. The care plan did not address the actual significant weight loss identified in October 2022. On 09/14/2023 at 3:00 p.m., the Administrator, Director of Nursing, and Assistant Director of Nursing were notified of the findings. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure care and services met professional standards of quality for 1 resident (Resident #2 ) in a survey sample of eight (8) residents. For Resident #2, the facility staff failed to follow physician's orders to weigh Resident #2 three times per week due to a diagnosis of congestive heart failure (CHF). On 09/13/2023 at approximately 12:00 p.m., an interview was conducted with Resident #2 who was asked about her diagnosis of CHF. She stated she was diagnosed when she was in her 40's and has had to watch her diet and weight frequently and watch for swelling of her legs and feet. When asked how many times per week she is supposed to be weighed she stated 3 times per week. When asked how she gets weighed, she stated, They are supposed to use the lift scale, but a lot of times they don't do it because they don't like getting the lift out and weighing me. A review of the clinical record revealed that Resident #2's weight was not documented from 05/11/2023 until 07/07/2023. From 07/07/2023 until 09/14/2023 the following weights are not documented as having been done: July: 07/14, 07/17, 07/28, and Aug.: 08/4, 08/14, 08/21, and 08/25 Sept.: 09/04, 09/11, and 09/13 On 09/12/2023 at approximately 1:00 p.m., an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) was conducted. They were both asked if it is the expectation of the facility that nurses will follow the physician's orders and/or clarify any orders they do not understand. They both indicated that it is the facility's expectation of all nurses. No further information was received.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents received the necessary services to maintain good grooming, and personal hygiene for 1 resident (Resident #1) in a survey sample of eight (8) Residents. The findings included: On 09/12/2023 at approximately 2:15 p.m., an observation was made of Resident #1 in bed with eyes closed, appeared to be resting, and did not respond to the knock on door. The room smelled of urine and feces, which was compounded by the heat and humidity of the room. On 09/13/2023 at approximately 9:50 a.m., Resident #1 was in bed with his eyes closed, appeared to be asleep, and dressed in a hospital gown. As surveyor moved closer to the resident, there was a smell of body odor, and the room had a distinct odor of urine, which was compounded by the warm humid air in the room. On 09/14/2023 at approximately 2:30 p.m., Resident #1 was observed in bed, awake, and alert. The resident was noted to have beads of sweat on his forehead and was covered in a sheet and light blanket. When asked if he had gotten a shower today, he stated that he had not. A review of the clinical records revealed that Resident #1's last recorded shower was 08/10/2023. On 09/13/2023, an interview with Employee C was conducted at 9:55 a.m. Employee C was asked how often residents were bathed, she stated they received showers twice a week or bed bath if they prefer. She stated sometimes they refuse. When asked what the Certified Nursing Assistant (CNA) is supposed to do if a resident refuses, she indicated they are supposed to notify the nurse so she can document it in the nurses' notes and that she can try again later to get them to shower. On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with the Ombudsman who stated she comes to the facility many times and finds the facility smells of urine and feces. She stated that Resident #1's wife complains that he is not bathed regularly, and it is evident by the body odor and urine smell. She stated the lack of adequate air conditioning is not helping with the body odor and incontinent smells either. A review of the policy entitled, Shift Responsibilities for CNA, read: 2. Obtain patient assignments at the beginning of shift with / from a licensed nurse. Examples of report information includes but is not limited to patient's name, room and bed, scheduled appointments, bathing needs, special care needs etc. 3. Provide pertinent information to the oncoming shift such as tasks not completed. On 09/14/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to arrange transportation to medial appointments for 1 resident (Resident #5) in the survey sample of eight (8) residents. The findings included: For Resident # 5, the facility staff failed to ensure transportation was arranged for medical appointments. Resident #5 was admitted to the facility in July 2022. Resident #5's diagnoses included but were not limited to heart failure, respiratory failure with hypoxia, diabetes, hypertension, and chronic kidney disease. Review of the clinical record was conducted on 09/12/2023 and 09/13/2023. On 09/13/2023 at 9:30 a.m., an interview was conducted with Resident #5. He stated it was upsetting that transportation to appointments was always a problem. Resident #5 stated he has missed several appointments in the past and did not have transportation to return to the facility at times. Resident #5 stated he needed to keep the medical appointments when they were scheduled. The facility's sign-in/sign-out sheet was reviewed. The May 2023 sign-in sheet revealed that on 05/22/2023, Resident #5 had an appointment at 2:00 p.m. and was picked up at 1:00 p.m. There was no documentation of the time of return. Additionally, the columns for Transportation Company, Return Time, and Scheduler, were not filled out for any of the entries on the sheet. On 09/13/2023 at approximately 4:00 p.m., an interview was conducted with the Administrator who stated Resident #5 often would secure his own transportation to appointments. The Administrator stated there was a scheduler on the units who arranged for transportation. The Director of Nursing (DON) stated the facility often was unaware when Resident #5 had appointments outside of the facility. The DON stated the facility used the transportation services that were approved by Medicaid. The DON stated that sometimes the transportation service did not show up as scheduled. Review of the progress notes revealed the following: Effective Date: 05/22/2023 17:38 Type: Plan of Care Note Note Text: Resident returned from dentist. No new orders at this time. Stated I had some teeth filled Effective Date: 05/19/2023 11:51 Type: Alert Note Note Text : pt has appt (appointment) 5-22-23 at 2pm with dentist (address redacted) with pick up at 1pm Effective Date: 05/19/2023 11:38 Type: Alert Note Note Text : transportation did not show for pt appt today 5-19-23 with cardiologist was told they could not find a provider to accommodate his transportation for today trip #71509 Effective Date: 05/18/2023 10:31 Type: Alert Note Note Text: pt has appt 5-19-23 at 745am with cardiologist at (address redacted) with pick up at 630am. Review revealed that Resident #5 did not have a dental appointment on 05/2/2023. There was an appointment on 05/22/2023 at 2:00 p.m. Review of the facility's transportation records revealed Resident # 5 was picked up at 1:00 p.m. The Nursing progress notes dated 05/22/2023 at 17:36 (5:36 p.m.) stated the resident returned to the facility from the dentist. Resident #5 was gone from the facility for over 4 hours and over 3 hours after his dental appointment time. There was no documentation that the dental office called the facility. Resident #5 did not have transportation for the appointment with the cardiologist on 05/19/2023. The transportation company did not show up. Further review revealed that transportation did not show up for a scheduled dental appointment on 04/17/2023 for Resident #5. On 09/14/2023 during the end of day debriefing, the Administrator, Director of Nursing, and Assistant Director of Nursing were informed of the findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to prevent a significant weight loss for one resident (Resident #6) of a survey sample of eight (8) residents. The findings included: For Resident #6, the facility staff failed to prevent a significant weight loss of 20.0093% within 90 days. In addition, the facility staff failed to recognize, evaluate, and address Resident #6's nutritional needs in a timely manner. Resident #6 was admitted to the facility in June 2022. Resident # 6's diagnoses included but were not limited to: failure to thrive, and dementia. On 09/12/2023, a review was conducted of Resident #6's clinical record. Review revealed Resident #6 was edentulous, had difficulty swallowing, and was prescribed a mechanically altered diet. According to the Monthly Weight Report, Resident #6 had a 20.0093% decrease in weight between July 2022 and October 2022. There were no monthly weights documented in July 2022 and August 2022. The weights from June 2022 to January 2023 were: 01/06/2023 - 96.1 lbs. 01/03/2023 - 95.2 lbs. - Wheelchair 11/21/2022 - 95.2 lbs. 10/11/2022 - 100.0 lbs. 10/6/2022 - 96.7 lbs. 07/07/2022 - 118.2 lbs. 06/28/2022 - 116.0 lbs. - Mechanical Lift 05/11/2022 - 117.0 lbs. 03/10/2022 - 110.8 lbs. Further review of weights taken monthly to twice monthly from January 2021 of 125.5 lbs. to November 2021 of 124 lbs. showed weights that were stable with slight fluctuations in weight. The first weight calculated for 2022 was in March 2022 and was documented as 110 lbs., which was an 11.243% difference from the November 2021 weight of 124 lbs. The Registered Dietitian's notes stated that Resident #6 was seen on 07/18/2022 and the plan was to continue the mechanically altered diet due to dysphagia, and continue with staff assisting with feeding. Gradual weight gain was noted. The next Dietitian note dated 10/12/2022 documented Nutrition Weight Change Note-significant weight loss noted and resident has dementia and weight loss is expected. Decreased oral intake noted. Ensure supplements increased to three times daily. Weight loss may be unavoidable. On 09/13/2023 at 1:10 p.m., an interview was conducted with Licensed Practical Nurse (LPN) C who stated the Certified Nursing Assistants (CNA) were expected to report food intake to the nurses. LPN C stated the nurses review the care plans of all residents, follow the plan of care, follow the physician's orders regarding diets, weights, and nutritional supplements. LPN C stated the physician should be notified to assess the residents. On 09/14/2023 at 2:45 p.m., an interview was conducted with the Director of Nursing (DON) who stated Resident #6 had dementia and failure to thrive. The DON stated the expectation was for the staff to assess and monitor for significant weight loss. The DON stated she did not see any weights for August 2022 and September 2022. When asked if the nursing staff would be expected to monitor this resident closely for weight loss due to the medical diagnoses, history, decreased food intake, and prognosis, the DON stated Yes. The DON agreed that a resident with a weight of 117 would look different at 96 pounds. There would be an obvious indication of a change in weight. Resident #6's care plan was reviewed. It read, Nutrition Risk R/t (related to) advanced dementia, advanced age, mechanically altered diet provided for ease of chewing/swallowing. Goal: The resident will maintain adequate nutritional status aeb (as evidenced by) no significant weight change by next review. Date Initiated: 01/06/2022 -Created on: 06/12/2018 Revision on: 10/25/2022 Interventions: · Monitor/document/report PRN any s/sx (signs or symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date Initiated: 07/18/2022 · Monthly Weights Date Initiated: 01/06/2022 · Provide adaptive equipment for feeding; divided plate Date Initiated: 01/06/2022 · Provide and serve supplements as ordered Date Initiated: 01/06/2022 · Provide staff supervision/assistance with feeding at meal times. The care plan did not address the actual significant weight loss identified in October 2022. On 09/14/2023 at 3:00 p.m., the Administrator, Director of Nursing and Assistant Director of Nursing were notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure the residents right to a clean, comfortable, and homelike environment, for four (4) residents (Residents #4, #2,# 7, and #8) in a survey sample of eight (8) residents. The findings included: For Residents #1, #2, #7, and #8, the facility staff failed to maintain a comfortable homelike environment due to the lack of effective and efficient HVAC cooling system in the building. The following observations were made regarding Resident #1, who has Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. On 09/13/2023 at approximately 9:50 a.m., Resident #1 was in bed with his eyes closed, appeared to be asleep, dressed in a hospital gown, had a distinct odor of urine in the room, which was compounded by the warm humid air in the room. On 09/14/2023 at approximately 2:30 p.m., Resident #1 was observed in bed, awake, and alert. The resident was noted to have beads of sweat on his forehead and was covered in a sheet and light blanket. When asked if he was warm, he stated that he was. He stated, It is a bit warm in here for me. When asked if he would like the room a little cooler he said, Yes ma'am a lot cooler. The following observations were made for Resident #2 who has a BIMS score of 15, indicating no cognitive impairment: On 09/12/2023 at 3:00 p.m., an interview was conducted with Resident #2, and she was asked about the air conditioning in the building. She stated the air conditioning has been broke for years. Resident #2 said, They use these little portable units like this one my family brought me. But unless you have one in each room, it isn't no good. These little units can cool off one room but not a whole hallway full of rooms. When asked what she did before getting the unit from her family, she stated she laid in bed hardly able to breathe good because she has respiratory issues. The unit her family gave her was a small portable air conditioner that was vented through the window and putting out cold air. The room was a comfortable temperature and not humid. The following observations were made for Resident #7, who has a BIMS score of 15, indicating no cognitive impairment. On 09/12/2023 at 3:15 p.m., Resident #7 was observed in bed dressed in only a hospital gown, and no sheet or blanket covering her. The resident's room had a [NAME] unit air conditioner running as well as a portable air conditioner not vented. When asked how she was feeling she said, Hot as Hell. When asked if the air conditioner is working, she stated that it has not worked since she arrived in May. Employee C was present and asked if the [NAME] units work and he stated they were operational. When asked to check the temperature of the [NAME] unit, he found it was putting out air at 77.8 degrees on its highest cool setting. When asked to check the temperature of the portable air conditioning unit that was set on its highest cool setting, it was putting out air at 75.5 degrees. When asked if that was efficient cooling, he stated that it was not. The portable air conditioner stopped running at that point, and Employee C was asked how the facility drains the condensation from the units, he stated they take them to the shower room. When asked if the unit automatically shuts off and does not work efficiently when it needs draining and he stated that it does. When asked if the unit runs cooler and more efficiently when it is vented, he stated that it did. The following observations were made for Resident #8: On 09/13/2023 at approximately 12:30 p.m., an interview was conducted with Resident #8 who stated the problem with the air conditioner has been brought up in resident council meetings and that residents are tired of the response, We have to wait for corporate to get the money to fix it. She further stated, The portable units in the hallways are not helping and the Administrator is the one who picks who can have one in their room and who can't. Well that's just not fair. If you can open your mouth and fuss you can get one but what about those poor folks who cannot speak for themselves, they just lay there and sweat. Resident #8 had a portable unit in her room vented in the window, and the room was cool and comfortable. When asked what she did before she got the portable unit she stated, I complained a lot and sweated a lot. On 09/12/2023 at 2:30 p.m., an interview was conducted with Employee C who was asked how long the cooling system has not been working effectively, and he stated that was before him working there over a year ago. When asked about the portable air conditioning units observed in the hallways, he stated that each unit has at least 2 of the portable air conditioning units. When asked why some of the units are properly vented to the ceiling or a window, he stated that they did not have the tubing to vent all the units. He stated the tubing to vent the air conditioning units is very expensive and corporate does not want to buy it. When asked if the units could run safely without the tubing, he stated they could. Employee C went around the building with Surveyor C and the temperatures in the building ranged from 64 degrees on the [NAME] wing to 78.8 degrees on the East Wing. On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with the Ombudsman who stated that she submitted complaints on behalf of residents because the building is too hot and humid and smells of urine. There are a few residents that have family bring in fans or portable air conditioning units but the ones who have no family will just suffer with the temperatures. The residents who cannot speak for themselves will not get a portable unit in their room either. On 09/14/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on staff interview, facility documentation, and clinical record review, the facility staff failed to provide routine medications to one resident (Resident #6) in a survey sample of eight (8) residents. The findings included: For Resident #6, the facility staff failed to ensure the medication, Lorazepam, was available for administration as ordered by the physician. Review of the clinical record was conducted 09/12/2023 through 09/14/2023. Resident #6 was admitted to the facility in June 2022. Diagnoses included but were not limited to: anxiety disorder, schizophrenia, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the progress notes revealed the following documentation about medications being unavailable: Effective Date: 12/25/2022 11:25 Type: Orders - Administration Note Note Text : LORazepam Tablet 0.5 MG (milligrams) Give 1 tablet by mouth two times a day for anxiety may give when arrive per MD RP (medical doctor, Responsible Party) is aware. Effective Date: 12/24/2022 20:56 Type: Orders - Administration Note Note Text : LORazepam Tablet 0.5 MG-Give 1 tablet by mouth two times a day for anxiety Pending to due pharmacy. Effective Date: 12/24/2022 09:13 Type: Orders - Administration Note Note Text : requires a new rx (prescription) Effective Date: 12/23/2022 20:08 Type: Orders - Administration Note Note Text : LORazepam Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety Effective Date: 12/23/2022 10:40 Type: Orders - Administration Note Note Text : LORazepam Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety on order Review of the OMNI Cell STAT Box contents revealed the medication Lorazepam 0.5 mg tablet, quantity of 6 tablets, were on hand. The nurses could have retrieved the medication from the OMNI Cell STAT box. Review of physician's orders revealed valid orders for the medications not available for administration. Review of the care plan revealed the following problem: The resident has history of anxiety and psychosis. Date Initiated: 01/06/2022 Revision on: 01/06/2022 Goal: The resident will have decreased signs and symptoms of anxiety and psychosis through the review date. Date Initiated: 01/06/2022 Target Date: 02/27/2023 Intervention: Administer medications as ordered. On 09/13/2023 at 11:48 a.m., an interview was conducted with Licensed Practical Nurse (LPN) D who stated the staff should notify the pharmacy when medications are not available for administration, check the OMNI Cell STAT box, notify the Medical Doctor (MD) and make sure the pharmacy sends the medication STAT. On 09/13/2023 at 2:42 p.m., an interview was conducted with the Director of Nursing (DON) who stated the expectation was for the pharmacy to make sure medications were available for administration as per the physician's orders. The DON also stated the facility staff should check the OMNI Cell STAT box for medications to see if the missing medication is available in that supply. The DON stated the pharmacy should deliver the missing medication on the next run if it was not in the OMNI Cell STAT box. Review of the OMNI Cell STAT box content list revealed the medication, Potassium Chloride capsule 10 milliequivalents and quantity of 5 were available to the staff. There was no documentation the staff informed the physician that the Potassium Chloride Powder was not available as ordered and that Potassium Chloride capsules were available. On 09/14/2023 during the end of day debriefing, the Administrator, Administrator in Training, Director of Nursing and Assistant Director of Nursing were informed of the findings. The Administrator and Director of Nursing stated the pharmacy should ensure medications were available for administration as ordered by the physician. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure one resident (Resident # 4) of eight (8) residents in the survey sample was free of significant medication errors. For Resident # 4, the facility staff failed to ensure the medication, Medrol, was available for administration as per physician's orders. The findings included: Resident #4 was admitted to the facility in March 2023 and discharged in April 2023. Resident # 4's diagnoses included but not limited to diabetes, methicillin susceptible staphyloccoccus aureus with sepsis (MSSA), and diabetic foot ulcer. Review of the physician's orders revealed an order for the medication: Medrol Oral Tablet Therapy Pack 4 MG (milligrams) (Methylprednisolone) Give 4 mg by mouth give four times a day. The times of scheduled administration of the medication, Medrol, 4 milligrams by mouth four times a day, were documented on the medication administration record (MAR) as to be administered at 9:00 a.m., 12:00 noon., 6:00 p.m., and 9:00 p.m. Review of Resident #4's MAR revealed the nursing staff failed to administer the medication as ordered by the physician on several dates and times to include: April 13, 2023 - 9:00 a.m., 12:00 noon., 6:00 p.m., and 9:00 p.m. April 14, 2023 - 9:00 a.m., 12:00 noon., 6:00 p.m., and 9:00 p.m. April 15, 2023 - 9:00 a.m., 12:00 noon., 6:00 p.m., and 9:00 p.m. April 17, 2023 - 9:00 a.m., 6:00 p.m., and 9:00 p.m. On 09/12/2023 during the initial tour, Licensed Practical Nurse (LPN) B was observed passing medications. LPN B was interviewed. LPN B stated if the medications were not available, she would notify the pharmacy, check the STAT box, notify the pharmacy, notify the doctor, and notify the family. On 09/13/2023 at 12:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) who stated it was important to administer medications as ordered by the physician. The ADON stated the expectation was that the pharmacy would ensure medications were available for administration and provide them on the next run after notification was received that the medication was not available. She stated the staff should notify the doctor and family if the medications are not available for administration. The ADON stated the medicine was a steroid and it was important to administer the medication, Medrol, as ordered. On 09/13/2023 at 4:15 p.m., the Administrator and Director of Nursing (Admin D) were informed of the findings. An interview was conducted with the Director of Nursing (DON) on 09/14/2023 at 2:25 p.m. regarding the medication not being administered. The DON stated she reviewed the clinical record and noted the Medrol was not available from 04/13/2023 - 04/15/2023 but was administered on 04/16/2023. She stated the facility staff did not administer the medication because it had not been available from the pharmacy. The DON stated the nurses were waiting for the pharmacy to deliver the medication and did notify the physician. The DON stated the expectation was the medication would have been available on the next delivery as documented by the nursing staff. The DON stated it was not the expectation for prescribed medications to be unavailable for administration for several days. Valid physician's orders were evident for the medications and treatments not documented as administered. Review of the facility's policy entitled, Medication Administration, revealed that all medications are to be given according to the prescriber's order. On 09/13/2023 at 3:30 PM, an interview was conducted with the Administrator who stated the expectation was that medications would be available for administration. The Administrator also stated staff were expected to check the OMNI Cell STAT box and notify the pharmacy so the medication could be delivered on the next run. The Administrator also stated staff should administer medications and treatments per physician's orders and to document them as having been administered immediately following administration. On 09/13/2023 at 4:00 p.m., the Administrator and DON were informed of the failure of the staff to ensure significant medications were administered. They were informed that more than 10 consecutive doses were not available for administration. On 9/14/2023 during the end of day debriefing, the Administrator, Director of Nursing and Assistant Director of Nursing were informed of the findings. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for the facility in general. The findings included: For the facility, the facility staff failed to maintain a comfortable temperature throughout the entire building, failed to operate portable air conditioners safely in accordance to the manufacturer's instructions, and failed to maintain working ice machines on 2 of the 3 units. On 09/12/2023 during the initial tour of the facility, it was noted that each hall had 2 portable air conditioning units. The [NAME] unit felt much cooler than the East and Central units. Temperatures varied from 68 degrees on the [NAME] unit to 78.8 on the East and Central units. On 09/12/2023 at approximately 3:30 p.m., an interview was conducted with Employee E who stated the chiller runs the air on East and Central units; however, the [NAME] unit has its own air system. Employee E stated that the chiller has not worked properly since before he started working there. Surveyors B & C noted the units on the hallways were vented to the drop ceiling. When asked if the units were safe to operate without venting through a window, Employee E stated they were safe to operate like that. When asked if they were safe to operate without venting to a window or the ceiling, he stated they were safe to operate that way as well. When asked why some units were vented and some were not, he stated because the facility ran out of tubing. When asked why some residents' rooms have portable units and some do not, he stated it is the Administrator and Director of Maintenance that make the decision of which rooms have portable units and he installs them where they tell me to. On 09/13/23 at approximately 11:45 a.m., an interview was conducted with Employee D who was asked why some residents' rooms have portable units and some do not, he stated that some parts of the building are warmer than others and some residents' families have supplied their own units. A phone call was placed to the manufacturer's help line and was found that the air conditioning units were Model #SLPAC105W Portable Air Conditioner Compact Home A/C Cooling Unit with Built-in Dehumidifier. 10,000 BTU. When asked if these units were commercial or for home use, the associate stated they were ideally designed for home use. When asked if they could be used without venting through the window, he stated the units were designed to be vented to the outside because the way the portable air conditioners work the push cool air into a room and vent hot air out through the compressor to the outside through a window. He stated not properly venting a portable air conditioning unit can result in the system not working, as moisture builds up, it will eventually overheat and shut off. He also stated that a 10,000 BTU air conditioner was only meant to cool a 20 ft x 20 ft area. On 09/13/2023 at 12:55 p.m., an interview was conducted with LPN B who stated the air conditioning has been a problem in this facility for years and it never gets fixed. These portable units do not cool enough to make a big difference. We have complained and residents and families complain but nothing gets done. Throughout the survey, staff, residents, and family members voiced complaints about the air conditioning not being effective. A review of resident council meeting minutes revealed the lack of air conditioning has been brought up in every meeting since May. Observations were made on 09/12/2023 at 2:00 p.m., and the ice machines that serves the East, Central, and [NAME] units were empty. An interview was conducted with Employee E who stated the ice machine on East and Central was down for cleaning. The ice machine on the [NAME] unit was having to produce ice for the entire building and that is why they were both empty. On 09/13/2023, an interview was conducted with the Administrator who stated the maintenance department had purchased ice for distribution until the ice machines could be on long enough to catch up and fill the bin. On 09/14/2023, the ice machine on the East and Central units was still empty. The ice machine on the [NAME] unit had ice barely covering the bottom of the bin. Residents' rooms had water pitchers full of water; however, most of them were without ice. On 09/14/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program so the facility is free of pests. The findings included: For the facility in general, the facility staff failed to maintain an environment free of flies, gnats, fruit flies, ants, and roaches. From 09/12/2023 through 09/14/2023 flies and gnats were noted throughout the facility by Surveyors B and C in the conference room, the hallways, and residents' rooms. On 09/14/2023 at approximately 1:00 p.m., a large live cockroach was noted under a chair in the hall just outside the kitchen area. A review of the grievances revealed the following: 08/24/2023 - room [ROOM NUMBER] A - Resident states there are ants in her bed. 09/01/2023 - room [ROOM NUMBER] B - Resident requested pest control services. 09/01/2023 - room [ROOM NUMBER] - Resident requested pest control services. 09/05/2023 - room [ROOM NUMBER] B - Resident requests pest control services. 09/11/2023 - room [ROOM NUMBER] B - Social Worker noticed ants while interviewing residents. A review of the resident council minutes revealed the following: June 26, 2023 - Resident #8: Excessive trash in the courtyard drawing bees, and wasps. Both insects are building nests in benches. A review of the Service Inspection Report revealed: Inspected and treated rooms [ROOM NUMBERS] for spiders. Treated rooms [ROOM NUMBERS] for roach complaints. Treated rooms [ROOM NUMBERS] for ants. Also, treated and inspected rooms 3, 5, 7, 9, 21, 39, 52, 62, 76, and 87 for flies. Recommend to clean trash cans, drains, and floor areas to help on the fly issues. Check pest sightings book at front desk. Also fly light near room [ROOM NUMBER] is out. **Please note that only 1 room (#59) out of the 5 above mentioned rooms were treated by pest control. On 09/13/2023 an interview was conducted with Employee E who stated the process of obtaining pest control services for a specific room is that if a staff or resident reports seeing bugs or flies, they inform maintenance so they can enter it into the pest sightings log. When the exterminator comes he will look at the book and know which rooms and/or areas need to be treated and for which pests. On 09/14/2023 during the end of day meeting, the Administrator was made aware of the findings. No further information was provided.

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to follow standards of nursing practice for 1 Residents (Resident #102) in a survey sample of 12 Residents. The findings included: For Resident #102, the facility staff failed to obtain lab work/urine sample as ordered by the physician. On 1/10/23-1/11/23, a clinical record review of Resident #102's chart was conducted. This review revealed the following: On 7/10/2022 at 2:52 PM, a progress note was entered into the record that read, Writer spoke with residents RP [responsible party] in regard to resident current condition. Per RP resident is having increased confusion and requiring more cueing with adls [activities of daily living] than usual. VSS [vital signs stable]. RP concerned that resident may have an UTI [urinary tract infection]. On call MD [medical doctor/physician] notified of concerns order obtained to obtain UA/ C&S [urine analysis with culture and sensitivity]. RP updated. A physician order dated 7/10/22, read, UA/C&S may straight cath [catheterize] if needed one time only. Review of the medication administration record, treatment administration record, results tab, and miscellaneous tab of the chart revealed no evidence of this urine sample being obtained. On 1/11/23 at 3:25 PM, Surveyor C met with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) in the DON office. The DON accessed Resident #102's clinical record and confirmed the progress note and MD order for the urine sample/test. She confirmed that the results were not under the results tab. The DON was asked to provide any evidence that this lab was obtained as ordered. On 1/12/23 at 10:19 AM, an interview was conducted with LPN E. LPN E was asked what the process is when she receives an order from a physician for labs or specimens. LPN E said, We do the labs, if a urine we collect the urine and call for the lab to pick it up. When the doctor orders it, we will do it as soon as possible, when the results come in the lab faxes them to the doctor, if they send it to us, we print it and put it in the doctor book. On 1/12/23 at 10:23 AM, an interview was conducted with LPN F. LPN F was asked about labs. LPN F said the lab sends someone to draw blood for labs and the facility staff collect urine samples. LPN F went on to explain the process as, We would obtain the specimen, label and date the specimen, put it in the fridge, document in the chart that I collected it and call the lab to pick up the sample. On 1/12/23 at 10:45 AM, Surveyor C called the facility's contracted laboratory. They looked in their system for any labs or specimens and noted that they did not have Resident #102 in their system and had never processed any specimens for this Resident. Review of the facility policy titled; Laboratory/Diagnostic Testing was conducted. This policy read, 1. A licensed nurse will obtain laboratory, radiology, or other diagnostic services to meet the needs of its patients as ordered by the physician or physician extender. 2. A licensed nurse will monitor and track all physician or physician extender ordered laboratory, radiology, and other diagnostic tests; ensure that tests are complete as ordered and communicate results to the physician in a timely manner. 3. Laboratory, radiology, and other diagnostic services will be provided only when ordered by the physician or physician extender. 4. The physician or extender will be notified of the results as soon as possible by a licensed nurse of any results that fall outside the clinical reference range. 5. Once the physician or extender has been notified, the licensed nurses will document the date of notification, the method of notification as well as any other necessary information related to the lab, radiology, or other diagnostic testing results in the patient's medical record. Copies of the results will be placed in the patient's clinical record. No further information was provided prior to the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to provide a significant antibiotic medication resulting in 8 missed doses for one Resident (Resident #101) a survey sample of 12 Residents. The findings included: For Resident #101, the facility staff failed to administer 8 doses of a significant antibiotic resulting in 8 consecutive doses being missed . Review of the clinical record for Resident #101 revealed that the Resident was admitted to the facility on [DATE]. The discharge orders/physician orders from the hospital discharging physician revealed an order, Fidaxomicin 200 mg Tablet, commonly known as: Dificid. Take 1 tablet by mouth two (2) times a day for 17 doses. Last time this was given: 200 mg on December 21, 2022, at 10:18 AM. Your next dose is: 12/21/22 at 9 PM. Another progress note written 12/22/2022 at 12:44 PM, read, Dificid Tablet 200 MG, give 1 tablet by mouth two times a day for c-diff for 17 Administrations Medication on next med run MD/RP [physician and responsible party] aware. Review of the Medication Administration Record (MAR) revealed Resident #101 did not receive her scheduled dose of Dificid on 12/21/22- 2 doses, morning dose on 12/22/22, 12/23/22- 2 doses, 12/24/22- 2 doses, and the morning dose on 12/25/22. The MAR was signed off for the evening dose of 12/22/22, however the medication had not been delivered to the facility at this time. Review of the on-site Omnicell [medication dispensing machine/emergency medication supply] revealed that Dificid was not available on-site for staff to administer. On the morning of 1/9/23, the facility Administrator reported to the survey team that initially the Resident expressed a desire to leave the facility and therefore they waited until they knew she was going to stay at the facility to have the Dificid delivered. The Administrator went on to say that the pharmacy had notified the facility the Dificid was an expensive medication and needed permission before filling the physician order/script for Dificid. The facility Administrator further explained that as soon as he saw the pharmacy notification, he authorized for the medication to be dispensed. The administrator provided the survey team with a copy of the emails which indicated that on 12/23/22 at 2:39 PM, the pharmacy emailed the facility staff indicating the Dificid was a High-Cost Medication and would cost $4,622.16. On 12/24/22 at 10:40 AM, the facility Administrator responded to the email with Please send. Thanks. On 1/11/23 at 4:53 PM, an interview was conducted with Employee F, the Quality Assurance Pharmacist at the facilities' contracted pharmacy. Employee F stated the pharmacy received the order/prescription for Resident #101's Dificid on 12/21/22 at 6:35 PM. The medication was out of stock at the pharmacy and on 12/23/22 at 6:47 AM, a notice was sent to the facility. [the notice being referenced was the High-Cost Medication. Employee F stated the mediation was delivered to the facility on [DATE] at 6:40 PM. Upon further review, Employee F noted that the medication Dificid was filled twice, and a second fill was delivered to the facility on [DATE] at 10:54 AM. The facility Administrator and Director of nursing were made aware of the findings. No further information was provided. Complaint related deficiency.

Based on observation, Resident and staff interviews, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to provide food that accommodates Resident preferences for one Resident (Resident #106) in a survey sample of 12 Residents. The findings included: For Resident #106 the facility failed to provide meals consistent with the Resident's dislike of broccoli. On 1/9/23 at 3:08 PM, the Ombudsman met with the survey team. The Ombudsman verbalized that Food has consistently been an issue here with poor quality, not enough food and lack of choices. I know they were renegotiating the food contract last spring. On 1/10/23 at 5:30 PM, observations were made of the evening meal. Resident #106 was served mixed vegetables that consisted primarily of broccoli. Resident #106 was noted to not eat the meal. The meal ticket on the meal tray at the bedside was noted to read, Allergies: Broccoli, Brussels Sprouts, Cabbage, Cauliflower, Zucchini Squash, Asparagus. When interviewed Resident #106 stated, I can't eat that. When asked if he was allergic to broccoli, the Resident said, no, I don't like it, but they send it all the time. On 1/10/23 at approximately 5:45 PM, CNA C accompanied Surveyor C to the room of Resident #106. CNA C confirmed the meal ticket indicated an allergy to broccoli and the Resident was served broccoli. On 1/10/23 at 5:55 PM, an interview was conducted with Employee F, the cook for the evening meal. Employee F was asked about the food items listed as an allergy and Employee F said the Residents are not to get those items. On 1/10/23 at 6:02 PM, an interview was conducted with Employee E, the dietary aide. Employee E stated that usually the meal tickets would have information in the middle of the ticket that would tell them what food items to put on the plate. Employee E went on to say, the ticket is blank in the middle that explains everything so without it we don't know what to put on the plate. On 1/11/23 at 12:09 PM, an interview was conducted with Employee G, the registered dietician (RD). The RD indicated she is currently at the facility 2 days per week and the facility is currently without a dietary manager. When asked about the meal tickets, the RD said, They have not been printing out the actual daily menu, [Employee H name redacted] the Regional is also new and hasn't been doing that. Indicating the meal tickets are not being printed where it details what the staff are to put on each meal tray taking preferences and allergies in consideration and making substitutions. The RD went on to say, As of tomorrow it will start printing the food items. During the above interview the RD was asked about Resident #106's notation on the meal ticket as an allergy to broccoli. The RD said, he doesn't like broccoli, preferences don't always print on the ticket if the meal were on the ticket, it would automatically substitute that food item for something else. The clinical record for Resident #106 was reviewed. The dietary progress notes didn't reference any meal/food preferences or dislikes. The physician orders revealed an active physician order that was entered 7/16/22, that read, Heart Healthy Diabetic diet Level 7 - Regular texture, Regular Liquids consistency. Resident #106's care plan was reviewed without any reference to dietary preferences/dislikes being noted. Review of the facility policy titled, Dining and Food Preferences was reviewed. This policy read, .4. Food allergies, food intolerances, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software program. 5. The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to insure [sic] adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups. 6. The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan into the plan of care. 7. The individual tray assembly ticket will identify allergies, food and beverage preferences or special requests, and adaptive equipment as appropriate. 8. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. 9. The alternate meal and/or beverage selection will be provided in a timely manner. On 1/10/23 during an end of day meeting the facility Administrator was made aware of the above findings. No additional information was provided prior to the conclusion of the survey. Complaint related deficiency.

Based on observation, Resident and staff interviews, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to provide a therapeutic diet as ordered by the physician for one Resident (Resident #107) in a survey sample of 12 Residents. The findings included: For Resident #107 the facility failed to provide a therapeutic diet of double portions as ordered by the physician. On 1/9/23 at 3:08 PM, the Ombudsman met with the survey team. The Ombudsman verbalized that Food has consistently been an issue here with poor quality, not enough food and lack of choices. I know they were renegotiating the food contract last spring. On 1/10/23 at approximately 5:35 PM, observations were made of the evening meal. Resident #107 was served the meal in his room. The Resident was not in the room at the time of the observation and the meal tray was left at the bedside on the over bed table. Observations of the meal ticket on the meal tray revealed the following text in the top left corner, NPO NPO [nothing by mouth] [sic] Double Portions. Further down on the ticket the following was noted, .Note: Send Double Portions. The plate was observed and revealed two pieces of meat and a regular serving of creamed potatoes and zucchini. On 1/10/23 at approximately 5:45 PM, CNA C accompanied Surveyor C to the room of Resident #107. CNA C confirmed the meal ticket indicated double portions were to be served. CNA C confirmed that the serving of potatoes and zucchini was the same portion served to all of the other Residents for that meal. CNA C further confirmed that he had distributed multiple trays on the unit and observed multiple plates and portions and knew this was not double servings. Resident #107 was not able to be located on the evening of 1/10/23 for an interview. On 1/10/23 at 5:55 PM, an interview was conducted with Employee F, the cook for the evening meal. Employee F was asked about double portions and what this meant, the cook said, double protein. On 1/10/23 at 6:02 PM, an interview was conducted with Employee E, the dietary aide. Employee E was asked what double portions meant, he said, They don't get 2 of everything, it is just double meat or double vegetable. When asked to clarify, Employee E said it is one or the other [meat or vegetable serving] that is doubled. Employee E went on to say, the ticket is blank in the middle that explains everything so without it we don't know what to put on the plate. On 1/11/23 at 12:09 PM, an interview was conducted with Employee G, the registered dietician (RD). The RD indicated she is currently at the facility 2 days per week and the facility is currently without a dietary manager. When asked about the meal tickets, the RD said, They have not been printing out the actual daily menu, [Employee H name redacted] the Regional is also new and hasn't been doing that. Indicating the meal tickets are not being printed where it details what the staff are to put on each meal tray taking preferences and allergies in consideration and making substitutions. The RD went on to say, As of tomorrow it will start printing the food items. During the above interview the RD was asked about Resident #107's meal ticket and was shown a copy of the meal ticket. The RD looked at the meal ticket and said, I didn't do that one. I will typically do double entree, but double portions is two of everything, you give them 2 meals. On 1/12/23 at 10 AM, an interview was conducted with Resident #107. When asked if he is receiving enough to eat, Resident #107 said, I was getting double portions but I don't get it now. The clinical record review for Resident #107 was conducted. The dietary progress notes didn't reference a double portion diet. The physician orders revealed an active physician order that was entered 6/6/22, that read, Regular diet Level 7 - Easy to Chew texture, Regular Liquids consistency, Double portions. Resident #107's care plan was reviewed without any reference to current diet order. Review of the facility policy titled, Dining and Food Preferences was reviewed. This policy didn't address therapeutic diets being provided. On 1/10/23 during an end of day meeting the facility Administrator was made aware of the above findings. On the morning of 1/11/23, the facility Administrator provided Surveyor C with a copy of Resident #107's meal ticket which had been edited and now read, Note: Double Entree. No additional information was provided prior to the conclusion of the survey. Complaint related deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documentation review, outside record review, and in the course of a complaint investigation, the facility staff failed to maintain a complete and accurate clinical record for two residents, Resident #105 and Resident #111, in a survey sample of 12 residents. The findings include: 1. For Resident #105, the facility staff failed to document events leading up to, and including, the administration of cardiopulmonary resuscitation (CPR) on [DATE]. On [DATE], a closed record review was conducted of Resident #105's clinical record. A progress note dated [DATE] at 09:07 read, NP [Nurse Practitioner, name redacted] notified of Resident's expiration. Per NP, she will notify [MD, name redacted] and at 09:09, Resident's emergency contact/sister [name redacted] notified of Resident's passing . Both progress notes were written by LPN C. Review of the physician orders for Resident #105 revealed an order dated [DATE] that read, Code Status (FULL CODE). There were no documented details within the clinical record with regard to the circumstance of Resident #105's death in the facility, to include clinical assessment, clinical response, and/or clinical interventions that may have been provided. On [DATE] at approximately 10:30 AM, an interview was conducted with the Director of Nursing (DON), the Regional Director of Clinical Services (RDCS), and the Facility Administrator, all of whom confirmed that CPR is expected to be provided for any resident having a Full Code status and documented in the clinical record. Facility policies for CPR and clinical documentation were requested and received. On [DATE] at approximately 2:10 PM, the DON, RDCS, and the Facility Administrator provided 2 written statements from LPN B and LPN C which read, in part, that Resident #105 was assessed, a Code Blue was called, LPN B and LPN C initiated CPR, EMS was called and took over CPR for Resident #105. LPN B's statement read, .if the documentation is not there, the probability is, I did not [document] but I meant too [sic]. LPN B and LPN C were unavailable to interview; phone calls were placed with messages left, however no return call received. On [DATE] at approximately 4:30 PM, a copy of the report from Emergency Medical Services (EMS) was obtained directly from the local EMS department and read, Upon making pt [patient] contact, the pt was found lying supine in his bed with nursing staff doing CPR and their AED [Automatic External Defibrillator device] was attached and Skin: Warm, dry, and of normal color. Review of the facility policy titled, Cardio-Pulmonary Resuscitation (CPR), effective date [DATE], subtitle Procedure, item 6 read, A licensed nurse will document on the Code Blue Documentation form, the condition and circumstance of initiating CPR, the duration and events of the procedure, and outcome of the situation. Review of the facility policy titled, Significant Change of Condition, effective date [DATE], subtitle Procedure, item 11 read, Each change of condition shall be documented in the progress notes . On [DATE] at approximately 10:40 AM, a meeting was conducted with the DON, RDCS, and Facility Administrator, all of whom were updated on the findings. The DON, RDCS, and Facility Administrator confirmed they had reviewed the clinical record for Resident #105 and were concerned about the lack of documentation. No further information was provided. COMPLAINT RELATED DEFICIENCY 2. For Resident #111, the facility staff failed to maintain a complete and accurate clinical record with regards to the events that occurred on the day the Resident expired. On [DATE], a clinical record review was conducted of Resident #111's chart. This review revealed the following nursing note entry from LPN D dated [DATE] at 4:10 AM, Resident noted to be unresponsive during rounds, code called, cpr [cardiopulmonary resuscitation] initiated, 911 called. Upon clarification of code status, cpr immediately stopped. EMS [emergency medical services] arrived, resident pronounced at 0309am. MD and RP made aware. Review of the physician orders revealed that on [DATE], the active physician order read, Code Status full code which was dated [DATE]. Review of the progress notes revealed an entry made by the social worker on [DATE] at 1:04 PM, that read, SW [social worker] spoke with family during admission assessment. RP/family would like to change code status to DNR [do not resuscitate]. MD [medical doctor] and DON [director of nursing] aware of DNR order to be put in place. There was a physician order entered into the clinical record on [DATE] at 05:01 AM, which was after the Resident had been pronounced expired, that read, Code Status DNR. On the afternoon of [DATE], the facility Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) were asked to explain the process with regards to Resident's code status, when CPR is initiated, when CPR can be stopped, etc. The DON and RDCS both explained that upon admission code status/CPR status is discussed and a physician order of their code status is entered into the chart. When CPR is initiated, it cannot be stopped unless a physician is onsite and orders for it to be stopped or the rescue squad have responded and took over CPR, they are able to stop it. They were made aware of the above findings and entries into the clinical record of Resident #111's chart which indicated CPR had been stopped by facility staff prior to the arrival of EMS. They indicated they were not aware of this prior to this conversation with the survey team and would have to look into it. On [DATE] at approximately 2:40 PM, attempts were made by the survey team to reach the facility staff that were involved with Resident #111 on the morning of [DATE]. All efforts were unsuccessful. On the afternoon of [DATE], the survey team was able to access outside records that indicated that CPR was in progress when the rescue squad personnel arrived on-site on the morning of [DATE] at 3:02 AM. The rescue squad personnel/EMS [emergency medical services] staff assessed the Resident and pronounced death at 3:09 AM. On [DATE] at approximately mid-morning, the facility Administrator, Director of Nursing and RDCS met with the survey team and provided a written statement from LPN D who charted on Resident #111 the morning of [DATE]. LPN D indicated in the written statement, .CPR continued until EMS arrived. The written statement and explanation provided by the facility management team indicated that when LPN D went to the nursing station following the EMS arrival and assumption of Resident #111's care, LPN D noted in the admission paperwork which was in the medical records bin a DNR was in the paperwork. The facility Administrator, DON and RDCS confirmed that the clinical record was not complete or accurate with regards to the events that had taken place on the morning of [DATE]. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility's contracted pharmacy failed to provide a physician ordered medication timely for one Resident (Resident #101) a survey sample of 12 Residents. The findings included: For Resident #101, the pharmacy failed to obtain and provide a physician ordered antibiotic resulting in 8 missed doses. Review of the clinical record for Resident #101 revealed that the Resident was admitted to the facility on [DATE]. The discharge orders/physician orders from the hospital discharging physician revealed an order, Fidaxomicin 200 mg Tablet, commonly known as: Dificid. Take 1 tablet by mouth two (2) times a day for 17 doses. Last time this was given: 200 mg on December 21, 2022, at 10:18 AM. Your next dose is: 12/21/22 at 9 PM. A progress note written 12/22/2022 at 12:44 PM, read, Dificid Tablet 200 MG, give 1 tablet by mouth two times a day for c-diff for 17 Administrations Medication on next med run MD/RP [physician and responsible party] aware. Review of the Medication Administration Record (MAR) revealed Resident #101 did not receive her scheduled dose of Dificid on 12/21/22, 12/23/22, 12/24/22, and the morning dose on 12/25/22. The MAR was signed off for the evening dose of 12/22/22, however the medication had not been delivered to the facility at this time and the Resident not in the facility during this scheduled dose. There were multiple progress notes entered into the clinical record of Resident #101 on 12/24/22, that indicated the Dificid was not available to give. Review of the on-site Omnicell [medication dispensing machine/emergency medication supply] revealed that Dificid was not available on-site for staff to administer. On the morning of 1/9/23, the facility Administrator reported to the survey team that initially the Resident expressed a desire to leave the facility and therefore they waited until they knew she was going to stay at the facility to have the Dificid delivered. The Administrator went on to say that the pharmacy had notified the facility the Dificid was an expensive medication and needed permission before filling the physician order/script for Dificid. The facility Administrator further explained that as soon as he saw the pharmacy notification, he authorized for the medication to be dispensed. The administrator provided the survey team with a copy of the emails which indicated that on 12/23/22 at 2:39 PM, the pharmacy emailed the facility staff indicating the Dificid was a High-Cost Medication and would cost $4,622.16. On 12/24/22 at 10:40 AM, the facility Administrator responded to the email with Please send. Thanks. On 1/11/23, in the afternoon, the Regional Director of Clinical Services indicated it was the facility's contracted pharmacy's responsibility to call the back-up pharmacy to obtain medications if they were not able to fill a physician order. The facility policy titled; unavailable medications was reviewed. This policy read, Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident. The above referenced policy continued to read, Procedure: The pharmacy staff shall: 1. Notify nursing staff that the order product(s) is/are unavailable. 2. Notify nursing staff of when it is anticipated that the drug(s) will become available. 3. Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available. The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for non-available medication. 3. Notify the pharmacy of the replacement order. The pharmacy contract between the facility and the pharmacy was reviewed. An excerpt from this contract on page 3 read, .(c) The Pharmacy shall deliver Medications and provide services to the Facility seven (7) days a week, three-hundred sixty-five (365) days a year, with modified schedules on national holidays based on a daily delivery schedule mutually determined by the Facility and the Pharmacy. Emergency delivery of Medications shall be done by the Pharmacy during normal business hours, except for circumstances beyond the Pharmacy's reasonable control, and emergency services shall be available after hours through an answering service with a pharmacist on-call. (i) The Pharmacy shall establish an emergency system for backup and/or interim order dispensing. Any emergency drug supply provided under this Section shall be the property of the Pharmacy as prescribed by Applicable Laws . The facility Administrator and Director of nursing were made aware of the findings. No further information was provided. Complaint related deficiency.

Based on staff interview, facility documentation review, and clinical record review, and in the course of a complaint investigation, the facility staff failed to notify the Resident Representative of a change in condition and room changes for one Resident (Resident #305) in a survey sample of 58 Residents. The findings included: 1. For Resident #305, the facility staff failed to notify the family of two room changes and didn't notify the family of a new diagnosis of COVID-19 until two days later. On 4/24/22 and 4/25/22, a closed record review was conducted. This review revealed that on 12/8/21, Resident #305 tested positive for COVID-19. Review of the census tab of the chart revealed that Resident #305 had a room change on the same day. There was an additional room change noted on the census part of the chart that took place on 12/23/21. The nursing notes revealed an entry dated 12/8/21, that didn't mention the positive COVID test, nor the room change. An entry dated 12/10/21 at 10:59 AM, read, RP [responsible party] notified [Resident #305's name redacted] have [sic] positive covid test on 12/8/2021 and updated of facility Covid update. There was no mention of the room change. There were no other entries in the clinical record to indicate the Resident and/or responsible party were notified of either of the room changes. On 4/26/22 at 4:31 PM, the Director of Nursing (DON) was interviewed. When asked about the process of notification when a Resident tests positive for COVID-19, the DON said, Nursing and staff will talk to the Resident and family and it is documented in the progress notes by the unit manager. On 4/26/22 at 4:42 PM, an interview was conducted with LPN C, the unit manager and author of the progress note dated 12/10/21. LPN C confirmed that her note was a follow-up and she was unable to say when the family was actually notified of the positive COVID test for Resident #305. On 4/27/22 at 2:22 PM, an interview was conducted with Employee J, the social worker. Employee J confirmed that he handles the Resident and family notifications regarding room changes. When asked if this is documented, he stated yes, there is a form in the misc. tab of the chart. Employee J then accessed the electronic health record for Resident #305 and confirmed 2 room changes had taken place. When asked to provide evidence that the Resident and/or family were made aware, he said, during this time people were getting moved a lot due to COVID. The social worker was asked if he made notifications during this time period and he said, Yes, but I can't find the paperwork for it right now. Review of the facility policy titled, Significant Change in Condition with an effective date of 11/01/19, read, .4. Responsible Party will also be notified of a change in condition .9. Notification of responsible party shall be documented in the progress notes including time and name of person informed. Review of the facility policy titled, Room Changes was performed. This policy read, .3. The Discharge Planner will notify the patient and the roommate of the room change and the reason for the change .7. Using the Discharge Planning Progress Note, document: Room patient moved from, Room patient moved into, Date room change occurred, Confirmation that the MFA Room change notification form was completed and a copy was delivered to the patient/RP. 8. Upon completion of the MFA Room Change Notification, scan and upload the document into the patient's electronic medical record. This document should be scanned into the Misc tab and filed under the MFA Room Change Notification category. On 4/27/22 at 5 PM, the facility Administrator, Director of Nursing and Corporate staff, were made aware of the above findings. No further information was provided. Complaint related deficiency.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #133) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #133, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #133 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill. The findings included: Resident #133 was discharged from a Medicare covered Part A stay on 2/13/22, he remained in the facility. Review of the clinical record revealed the facility staff/social worker issued a NOMNC (notice of Medicare non-coverage) which noted, Resident #133's RP was notified of the notice and appeal rights on 2/11/22. The clinical record revealed no evidence of an ABN being issued. The progress notes made no reference to the NOMNC or ABN. On 04/26/22 at 9:38 AM, an interview was conducted with the facility Social Worker/Employee J. The Social Worker stated the NOMNC is when we issue a last covered day to let them know when they will be liable. The ABN is when they don't plan on leaving to let know how much the rate would be and they are ok with that rate. When asked if an ABN is issued to everyone who stays in the facility, the social worker said, Not necessarily, it is a statement of what the rate will be if they don't discharge, if they will be paying privately. During the above interview, the social worker accessed the clinical record for Resident #133 and confirmed that the NOMNC was present but he did not see an ABN, he further confirmed that he did not have an ABN for Resident #133 that was not scanned into the electronic health record. On 4/26/22 at 9:51 AM, the facility Administrator was made aware of the findings. She stated she could reach out to the previous business office manager to see if she had something. When asked if she would expect it to be in the clinical record since the NOMNC was, she stated that she was unsure. The Administrator stated, When they are cut from insurance they should get both notices. The facility policy was requested. A review of the facility policy titled, Advance Beneficiary Notice, was conducted. It read, The Advanced Beneficiary notice is to be used to comply with federal guidelines for notifying a beneficiary or the responsible party the care the patient is receiving will not be covered by Medicare B. CMS identifies when the ABN is required to be issued in their document titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) read, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: Not medically reasonable and necessary; or Considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Accessed online at: https://www.cms.gov/search/cms?keys=ABN The Administrator was informed on 4/25/22 at 9:51 AM, of the failure of facility staff to provide Resident #133 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #133, to make a decision about continuation of services and have Medicare make the coverage determination. On 4/27/22, during an end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware of the above concern. No further information was provided prior to survey exit.

Based on observations, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise care plans for unplanned weight loss for Two Residents (Resident #105, and #110 ) in a survey sample of 58 Residents. 1. For Resident #105, the facility failed to specifically care plan Resident centered weight loss interventions. 2. For Resident #110, the facility staff failed to care plan weight loss interventions recommended by dietary, and failed to specifically care plan Resident centered weight loss interventions. Findings include: 1. Resident #105's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3-24-22, was a quarterly assessment. The document revealed the Resident had minimal cognitive impairment and further documented the Resident was on a Therapeutic Diet, and had no weight loss. The Resident was independent in eating, and required no assistance. The Resident's weight record was reviewed and revealed the following; 12-18-21 - 165.1 lbs standing 3-10-22 - 156.6 lbs standing This revealed no monthly weight taken for January and February 2022, and a greater than 5% weight loss of 8.75 lbs in less than 3 months. Review of the Resident's care plan revealed the following; Focus: created 12-20-21 Nutrition risk on admission. Goal: created 12-20-21, revised 3-30-22, resolved 12-20-21 Will avoid significant weight change through next review. No interventions were planned for this focus, and the resident's weight loss was found after the goal resolved date. Focus: created 12-20-21 Nutrition Risk related to recent hospitalization, therapeutic diet related to insulin dependent diabetes mellitus, history of hyponatremia (low sodium) respiratory failure and hypertension. Interventions: all created 12-20-21 Labs as ordered, Provide,serve diet as ordered, monitor intake and record every meal, RD (Registered Dietician) to evaluate and make diet change recommendations as needed, weekly weights related to admission, created 4-11-22 (after weight loss) Monthly weights, No therapeutic Diet was ever ordered, and weekly weights were never obtained. Monthly weights were not obtained for January, and February 2022. No RD evaluation was found in the clinical record. On 4-15-22 a doctor's order was received for Ensure Plus once in the evening as a supplement, and Med plus 2.0 twice per day as a supplement, over a month after the Resident's weight loss was known. These interventions were not documented on the Resident's care plan for nursing staff to provide. On 4-26-22, and 4-27-22 at 5:00 PM, the Director of Nursing (DON), Regional RN, and Administrator were made aware of the issues with Resident #105's care plan. 2. Resident #110's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4-20-22, was a quarterly assessment. The document revealed the Resident had moderate cognitive impairment and further documented the Resident was on a Mechanically altered Diet. The Resident required feeding, and was documented as having no weight loss. The Resident's weight record was reviewed and revealed the following; 1-1-22 - 143.5 lbs via mechanical lift 3-11-22 - 130.0 via mechanical lift This revealed no monthly weight obtained for February 2022, and a greater than 7.5% significant weight loss of 13.5 lbs in 2 months and 10 days. Review of the Resident's care plan revealed the following; Focus: dated 2-13-18, revised 3-23-21, Nutrition risk related to advanced parkinson's disease failure to thrive, mechanically altered diet provided for ease of chewing and swallowing, and history of dysphagia. Goal: created 3-26-21, revised 3-30-22, Resident will avoid significant weight change through next review. Interventions: all were created on 3-23-21, with no new additions on 3-30-22 monitor and report signs of dysphagia (pocketing, choking, coughing, drooling, difficulty swallowing, refusing to eat, appears concerned during meals., monthly weights, provide and serve supplements as ordered, provide and serve diet as ordered, monitor intake and record every meal, RD (registered dietician) to evaluate and make recommendations as needed, staff assistance with feeding. Review of physician orders revealed the following: 2-26-20 regular diet easy to chew (mechanical soft) with mildly thick liquids. 6-29-21 Ensure plus supplement one time per day. No special diet, thickened liquids, nor supplements were documented on the care plan for nursing to provide. On 4-26-22, and 4-27-22 at 5:00 PM, the Director of Nursing (DON), and Administrator were made aware of the issues with Resident #110's significant care plan.

Based on staff interviews, record review, and in the course of a complaint investigation the facility staff failed to provide activities of daily living care to one resident, Resident #1400, in a sample of 17 residents. The findings included: Resident #1400 was a closed record review. On 06/08/22 at approximately 9:22 a.m., an interview was conducted with Staff L. Staff L stated that the point-of-care system (POC) was used to track whether or not residents receive a bath. On 06/08/22 at approximately 12 p.m., review of POC documentation showed that Resident #1400 did not receive a bath between the dates of 04/12/22 - to - 04/18/22. Per POC documentation the first bath Resident #1400 received was on 04/19/22. The Administrator and Regional consultants made aware on 06/08/22 at approximately 1:00 p.m. and stated that they have no other findings to submit. Complaint deficiency

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary care and treatment as ordered by the physician to promote healing of a pressure wound for one Resident (Resident #28) in a sample size of 58 Residents. Specifically, the facility staff failed to: 1) Administer pressure wound treatments on 03/18/22, 03/19/22, 03/22/22, 03/24/22, 03/25/22, 03/28/22, 04/10/22, and 04/22/22 as ordered by the physician. 2) Apply an air mattress as ordered by the provider. The findings included: On 04/24/2022 at approximately 2:10 P.M., Resident #28 was observed in bed. Resident #28 was not on an air mattress. When asked about wounds and wound care, Resident #28 indicated that he had one wound on his right buttock and the dressing changes weren't being done consistently. On 04/24/2022 at approximately 2:20 P.M., this surveyor and Licensed Practical Nurse F (LPN F) entered Resident #28's room for an observation. LPN F assisted Resident #28 to reposition. The dressing on the right buttock was dated 04/22/22. On 04/24/2022 and 04/25/2022, Resident #28's clinical record was reviewed. An active physician's order with a revision date of 03/28/22 documented, Right Buttock: clean with wound cleanser, apply honey fiber, cover with bordered foam every day shift for pressure ulcer. A review of the Treatment Administration Record for March 2022 and April 2022 revealed that this wound care was not signed off as administered on 03/18/22, 03/19/22, 03/22/22, 03/24/22, 03/25/22, 03/28/22, 04/10/22, and 04/22/22. There were no orders for an air mattress. A review of the Wound Care Nurse Practitioner note dated 02/03/2022 revealed that Resident #28 was admitted with a Stage 3 pressure wound to the right buttock. Under the sub-header entitled, Pressure Reduction/Offloading it was documented, Ensure compliance with turning protocol, specialty bed. On 04/26/2022 at approximately 3:00 P.M., Resident #28 was observed in bed. Resident #28 was not on an air mattress. On 04/26/2022 at approximately 3:15 P.M., the Wound Care Nurse Practitioner was interviewed. When asked to define specialty bed, the Wound Care Nurse Practitioner stated that [Resident #28] was admitted with a Stage 3 wound so I recommended an air mattress. On 04/26/2022 at approximately 4:00 P.M., the physician's orders were reviewed. A physician's order dated 04/26/2022 documented, Air Mattress: Monitor settings every shift for Wounds. This was 83 days after the Wound Care Nurse Practitioner recommended the air mattress for Resident #28. On 04/26/2022 at approximately 5:15 P.M., the administrator and Director of Nursing were notified of findings. The facility staff provided a copy of their policy entitled, Wound Care. Under the header Policy, it was documented, A licensed nurse will provide wound care/dressing change(s) as ordered by physician. On 04/27/2022 by the end of survey, no further information was submitted.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy as ordered by the physician for 1 Resident, Resident #118, in a survey sample of 58 Residents. The findings included: For Resident #118, facility staff failed to change the oxygen tubing weekly as ordered. During initial tour on 4/24/22 at approximately 1:30 PM, Resident #118 was observed with oxygen being administered via nasal cannula at 2 liters per minute as ordered by the physician. The date on the oxygen tubing was 4/4/22. Resident #118 stated, it has been several weeks since anyone has changed my tubing. These findings were shared with the Facility Administrator and the Corporate Clinical Nurse at the End of Day Conference at approximately 5:30 PM on 4/24/22. The facility's policy for the maintenance of oxygen equipment was requested and received. Review of Resident #118's clinical record revealed a physician's order dated 1/17/2022 that read, Oxygen tubing change weekly (11-7) .every night shift every Monday. Review of the facility's policy entitled, Respiratory/Oxygen Equipment, effective date 11/01/19, heading Policy, read, Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per physician's order and in accordance with standards of practice and subheading, Oxygen Therapy via Nasal Cannula, Simple Mask, Venturi Mask, and Oximizer, item 6, Nasal cannulas, Simple masks, Venturi mask, and Oximizer must be changed every week, dated, and initialed. On 4/27/22 at approximately 10:30 AM, Resident #118 was interviewed and stated, They [nursing staff] finally changed the tubing for my oxygen yesterday. The label on the oxygen tubing was dated 4/26/22 [Wednesday]. The Facility Administrator and Director of Nursing were updated on the additional findings at the End of Day Conference on 4/27/22. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to label and store medications in accordance with currently accepted professional standards for 2 medication carts (Cart (1,2) and Cart (2,3) out of 9 medication carts. The findings included: On 04/27/2022 at 11:30 A.M., Surveyor C reviewed the contents of Med Cart (2, 3) on the [NAME] Wing with Licensed Practical Nurse J. The following medications were opened and not dated: 1. Active liquid protein - two 32 ounce bottles 2. Robitussin - one 16 ounce bottle 3. Lidocaine viscous 2% solution 4. Miralax 8.3 Oz 5. Senna 237 milliliters 6. Megace suspension 16 fluid ounces On 04/27/2022 at approximately 12:00 P.M., Surveyor E reviewed the contents of Med Cart (2, 3) on the [NAME] Wing with LPN F. An inhalant for Resident #259 (Mometasone 50 mcg [micrograms]/act) was housed in a medication bottle labeled with Resident #258's name on it for Humalog 100 unit/10ml [milliliters]. Upon surveyor pointing out discrepancy, LPN F stated I don't know how that got there. According to the publication dated 06/18/2020 in U.S. Pharmacist(1), an article entitled Medication Management under the sub-header Proper Medication Storage an excerpt documented, .multidose vials must be labeled to prevent them from being used beyond the expiration date. Under the sub-header entitled, The Five Rights, an excerpt documented, Nurses cannot confirm that a specific tablet or vial is the correct drug or that the strength and dosage are correct. However, they are accountable for reading the label . On 04/27/2022 at approximately 5:00 P.M., the administrator and Director of Nursing were notified of findings. (1) U.S. Pharmacist is a monthly journal dedicated to providing the nation's pharmacists with up-to-date, authoritative, peer-reviewed clinical articles relevant to contemporary pharmacy practice in a variety of settings, including community pharmacy, hospitals, managed care systems, ambulatory care clinics, home care organizations, long-term care facilities, industry, and [NAME].

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed, for 2 Residents (Resident #105, and #110) in the survey sample of 58 residents, to provide follow preferences and/or drinks for hydration. The Findings included: 1. For Resident #105, the facility staff failed follow the resident's preference for a water pitcher so that he could consume water at will. Resident #105's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3-24-22, was a quarterly assessment. The document revealed the Resident had minimal cognitive impairment and, was independent in eating, and required no assistance. On 4-24-22 at 12:20 P.M., an interview was conducted with Resident #105. His lunch tray had not been delivered, and he stated that his food was always late. He asked if the surveyor would bring him a drink of water, and stated he was thirsty. His room mate was sitting in a wheel chair between the foot of the two beds, and the two were watching television together. Both Residents were found to be oriented to person, place, time and situation. Both Resident's stated that Resident #105 had recently been moved into the room stating 4-5-days ago, and agreed that Resident #105 had not been given a water pitcher, and stated it had been left in Resident #105's old room. The room mate had a water pitcher on his over bed table. Resident #105 stated I have to ask for water every day, and they just bring me a cup full. I want my pitcher but they don't give me one. Review of the Resident's care plan revealed the following; Focus: created 12-20-21, revised 1-3-22. The Resident has dehydration risk. Goal: created 12-20-21, revised 3-30-22. The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: all created 1-03-22. Administer diuretic as ordered, encourage resident to drink fluids of choice as needed, Lab work as ordered, monitor document signs of dehydration (signs of dehydration). On 4-26-22, and 4-27-22 at 5:00 PM, the Director of Nursing (DON), Regional RN, and Administrator were made aware of the issues with Resident #105's lack of water pitcher and available water. The DON and Administrator were asked what their expectation was, and it was collectively stated that the Resident should have a water pitcher at bedside They stated they had nothing further to provide. 2. For Resident #110, the facility staff failed to provide the ordered form of hydration in addition to water. Resident #110's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4-20-22, was a quarterly assessment. The document revealed the Resident had moderate cognitive impairment and further documented the Resident was on a Mechanically altered Diet. The Resident required feeding. Review of the Resident's care plan revealed the following; Focus: dated 6-19-20, revised 3-30-22, The resident has dehydration or potential fluid deficit related to diet/beverage consistency. Goal: created 6-19-20, revised 3-30-22, The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: all were created on 6-28-18, with no new additions on 6-19-20, and 3-30-22. Encourage the resident to drink fluids of choice (specify frequency) the resident prefers the following fluids:ginger ale, cranberry juice, tea, ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements, offer fluids during various times of day. No thickened liquids, nor supplements were documented on the care plan for nursing to provide. Review of physician orders revealed the following: 2-26-20 regular diet easy to chew (mechanical soft) with mildly thick liquids. 6-29-21 Ensure plus supplement one time per day. During initial tour of the facility on 4-24-22 Resident #110 was in bed and asleep. The Resident's meal tray was on the over bed table, untouched, and cold. The drinks on the tray were thin liquids with no thickening, and no supplements were on the tray. This situation was observed for 30 minutes, as the CNAs continued to open, prepare, and pass out the trays, one resident at a time. At 2:00 p.m., Resident #110's room was again observed with no change. The tray was still on the overbed table untouched, and the Resident was sleeping. The CNA on the hall was asked when the Resident would be fed, and she stated as soon as all of the trays are passed we will feed the feeders. At 2:30 p.m. Resident #110's room was entered and the tray was gone. The surveyor went to the cart in the hall and found the tray back in the cart untouched. A different CNA was on the hall removing trays and was asked why Resident #110 didn't eat, and she stated I don't know she was not my feeder. On 4-26-22, and 4-27-22 at 5:00 PM, the Director of Nursing (DON), and Administrator were made aware of the issues with Resident #110. They stated they had nothing further to provide.

Based on observation, staff interviews, and facility documentation review the facility staff failed serve food in a sanitary manner for two out of six kitchen employees observed in the kitchen over the course of the survey. The findings included: On 04/24/22 at approximately 12:18 p.m. during the initial dining observation observed one out three dietary staff members - Staff O was observed eating at the steam table in the kitchen. Staff O threw food into air and caught the food with his/her mouth. As well, Staff O was not wearing a facial mask at the steam table, nor was Staff O wearing a hair net. On 4/26/22 at approximately 1:30 p.m. Staff N was noted to wear face mask incorrectly while carrying out duties in the kitchen at the steam tables. Staff N's mask was worn in such a manner that the staff member's nose was not covered by the mask. An interview with Staff L at approximately 1:35 p.m., was conducted Staff L stated the staff are to wear facial mask that cover the nose and mouth in the kitchen. As well, Staff L states staff are to wear hair nets at all times while in the kitchen. In review of the facility's COVID-19 policy, dated 2/11/22, on page 28, section 11 an excerpt documented prevention include but not limited to universal source control - employee will wear a face mask while at work. Section 13, of the same policy states face covering or mask covering mouth and nose. The Administrator and Director of Nursing were notified of findings on 4/27/22 at approximately 2 p.m. and stated they had no other findings to submit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one Resident, Resident #154, in a survey sample of 58 Residents. The findings included: For Resident #154, the facility staff failed to maintain an accurate and complete clinical record, indicating the events and actions that occurred on [DATE], to include CPR (cardio pulmonary resuscitation) being performed. On [DATE] and [DATE], a closed record review was conducted of Resident #154's clinical record. This review revealed that Resident #154 had expired at the facility. The progress notes had the following entries: 1. [DATE] at 2:27 PM, Resident pronounced deceased at 1:41 [PM] via emergency personnel. [Family members of Resident #154's names redacted] both informed via phone. Awaiting family to give funeral home arrangements. UM [unit manager] and [Nurse Practitioner's name redacted] NP aware. 2. [DATE] at 5:11 PM, Resident was picked up by [funeral home name redacted] funeral home at 5: 00 PM, [street address of funeral home redacted] Resident family aware. Review of the physician orders for Resident #154 were reviewed and revealed an order dated [DATE], that read, Code Status (FULL CODE). The entire clinical record was reviewed without any evidence of the details of Resident #154's condition, a nurse assessment, when 911 was called, what the facility staff's response was, etc. There were no details surrounding the events that occurred that day. On [DATE] at 8:00 AM, Surveyor F spoke with LPN D, the author of the progress note written on [DATE] at 2:27 PM. LPN D was asked to recall the events regarding Resident #154 on [DATE]. LPN D stated, she had stepped out of the facility on her meal break, upon her return the Fire Department was going into the facility and when she entered she found out it was her patient. She remembered Resident #154 had complained of pain earlier that day and she had given Tylenol and the nurse practitioner was in the building and was going to see him. LPN D said she saw the emergency medical staff performing CPR and observed the facility nurses outside of the room. LPN D was able to recall that she saw a crash cart and equipment in the room which indicated the facility staff had initiated CPR. On [DATE] at 10:05 AM, an interview was conducted with LPN C, the unit manager. LPN C was able to recall the following events regarding Resident #154. She said, A code was called, he was unresponsive when they went in, started CPR, 911 was called, the fire department came, they continued CPR on him. When asked what she would expect to see charted in the clinical record with regards to the events that day she said, From the time he was found unresponsive, their assessment, vital signs, when the code was called, when 911 was called, everything from the beginning to the end. LPN C reviewed Resident #154's clinical record and was asked what she saw. LPN C said, I see that he was pronounced and that his RP [responsible party] was informed, it says unit manager and nurse practitioner made aware. I don't see any details about the events. When asked why it is important to document such events, LPN C said, Because if it is not documented, you can't prove it was done, the situation or what caused it. LPN C confirmed that she agreed that the clinical record for Resident #154 is incomplete. On [DATE] at 2:15 PM, an interview was conducted with LPN B. LPN B was asked if she recalled Resident #154 and the events that occurred on [DATE]. LPN B said, I remember, he is the guy we did CPR on. I wasn't here but when I came back they told me. LPN B accessed Resident #154's clinical record and read the progress notes. LPN B confirmed that she saw no documentation of the events or actions taken on the day of [DATE]. LPN B said, I would put a note of exactly what was done, CPR, 911 called, etc. On [DATE] at 3:06 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked what she expects to be charted when CPR is performed in the facility. The DON said, So after the code is called, what should happen is the charge nurse should document what steps were taken, if EMS (Emergency medical services) came in, if pronounced . The DON reviewed Resident #154's chart and said No, it's definitely not complete. On [DATE], a copy of the report from the Emergency Medical Responders was received and reviewed. This document did reveal that the facility staff were performing CPR at the time they arrived. A review of the policy titled Significant Change of Condition was reviewed. This policy read, .11. Each change of condition shall be documented in the progress notes . On [DATE], during an end of day meeting, the facility Administrator, DON, and corporate staff were made aware of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to conduct COVID-19 testing in accordance with the CDC recommendations for 15 facility staff and two Residents (Resident #11 and #104) in a survey sample of 58 Residents. The findings included: 1. The facility staff failed to conduct routine testing of facility staff who were not fully vaccinated for COVID-19. On [DATE], during the entrance conference, the facility staff was provided a copy of the entrance conference worksheet and asked to submit documentation related to COVID-19 testing, to include the facility's testing plan, log of the level of community transmission, and if there were any testing issues and contact with the local and state health departments with regards to testing issues. On [DATE], the facility submitted an employee vaccination matrix and employee testing records for [DATE], [DATE], and the month of [DATE]. During the survey, the employee vaccination matrix was noted to not be accurate. Surveyor F identified 31 employees who were working during the survey, that were not listed on the staff vaccination matrix. During further review, Employee E and Employee T only had evidence of receiving one dose of a multi-dose primary vaccination for COVID-19 and 13 employees whose vaccination status was unknown. On [DATE] at 3:30 PM, the facility submitted the log of the level of community transmission. Review of this document revealed that the facility was checking this level every other week and for the time period of Jan. 14, 2022-[DATE], the facility should be testing staff who are not up to date [current with primary COVID-19 vaccination and booster doses] should be tested twice weekly. On [DATE], [DATE], and [DATE], conversations were held with the facility Administration to include but not limited to the facility Administrator, Infection Preventionist, Regional Director of Operations and the Corporate Clinical Consultant, and at no point did any of them mention or submit any evidence of any difficulty with testing or obtaining COVID-19 testing, to be considered by the survey team. On [DATE] at 10:11 AM, a video conference/interview was conducted with Employee C, the infection preventionist. Employee C was asked to identify all testing dates of COVID testing in 2022. He listed the following dates for January and February: [DATE], [DATE], [DATE], and [DATE]. Employee C stated, We did no routine testing in January or February, only outbreak testing. Employee C was asked if he was sure there were not testing records kept by another party or located somewhere else and he confirmed, he was sure this was all of the testing performed in Jan and Feb. During the above conversation, Employee C said, in January we were using a lot of the test that had expired that they extended the time we could use them and we had to wait for VDH [Virginia Department of Health] to send more tests, no one had any tests. Employee C was asked if he had evidence of where he had reached out the health department and/or tried to order test kits during this period. He said, Yes, and was asked to submit evidence of this, as well as the details of COVID testing for the two occurrences in January and the two occurrences in February. None of the items requested from Employee C were received prior to the end of the survey. The facility was unable to submit evidence that Employee E and Employee T, and the 13 employees whose vaccination status was unknown had submitted to routine testing during January and February. A review of the facility policy titled, COVID-19 with an effective date of [DATE], was conducted. This policy read, .The center will follow CDC guidelines .13. d.Patient and Employee testing conducted as required. No details were noted within the policy with regards to routine testing. A review of the CMS (Centers for Medicare and Medicaid Services) QSO Memo 20-38-NH, with a revision date of [DATE], which was in effect at the time, was conducted. This memo stated, Unvaccinated refers to a person who does not fit the definition of fully vaccinated, including people whose vaccination status is not known, for the purposes of this guidance To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. Facilities can meet the testing requirements through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory. POC Testing is diagnostic testing that is performed at or near the site of resident care .Facilities without the ability to conduct COVID-19 POC testing should have arrangements with a laboratory to conduct tests to meet these requirements. Laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) should be selected to rapidly inform infection prevention initiatives to prevent and limit transmission. The CMS memo went on to read, The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table based on the county positivity rate reported in the past week. Facilities should monitor their county positivity rate every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table above .The guidance above represents the minimum testing expected. Facilities may consider other factors, such as the positivity rate in an adjacent (i.e., neighboring) county to test at a frequency that is higher than required. On [DATE], during an end of day meeting, the facility Administrator and Director of Nursing were made aware of concerns with regards to COVID testing. No further information was submitted prior to the end of survey. 2. The facility staff failed to conduct Resident COVID testing following a known exposure for two Residents (Residents #11 and #104). On [DATE] at 4:31 PM, an interview was conducted with the Director of Nursing (DON). The DON said, Resident testing is documented in [electronic health record name redacted]. When asked about what kind of testing is conducted in the event they have a positive COVID case identified, the DON said, initially VDH [Virginia Department of Health] said we could do contact tracing if it was 1 person, other than that we do broad based testing. On [DATE], a review was conducted of the facility submitted log of COVID infections. This listing revealed that on [DATE], Resident #139 tested positive for COVID-19. Review of the facility census for that day, revealed Resident #11 and Resident #104, were roommates of Resident #139. Review of the clinical record for Resident #11 revealed he was tested for COVID-19 on [DATE]. The next instance of him being tested for COVID-19 was [DATE]. Review of the clinical record for Resident #104 revealed he was tested for COVID-19 on [DATE]. The next instance of him being tested for COVID-19 was on [DATE]. On [DATE] at 10:11 AM, an interview was conducted with Employee C, the infection preventionist. Employee C stated that for the entire year of 2022 broad based testing was performed after each identification of a new COVID case within the facility. He stated that no contact tracing was performed. Employee C confirmed that all COVID testing for Residents is documented in the electronic health record, he doesn't maintain a listing of which Residents were tested on occurrences of testing. A review of the facility policy titled, COVID-19 was conducted. This policy read, It is the policy of the Center to establish standards of practice for prevention of Coronavirus Disease 2019 (COVID-19) and to control activities to protect employees and patients .The Center will follow CDC guidelines. The CDC (Centers for Disease Control and Prevention) gives the following guidance regarding testing of new admissions, in their document titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes: Nursing Homes & Long-Term Care Facilities. Updated Feb. 2, 2022. This guidance read, . Asymptomatic residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but generally not earlier than 24 hours after the exposure) and, if negative, again 5-7 days after the exposure. Accessed online [DATE], at website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031062858 On [DATE], during an end of day meeting, the facility Administrator and Director of Nursing were made aware of concerns with regards to COVID-19 testing within the facility. No additional information was received prior to the conclusion of the survey.

Based on staff interview and facility documentation review, the facility staff failed to 1) have an accurate system to track the immunization status of all facility employees, and 2) failed to ensure 100% of facility staff were vaccinated, the facility vaccination rate was 92.9%. 1. The facility failed to include all staff members on the vaccination tracking, therefore rendering it as incomplete. 2. The facility staff vaccination rate for COVID-19 was 92.9%. The findings included: 1. The facility failed to include all staff members on the vaccination tracking, therefore rendering it as incomplete. On 4/24/22, at approximately 11:30 AM, during an entrance conference held with the facility's corporate clinical nurse, the facility's staff vaccination matrix was requested. On 4/25/22 at 10:25 AM, the facility staff submitted a staff vaccination matrix. Review of this matrix revealed 181 facility staff members were listed. A review was then conducted by Surveyor F, using the as worked schedule for 4/24 and 4/25, as well as the facility submitted key personnel listing. This review revealed 31 employees that were working during the survey period, that were not listed on the staff vaccination matrix. On 4/25/22 at 2:03 PM, an interview was conducted with Employee C, the facility infection preventionist. Employee C confirmed that he is responsible for the staff vaccination tracking. Employee C was given several of the employees Surveyor F noted to not be on the staff vaccination tracking log. Employee C confirmed that he was not able to find them on the listing either and agreed that the log was incomplete/inaccurate. On 4/25/22 at 4:06 PM, an interview was conducted with the facility Administrator. The Administrator was advised that upon the survey team's entry, the corporate clinical nurse had reported that the Administrator and Infection Preventionist oversee the COVID vaccination program within the facility. The administrator was asked to explain her role. The Administrator stated, [IP name redacted] makes sure we have each employee's card and I check to make sure he and HR [human resources] have it. He maintains the cards and he can pull them from the VIIS [Virginia Immunization Information System] system and he prints and keeps a copy and puts them on the line listing [staff vaccination matrix]. I am just the checker. On 4/26/22, Employee C, the infection preventionist confirmed that the staff vaccination log is used to report to NHSN (National Healthcare Safety Network) and its accuracy is important so that accurate information is reported. Review of the facility policy titled, COVID-19 Vaccination Policy, was reviewed. This policy read, .9. Proof of full COVID-19 vaccination should be maintained for all employees in their personnel file. The center will track and securely document each staff member's vaccination status including exemptions. On 4/25/22, the facility Administrator and Corporate Clinical Consultant were notified of the staff vaccination matrix missing multiple employees. No further information was provided. 2. The facility staff vaccination rate for COVID-19 was 92.9%. On 4/24/22, at approximately 11:30 AM, during an entrance conference held with the facility's corporate clinical nurse, the facility's staff vaccination matrix was requested. On 4/25/22 at 10:25 AM, the facility staff submitted a staff vaccination matrix. Review of this matrix revealed 181 facility staff members were listed. A review was then conducted using the as worked schedule for 4/24 and 4/25, as well as the facility submitted key personnel listing. This review revealed 31 employees were noted as active employees, working during the survey period, that were not listed on the staff vaccination matrix. These 31 employees were added to the 181 employees listed on the staff vaccination matrix making the total number of staff 212. On 4/25/22 at 4:32 PM, a video call was held with Employee C. Employee C was given the list of 31 employees and only had evidence of COVID vaccination status for 5 of the 31 employees. Employee C confirmed that if he looks up an employee's immunizations on the VIIS system, he doesn't maintain a record or copy of this. On 4/25/22 at approximately 5:10 PM, a video call was held with Employee C and Employee D, the Human Resources (HR) Manager. The HR manager was given the list of remaining 26 employees. The HR manager had copies of 6 employee's vaccination cards. However, for 2 of the employees (Employee E and Employee T) their card only revealed evidence of having received 1 dose of a multi-dose vaccination series. Employee E had dose 1 of Moderna on 1/14/22 and Employee T, had dose 1 of Pfizer on 2/13/22. Therefore, both were eligible for the second dose to complete their primary vaccination series for COVID-19. On 4/26/22, the facility staff submitted vaccination cards for 7 employees that had been identified as not being on the staff vaccination matrix. Therefore, 13 employees vaccination status remained unknown, with no supporting evidence of any vaccinations. On 4/26/22 at 3:06 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked how she knows the vaccination status of staff. She said, My IP [infection preventionist] guy is supposed to get their information and file it and HR [human resources] deals with him with that as well. The 13 employees whose vaccination status was unknown and the 2 employees (Employee E and Employee T) that had only 1 dose of a multi-dose series, were considered as not having completed the primary vaccination series for COVID-19. This made the facility have only 197 staff members who had completed the primary vaccination series. The staff vaccination rate of the facility employees was calculated to be 92.9%. Review of the facility policy titled, COVID-19 Vaccination Policy was conducted. This policy read, 1. This mandatory COVID-19 vaccination policy applies to all facility staff, regardless of clinical responsibility and resident contact .3. Contracted workers (including but not limited to agency, travelers, students, and vendors) are also required to have received the full vaccine 9. Proof of full COVID-19 vaccination should be maintained for all employees in their personnel file. The center will track and securely document each staff member's vaccination status including exemptions. On 4/27/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the findings. No further information was submitted prior to the survey team's exit.

Based on Resident interview, staff interview, facility documentation review, the facility staff failed to respond to Resident Council grievances. The findings included: The Resident Council President gave permission on 4-24-22 for surveyors to review the Resident Council minutes for the last 3 months prior to a meeting with the Council, planned for 4-25-22. Resident Council minutes were reviewed from January 2022 through March 2022. The minutes revealed ongoing concerns and complaints regarding: late food delivery and comes cold, quality and quantity of meals served, water and ice not being passed, call bells not answered timely, short staffing and agency staffing, and lack of care during the night shift. These concerns persisted over the course of the 3 months reviewed, and during the survey. On 4-25-22 at 11:00 A.M., a surveyor met with 5 members of the Resident Council. The Council stated that no one from administration ever comes to Council meetings, they say they are too busy, and nothing ever gets resolved. The Residents verbalized that the same issues and complaints remain with no resolution. This is borne out by the repetition of the same grievances in all 3 months of council minutes that were reviewed by surveyors. Throughout the survey, conducted from 4-24-22 through 4-27-22, other residents expressed the same concerns about the same issues. On 4-26-22 at 3:30 PM, an interview was conducted with a family member of one of the Residents. The daughter of the Resident stated Nursing is a big issue here, they have a lot of agency staff, and they don't know the Residents, and don't really care. I asked one of them how they would feel if this was their mother, and the nurse replied it's not my mother. On 4-26-22, and 4-27-22, the facility Administrator was made aware of the concern that Resident Council expresses the same concerns for months with no resolution being indicated. The Administrator stated, I have not been able to attend Council recently, however, I will go this month. The Administrator revealed that the Residents had requested that the Administrator and DON (director of nursing) attend the next scheduled meeting. No additional information was received.

Based on staff interview, facility documentation review, and in the course of a complaint investigation, the facility failed to ensure that an RN (Registered Nurse) was on duty 8 hours per day 7 days per week. The facility had no RN on duty on 3-1-22, 4-21-22, and 4-24-22. The findings included: The facility staffing was reviewed for the prior 2 months before survey, as a result of multiple complaints of inadequate staffing. Review of the as worked schedule revealed that on 3-1-22, 4-21-22, and 4-24-22, no RN was scheduled to work, and none worked on at least those three occasions. On 4-24-22 at approximately 2:30 PM, an interview was conducted with the LPN in charge, who stated, no I am in charge by default I guess, we don't have an RN today. They will be here tomorrow. On 4-26-22 at 4:45 PM, an interview with the facility Administrator was conducted. She stated that staffing had been a struggle. She stated the facility had done a wage comparison last year and that staff were going to received a raise. She also stated a sign up bonus and referral bonus was added. The Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 4 Residents (Resident #10, 100, 127, and 135), in a sample of 5 Residents reviewed for immunizations. The findings included: On 4/25/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: 1. Resident #10 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the flu or pneumonia vaccine status of Resident #85. Review of the misc. (miscellaneous) tab revealed no evidence of vaccine administration or offering of either. Review of the Medication Administration Records (MAR) revealed no evidence of the flu or pneumonia immunization being provided to Resident #85. 2. Resident #100 had been admitted to the facility on [DATE]. On the immunization tab of the EHR, there was no recorded information with regards to flu immunizations. Review of the misc. tab, nursing notes and MAR(s) revealed no evidence of the flu vaccine being offered to Resident #100. 3. Resident #127 was admitted to the facility on [DATE]. On the immunization tab of the EHR there was no information recorded with regards to flu or pneumonia immunization status. Review of the remainder of the EHR revealed no evidence of Resident #127 being asked or offered either of the immunizations. 4. Resident #135 was admitted to the facility on [DATE]. Review of the immunization tab of the EHR revealed consent required for the pneumonia immunization. Review of the remainder of the EHR revealed no further information with regards to pneumonia immunization. On 4/25/22 at 11:39 AM, an interview was conducted with LPN B. LPN B was asked where immunization records/information is found for Residents. LPN B said, under the immunization tab in the EHR. LPN B was asked to explain the admission process with regards to immunizations for Residents. LPN B said, When we get report I ask the nurse to tell me the immunization status. I have a list of questions to ask and then document under the immunization part of the record. LPN B accessed the EHR for Resident #127 and confirmed that she did not see any information and was not aware of her immunization status with regards to flu and pneumonia and would have to research it. LPN B went on to say that the immunizations are offered on admission and documented in the progress notes and immunization tab. On 4/26/22 at 10:05 AM, an interview was conducted with LPN C, the unit manager for the west wing. LPN C said flu shots are offered around flu season if they don't come in with it already. Pneumonia shots are offered and this is directed through the IP (infection preventionist) person, if they have documentation they received it prior to admission, we will note that. LPN C went on to say, If I'm doing an admission I ask when I'm doing report, usually it is documented within the admission packet and I ask the Resident and family about immunization history. I go into the immunization tab and enter when they received it as historical. On 4/26/22 at 10:23 AM, an interview was conducted with RN B, the staff development coordinator. RN B said, Flu shots are given during flu season and is usually done by the staff nurses, because they have a standing order. It is given by the unit nurse and documented in the EHR. Our admitting coordinator asks and gets information about vaccine status and it is added into the record by the admitting nurse. When RN B was asked why it is important to know someone's immunization status, she said, Anytime we have the possibility for outbreaks, Flu season is September through April, we want to offer all employees and Residents flu shots since it is a relatively common disease the pandemic made it necessary to receive immunization status and offer it at the time of admission. RN B confirmed that immunizations are documented in the immunization section of the chart. RN B accessed the EHR for Resident #135. RN B confirmed that for the pneumonia vaccine consent required was noted. RN B said, This means she has not offered consent yet, it says to be given at time to be determined. When RN B was asked if this has been discussed with the Resident or her family, she said no date is listed and the doctor doesn't address that issue in his notes. Employee C, the infection preventionist then came into the office and joined RN B. Both RN B and Employee C accessed each of the Residents (Resident #10, 100, 127, and 135). Employee C confirmed the surveyor's findings and was unable to locate any information that the Residents had been offered the vaccinations. On 4/26/22 at 3:06 PM, the facility Director of Nursing (DON), was made aware that of the 5 Residents reviewed for immunizations concerns were noted with all 5. She stated, I am not surprised, unfortunately it is definitely a work in progress. I've been working on things ever since I came into this position and with having agency staff it is hard to get people to do the right thing. Review of the facility policy titled, Influenza & Pneumococcal Vaccinations was conducted. This policy read, .Vaccination against influenza will be offered to Center patients and staff annually. Vaccination against pneumonia will be offered to Center patients as indicated. 1. c . The center will check the immunization status of patients admitted during the flu season. Those who have not had a flu shot will be offered on upon admission. On 4/27/22 at 5:00 PM, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to offer COVID vaccination(s) for Residents who were not vaccinated against COVID-19, for 2 Residents (Resident #127 & #100), in a sample of 5 Residents reviewed for immunizations. The findings included: 1. The facility staff failed to provide evidence that Resident #127 was offered, educated and provided/or declined COVID vaccination. On 4/25/22, a clinical record review for Resident #127 was conducted. This review revealed the following: Resident #127 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the COVID vaccine status of Resident #127. All of the progress notes for Resident #127 were reviewed, which included social work, nursing and medical providers, to include from admission through the date of review. There was no indication of Resident #127 being offered or educated on the benefit of immunization for COVID. Review of the misc. (miscellaneous) tab revealed no evidence of vaccine administration or offering of the COVID vaccine. Review of the nursing admission assessment completed on 1/25/22, didn't address the immunization status of the Resident. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR), revealed no evidence of the COVID immunization being provided to Resident #127. On the misc. tab of the chart, the admission alert noted Resident #127 as not vaccinated. Review of the listing of Resident's COVID immunization status form provided by the facility staff on 4/25/22, indicated Resident #127 was unvaccinated for COVID-19. 2. For Resident #100, the facility staff failed to offer, educate and provide COVID vaccination. On 4/25/22, a clinical record review for Resident #100 was conducted. This review revealed the following: Resident #100 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the COVID vaccine status of Resident #100. All of the progress notes for Resident #100 were reviewed, which included but were not limited to: social work, nursing and medical providers, from admission through the date of review. There was no indication of Resident #100 being offered or educated on the benefit of immunization for COVID. Review of the misc. (miscellaneous) tab revealed no evidence of vaccine administration or offering of the COVID vaccine. Review of the nursing admission assessment completed on 3/28/22, didn't address the immunization status of the Resident. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR), revealed no evidence of the COVID immunization being provided to Resident #100. On the misc. tab of the chart, the admission alert noted Resident #100 as not vaccinated and had a handwritten note that read, Will need to quarantine 14 days. A second admission alert was noted dated 4/12/22, following a hospitalization where Resident #100 was being readmitted . This admission alert read, Quarantine 14 days and not vaccinated. Review of the listing of Resident's COVID immunization status form provided by the facility staff on 4/25/22, indicated Resident #100 was unvaccinated for COVID-19. On 4/25/22 at 11:39 AM, an interview was conducted with LPN B. LPN B was asked where immunization records/information is found for Residents. LPN B said, under the immunization tab in the EHR. LPN B was asked to explain the admission process with regards to immunizations for Residents. LPN B accessed the EHR for Resident #85 and confirmed that she did not see any information under the immunization or misc. tabs regarding COVID immunization status. On 4/26/22 at 10:05 AM, an interview was conducted with LPN C, the unit manager. LPN C stated that COVID immunizations are offered to Residents during the COVID clinics which are held twice a week, if they want it, we give it. That is all directed through the IP (infection preventionist) person. On 4/26/22 at 10:23 AM, an interview was conducted with RN B, the staff development coordinator. RN B stated that, Immunizations are offered at the time of admission. We are having less people not fully vaccinated. It is placed in the chart, the information is obtained from the patient or patient's family, but we offer those to the unvaccinated at the time of need and we offer boosters too. RN B confirmed that Resident #127 is not vaccinated for COVID-19 as she can tell in chart. RN B stated that she believes consent forms are signed and kept on record, but would have to look it up to be sure. On 4/26/22, during the interview with RN B, Employee C, the infection preventionist entered the room and participated in the interview. Employee C then accessed Resident #127's clinical record and stated, She is not vaccinated for COVID-19. Employee C was asked if Resident #127 was offered the vaccine and he said, We just did our clinic on the 15th [referring to April] and she declined. Employee C stated the process is to document this on the immunization tab that she declined. Employee C said he spoke to Resident #127's daughter and let her know she declined, but I didn't document it. Employee C confirmed that documentation of being offered the COVID vaccine should be documented in the clinical record but was not. Employee C also confirmed that Resident #100 was offered the COVID immunization but the clinical record doesn't document this offer or refusal. Employee C was asked why it is important to document, he said To let us know why and when they refused. Employee C said the importance of vaccination is, To prevent hospitalizations and prevent outbreaks. On 4/26/22 at 3:06 PM, an interview was conducted with the DON. She was asked how immunizations for Residents are handled. She said, We get it from report in the hospital, if historical [received prior to admission] it goes in immunization tab for long-term care. That is oversaw by IP, then he communicates to nursing and if they are not immunized we get consent from the patient or RP [responsible party] to determine if they do or don't want it. The DON was asked if the consent is obtained on a form, she said, Yes. On 4/26/22, the facility Director of Nursing (DON) was made aware that concerns were had with Residents reviewed for immunizations. The DON stated, I am not surprised. Review of the facility policy titled, COVID-19 was reviewed. This policy read, .5 .The center should continue to encourage vaccination among new admissions . CDC (Centers for Disease Control and Prevention) provides the following guidance to nursing facilities in their document titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes. This document read, .New Admissions and Residents who Leave the Facility: Create a Plan for Managing New Admissions and Readmissions In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine .COVID-19 vaccination should also be offered. Accessed online 4/27/22, at web address: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631030153017 On 4/27/22 at 5 PM, during an end of day meeting the facility Administrator and Director of Nursing were made aware of concerns regarding immunizations. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to ensure 1 resident (Resident #260) of 57 residents in the survey sample was assessed to self administer medications. For Resident #260, a bottle of colace (for constipation) was observed on the over bed table. The findings included: Resident #260 was admitted to the facility on [DATE]. Diagnoses included constipation, chronic obstructive pulmonary disease, and dysphagia. As Resident #260 was new to the facility, a minimum data set assessment had not been completed. On 12/4/18 at 11:10 a.m., Resident #260 was interviewed in her room. She was seated in a wheel chair. The over bed table was in front of her. During the interview, a small bottle of colace was observed on the over bed table. On 12/5/18 at 8:20 a.m. Resident #260 was observed in her room eating breakfast. The bottle of colace had been removed from the over bed table. Resident #260's care plan was reviewed. It did not include any information regarding self administration of medications. At the end of day meeting on 12/5/18, the Administrator, Director of Nursing and Corporate Nurse were notified that the bottle of colace was observed on Resident #260's over bed table. The facility staff were asked to provide a physician order or resident assessment determining that Resident #260 was safe to administer her own medications. On 12/6/18 at the end of day meeting, the Corporate Nurse stated that Resident #26's family had brought in the colace.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility staff failed for 1 resident (Resident 358) in the survey sample of 57 residents, to provide the resident's caregiver with written discharge instructions and prescriptions for medications for continuity of care. The facility staff failed to provide Resident #358's caregiver with written discharge instructions and prescriptions for medications for continuity of care. The Findings included: Resident #358 was an [AGE] year old who was admitted to the facility on [DATE] and discharged home on 9/28/18. Resident#358's diagnosis included Cerebral infarction, Generalized Muscle Weakness, Aphasia, Dysphasia, Spinal Stenosis, Glaucoma, Heart Failure, Polyosteoarthritis, and Age-Related Physical Debility. The Minimum Data Set, which was a 30-Day Assessment with an Assessment Reference Date of 9/12/18 was reviewed. Resident #358 was coded as having a Brief Interview of Mental Status Score of 14, indicating intact cognition. In addition, she was coded as being totally dependent on the physical assistance of at least 2 people for transfers. On 12/4/18, a review was conducted of Resident #358's clinical record. She was discharged home on 9/28/18. There was no record of the discharge in the progress notes on 9/28/18. The last nursing progress note prior to discharge was written by the night shift on 9/28/18 at 6:55 A.M. It read, Resident alert, verbal, able to make needs known. Skilled for therapy and nursing services. Here post CVA (cardiovascular accident - stroke) for strengthening. Slept well this shift, no distress noted, no complaints voiced. No needs at this time. Call bell in reach. The following Discharge Planning note was documented two days prior to discharge: Met with patient's daughter. Durable Medical Equipment has been ordered including hospital bed. Made transportation arrangements through Anthem for 2:00 P.M. Explained discharge procedures. [Redacted] stated that no family will be at the facility for discharge and to send any information in a folder. Reviewed prescriptions and order for outpatient therapy will be provided along with discharge instructions. Discharge planning will continue to provide support. On 12/4/18 at 10:00 A.M., an interview was conducted with the Director of Nursing (DON - Employee B). The DON was asked to describe the manner in which discharge instructions and prescriptions are handled. She stated, Prior to discharge we receive handwritten prescriptions and give them to the patients family, or call them in to the pharmacy of their choice on the day of discharge. We also give the Discharge Instructions form to the patient's family. The DON stated that she did not know when the wheelchair was returned to the facility, or who helped Resident # 358 to get into her house. The DON was unable to provide a copy of the prescriptions or Discharge Instructions. The DON submitted a copy of an email she received from a nurse on Friday, September 28, at 10:28 P.M. It read, (Resident #358) was discharged today, daughter is very upset related to discharge forms or scripts were not sent home with resident. Resident daughter states when she called the facility and spoke with the nurse on duty, the nurse stated that she did not know the resident had left. This writer sent the scripts to CVS pharmacy per daughter's request, they were unable to fill related to no signature from MD. This writer called beforehand to ensure that they would accept, I was told yes. Nurse practitioner was called with no return call back. Received another call from daughter stating she need her discharge paperwork ASAP as she was attempting to set up home care, all paperwork including scripts were faxed to [redacted]. Resident daughter stated she will be contacting state because she have pictures etc / proof of neglect. The following afternoon, the clinical record contained a progress note dated 9/29/18 at 3:36 P.M. [redacted] was notified that prescriptions are at CVS and available for pickup. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and facility documentation, the facility staff failed to develop and implement comprehensive care plans for three residents (Resident #44, #23, #34) in a sample size of 57 residents. 1. For Resident #44, the facility staff failed to develop and implement care associated with contractures in bilateral hands. 2. For Resident #23, the facility staff failed to develop and implement care associated with contractures in bilateral arms and hands. 3. For Resident #34, the facility failed to develop and implement an individualized care plan that addresses contractures The findings include: 1. For Resident #44, the facility staff failed to develop and implement care associated with contractures in bilateral hands. Resident #44, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include paraplegia, idiopathic neuropathy, failure to thrive, age-related debility, and dementia. Resident #44 also had contractures both hands. Resident #44's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 09/11/2018. Resident #44's Brief Interview of Mental Status (BIMS) was coded as 6 out of possible 15 indicative of severe cognitive impairment. Functional status for dressing, eating, and personal hygiene was coded as requiring extensive assistance. Physical therapy and restorative nursing programs did not occur. On 12/04/2018 at 4:00 PM, Resident #44 was observed resting in bed with the head of the bed elevated. The Resident's arms were bent slightly and fingers on both hands were flexed into the palms consistent with contractures. Hand padding was not visualized. On 12/05/2018 at 08:30 AM, Resident #44 was observed sitting up in geri-chair, fully dressed. The Resident's arms were bent slightly and fingers on both hands were flexed into the palms consistent with contractures. Hand padding was not visualized. On 12/05/2018, the physician's orders were reviewed. An active entry with a revision date of 07/31/2018 documented, apply bacitracin to laceration on left palm after cleaning with NS (normal saline). every day and evening shift for skin care if resident allows, place cloth in hand (sic) The nurse's notes were reviewed. An entry dated 07/08/2018 at 18:31 documented, both hands/fingers remain contracted. able to place palm guard in right hand but unable to left hand due to degree of contracture. clean cloth applied. resident will remove cloths and palm guard from hands on her own. noted small lacreaction (sic) in left palm due to fingernails. Dr [redacted] notified. area cleaned and bacitracin ointment applied. RP (responsible party) (name) aware. (sic) The treatment administration record for December 2018 was reviewed. The treatment apply bacitracin to laceration on left palm after cleaning with NS. Every day and evening shift for skin care if resident allows, place cloth in hand is signed off as administered every day and evening shift in December 2018. The care plan was reviewed. Contractures of bilateral hands are not listed as a focus with associated goals, intervention, and measures to include skin integrity, range of motion, and bathing. On 12/05/2018 at approximately 11:07 AM, LPN A and surveyor entered Resident's room and observed the Resident reclined in the geri-chair. There were two rolled washcloths in the Resident's lap and no padding on palms. When LPN A extended the Resident's fingers of the right hand, the LPN and surveyor observed one round indentation on the palm where the Resident's finger had been pressing into the palm. There was no discoloration or open wound on the right palm. When the nurse extended the fingers of the left hand, the LPN and surveyor observed one round indentation on the palm where the Resident's finger had been pressing into the palm. There was no discoloration or open wound on the left palm. LPN A was unable to fully extend fingers on both hands due to the contractures and limited range of motion. When asked about the importance of hand padding, nurse stated it's important to prevent skin breakdown. On 12/05/2018 at approximately 1:05 PM, an interview with CNA A was conducted. When asked about the bathing process for Resident #44, CNA A stated the Resident was scheduled to receive a shower twice a week and a daily bed bath. When asked about the bed bath process, CNA A stated she fills a basin with warm water and facility soap, provides Resident privacy, washes Resident head-to-toe, washes 'the front', washes 'the back', and washes the 'private areas.' CNA A didn't mention the hands specifically. On 12/05/2018 at approximately 3:00 PM, an interview with Employee D was conducted. When asked about the process for evaluating residents, she stated that physical therapy needs a referral from nursing to assess and evaluate residents with contractures. She also stated nursing may not make a referral if they can 'handle it.' When asked about the importance of splints in residents that need them, Employee D stated if splints aren't used, the resident will get contractures. On 12/05/2018 at approximately 4:00 PM, an interview of the Resident's current nurse, LPN F, was conducted. LPN F stated the open area on Resident's left palm was healed but we continue to apply bacitracin ointment to protect the skin. On 12/05/18 at 4:25 PM, the DON was asked about the bed bath process and she stated it is the expectation that hands will be washed during daily bed bath. On 12/06/2018 at 9:10 AM, an interview of the Resident's current nurse, LPN B, was conducted. When asked about origin of the open area on the Resident's left palm that had since healed, she stated it was due to the Resident's nail digging into her skin. On 12/06/2018 at 1:50 PM, an interview with the Resident's current CNA, CNA G, was conducted at the Resident's bedside. CNA G stated he has worked at the facility for 13 years and feels very familiar with Resident #44. CNA G states the Resident used to have palm guards for both hands but then she would cry when opening left hand so they switched to using a washcloth for the left hand and a palm guard for the right hand. When asked how a CNA unfamiliar with the Resident would know to place a washcloth in the left hand and a palm guard on the right hand, he stated he didn't know because that information is not in PCC ([NAME]-Click-Care electronic health record). On 12/06/2018 at approximately 2:00 PM, and interview with the DON was conducted. When asked about the process for obtaining a palm guard for a resident, she stated a physician's order is not necessary, it is a nursing intervention. She stated that nurses can implement the palm guards, they are located in the supply closet, and then typically the nurses would consult physical therapy for treatment and evaluation. The DON agreed there is no evidence physical therapy was consulted and she went on to say it is a process issue, it's something we need to look at. When asked about the appropriateness of calling the open area on the Resident's left palm a laceration, she stated, To me, it would be an indentation, not a laceration, a laceration is a cut. She agreed the open skin wound on the Resident's left palm was caused by the Resident's nail pressing into the palm. Facility documentation regarding rehabilitation was reviewed. The facility policy entitled, Rehabilitation Needs Assessment Referral documented, A licensed nurse will complete a therapy screening tool to notify therapy personnel of patient's needs. The procedure steps for this policy are documented, 1. Screen for therapy needs. 2. Document information on the Rehabilitation Services Screen. 3. Notify therapy personnel as appropriate. On 12/06/2018 at approximately 5:15 PM, the Administrator and DON were notified of findings and they offered no further information. 2. For Resident #23, the facility staff failed to develop and implement care associated with contractures in bilateral arms and hands. Resident #23, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include osteoarthritis, age-related debility, malaise, and dementia. Resident #23's most recent quarterly Minimum Data Set had an Assessment Reference Date of 08/28/2018. Resident #23's Brief Interview of Mental Status (BIMS) score was not coded but cognitive skills for daily decision-making was coded as severely impaired. Functional status for eating, toileting, and personal hygiene was coded as total dependence on staff for assistance. Physical therapy and restorative nursing programs were not coded for any occurrence. On 12/04/2018 at approximately 11:15 AM, Resident #23 was observed in her room, fully dressed and sitting up in her geri-chair. Both arms were fully flexed at the elbow and both hands were on upper chest under the Resident's chin. Wrists and fingers were flexed consistent with contractures. No splints, palm guards, or hand padding was observed. On 12/04/2018 at approximately 2:37 PM, Resident #23 was observed in her room and sitting up in her geri-chair. Both arms were fully flexed at the elbow and both hands were on upper chest under the Resident's chin. Wrists and fingers were flexed consistent with contractures. No splints, palm guards, or hand padding was observed. On 12/05/2018 at approximately 8:25 AM, Resident #23 was observed in her room and sitting up in her geri-chair. Both arms were fully flexed at the elbow and both hands were on upper chest under the Resident's chin. Wrists and fingers were flexed consistent with contractures. No splints, palm guards, or hand padding was observed. On 12/05/2018, the care plan was reviewed. One focus created on 08/23/2014 documented, The resident has an ADL self-care performance deficit r/t (related to) Limited Mobility. The goal for this focus dated 08/23/2014 and revised on 09/07/2018 documented, The resident will maintain current level of function in through the review date. The intervention that focused on contractures documented, The resident has contractures of the bilateral hands. Provide skin care daily to keep clean and prevent skin breakdown. Another focus on the care plan, created on 08/23/2014, documented, The resident has limited physical mobility r/t (related to) weakness. The goal associated with this focus dated 08/23/2014 and revised on 09/07/2018 documented, The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall-related injury through the next review date. Interventions associated with this focus documented, heelz up (created on 08/08/2017) (sic). Recliner for socialization and comfort-gel cushion for comfort and prevention (created 06/24/2015). The resident is non-weight bearing (created on 08/23/2014). Interventions, preventative measures, and evaluations associated with contractures of bilateral arms and hands are not listed. On 12/05/2018 at approximately 11:10 AM, LPN B and surveyor observed Resident #23 in her geri-chair. When LPN B extended the Resident's fingers of the right hand, LPN B and surveyor observed there was no discoloration or open wound on the right palm. When LPN B extended the fingers of the Resident's left hand, the LPN and surveyor observed there was no discoloration or open wound on the left palm but it was malodorous when fingers were extended. LPN B was unable to fully extend fingers on both hands due to the contractures and limited range of motion. When asked if palm guards would be beneficial for this Resident, LPN B stated it would be (beneficial) for the right hand but left hand is so tight, it might hurt her. On 12/05/2018 at approximately 1:05 PM, an interview with CNA A was conducted. When asked about the bathing process for Resident #23, CNA A stated the Resident was scheduled to receive a shower twice a week and a daily bed bath. When asked about the bed bath process, CNA A stated she fills a basin with warm water and facility soap, provides Resident privacy, washes Resident head-to-toe, washes 'the front', washes 'the back', and washes the 'private areas.' CNA A didn't mention the hands specifically. On 12/05/2018 at approximately 3:00 PM, an interview with Employee D was conducted. When asked about the process for evaluating residents, she stated that physical therapy needs a referral from nursing to assess and evaluate residents with contractures. She also stated nursing may not make a referral if they can 'handle it.' When asked about the importance of splints in residents that need them, Employee D stated if splints aren't used, the resident will get contractures. On 12/05/18 at 4:25 PM, the DON was asked about the bed bath process and she stated it is the expectation that hands will be washed during daily bed bath. On 12/06/2018 at approximately 2:00 PM, and interview with the DON was conducted. When asked about the process for obtaining a palm guard for a resident, she stated a physician's order is not necessary, it is a nursing intervention. She stated that nurses can implement the palm guards, they are located in the supply closet, and then typically the nurses would consult physical therapy for treatment and evaluation. The DON agreed there is no evidence physical therapy was consulted and she went on to say it is a process issue, it's something we need to look at. Facility documentation regarding rehabilitation was reviewed. The facility policy entitled, Rehabilitation Needs Assessment Referral documented, A licensed nurse will complete a therapy screening tool to notify therapy personnel of patient's needs. The procedure steps for this policy are documented, 1. Screen for therapy needs. 2. Document information on the Rehabilitation Services Screen. 3. Notify therapy personnel as appropriate. On 12/06/2018 at approximately 5:15 PM, the Administrator and DON were notified of findings and they offered no further information. 3. For Resident # 34 the facility failed to develop and implement an individualized care plan that addresses Contractures. Resident #34 is a [AGE] year old woman admitted to the facility on [DATE] with diagnoses including but not limited to Dementia with behavioral disturbance, muscle weakness, Dysphagia, Anemia, Anxiety disorder, Hypertension, Cataracts (bilateral) and chronic kidney disease. The latest MDS (Minimum Data Set) was a quarterly and it coded Resident #34 as having a (Brief Interview of Mental Status) BIMS score of 99 indicating that the Resident was unable to complete the interview. Resident has Dementia and is unable to follow simple conversation. During initial facility tour on 12/4/2018 at 11:45 AM Resident #34 was observed sitting in wheelchair in room. The Resident was noted to have both arms bent at the elbow hands clenched and resting on chest. The Resident did not respond when spoken to however she did make eye contact and smile. The curtain was open and the Resident's roommate stated She can't talk, well she sometimes mumbles but doesn't make sense. On 12/4/2018 at 2:45 PM, Resident #34 was observed again in her room in her wheel chair without splints or palm guards. An interview was conducted with LPN A. LPN A stated that Resident # 34 had Contractures to both hands, the elbow joints, the wrist, and hands. She further stated that they don't use any devices, splints, or palm guards for her. On 12/4/2018 during clinical record review it was noted that Resident #34 did not have an order for splints, palm guards or any orthotic devices for Contracture management. On 12/05/2018 during review of clinical record it was found that the care plan did not address contractures or preventing further contractures. Resident #34's care plan addresses: Limited Physical Mobility r/t Wheel chair use initiated 08/23/2014 Dependent on Staff for meeting emotional, intellectual, physical and social needs related to Physical Limitations muscle weakness and Cognitive Impairments. initiated 08/23/2014 The Administrator was made aware of these concerns on 12/5/2016 during end of day meeting no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility staff failed for 1 resident (Resident 358) in the survey sample of 57 residents, to ensure that a written reconciliation of pre-discharge medications with the residents post discharge medications was done. For Resident #358, the facility staff failed to ensure that a written reconciliation of pre-discharge medications with the residents post discharge medications was done. The Findings included: Resident #358 was an [AGE] year old who was admitted to the facility on [DATE] and discharged home on 9/28/18. Resident #358's diagnosis included Cerebral infarction, Generalized Muscle Weakness, Aphasia, Dysphasia, Spinal Stenosis, Glaucoma, Heart Failure, Polyosteoarthritis, and Age-Related Physical Debility. The Minimum Data Set, which was a 30-Day Assessment with an Assessment Reference Date of 9/12/18 was reviewed. Resident #358 was coded as having a Brief Interview of Mental Status Score of 14, indicating intact cognition. In addition, she was coded as being totally dependent on the physical assistance of at least 2 people for transfers. On 12/4/18 a review was conducted of Resident #358's clinical record. She was discharged home on 9/28/18. There was no record of the discharge in the progress notes on 9/28/18. The last nursing progress note prior to discharge was written by the night shift on 9/28/18 at 6:55 A.M. It read, Resident alert, verbal, able to make needs known. Skilled for therapy and nursing services. Here post CVA (cardiovascular accident - stroke) for strengthening. Slept well this shift, no distress noted, no complaints voiced. No needs at this time. Call bell in reach. The Discharge Summary, written on 10/2/18 was reviewed. It stated that Resident #358's admitting diagnosis was CVA with Left side weakness, and that she received physical and occupational therapy. Neither pre-discharge medications or post-discharge medications were addressed in the Discharge Summary. The clinical record did not contain a written reconciliation of pre-discharge medications with post discharge medications. There was no list of post-discharge medications. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation the facility failed to act on pharmacy alerts to possible drug interactions for 1 Resident (Resident #260) in a survey sample of 10 Residents. For Resident # 260 the facility failed to act on pharmacy alerts of medications that were incompatible or known to alter the effects of Coumadin (a blood thinner). The findings include: Resident #260 is an [AGE] year old admitted to the facility on [DATE] with diagnoses of but not limited to; Pleural Effusion, Acute Respiratory Failure, (Chronic Obstructive Pulmonary Disease) COPD, Atrial Fibrillation, Coronary Artery disease, (Gastro-Esophageal Reflux Disease) GERD and diabetes. On 01/15/2019 a review of clinical records was conducted and it was found that on 01/11/2019 orders were entered into the computer for Resident #260 that include Coumadin (a blood thinner), Prilosec (a Proton Pump Inhibitor), Symbicort (an aerosol steroid based inhaler), Lexapro (an antidepressant), Bengay, Nystatin (anti-fungal), and Trazodone (an antidepressant). A review of the nurses notes for 1/11/2019 at 10:24 AM state: NOTE TEXT: The order you have entered COUMADIN Tablet 7.5 [Milligrams] MG (WARFARIN SODIUM) Give one tablet by mouth in the evening for blood clot prevention. Has triggered the following drug protocol alerts / warnings. Drug to Drug Interaction: Prilosec Capsule Delayed Release 20 [milligrams] MG Give 1 capsule by mouth two times a day for GERD take with meals SEVERITY: MODERATE Interaction: The hypoprothrombinemic effect of Coumadin may be increased by proton pump inhibitors. Symbicort Aerosol 160-4.5 MCG/ACT 2 puffs inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. SEVERITY: MODERATE Interaction: The hypoprothrombinemic effect of Coumadin may be altered unpredictably by Symbicort Aerosol. Bengay Ultra Strength Cream 4-10-30% Apply to back topically one time a day for pain SEVERITY: SEVERE Interaction: The hypoprothrombinemic effect of Coumadin may be increased by Bengay Ultra Strength Cream 4-10-30% Lexapro Tablet 10 MG Give 1 tablet by mouth one time a day for depression SEVERITY: MODERATE Interaction: The risk of bleeding with Coumadin Tablet 7.5 MG may be potentiated with concomitant use of Lexapro Tablet 10 MG and patients are at an increased risk of bleeding. Nystatin Powder 100,000 Units/ GM [Gram] Apply topically to bill [bilateral] breast every shift for yeast. SEVERITY: SEVERE Interaction: The hypoprothrombinemic effect of Coumadin may be increased by Nystatin Powder 100,000 Units/GM Trazodone HCL Tablet 50 MG Give 25 MG by mouth at bedtime for depression SEVERITY: MODERATE Interaction: The hypoprothrombinemic effect of Coumadin may be decreased by Trazodone HCL Tablet 50 MG On 1/15/2019 a review of the [Medication Administration Record] MAR shows that the medications were administered as ordered on 1/11/2019 On 1/16/2019 at 10:30 AM an interview was conducted with the DON and the Administrator and the DON stated These are just FYI's from our computer program. When asked if the physician had been contacted on 1/11/2019 when the orders were entered and the drug protocol alerts / warnings showed up the DON submitted a Follow up note Recertification 60 day visit recertification note dated 1/15/2019. The Recertification note states: Plan: 1. Renew orders and certification 2. The patient's total plan of care including medications were reviewed 3. Prognosis remains poor due to multiple comorbidities 4. Code status is DNR. When asked again if the physician was notified when the alerts showed up on 1/11/2019 the DON stated No but he was in here and signed the recertification yesterday. The DON and Administrator were made aware of the deficient practice, and offered no further information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family interview, staff interview, clinical record review, facility documentation, and facility policy review, the facility staff failed to provide timely dental services for one resident (Resident #115) in a sample of 57 residents. The findings include: Resident #115, an [AGE] year old female, was admitted to the facility 02/06/2016. Diagnoses include Alzheimer's disease, anxiety, depression, diabetes, gastroesophageal reflux disease, dysphagia, failure to thrive, and age-related debility. Resident #115's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 10/31/2018. Resident #115's Brief Interview of Mental Status (BIMS) was coded as 6 out of possible 15 indicative of severe cognitive impairment. Functional status for eating and toileting was coded as requiring extensive assistance. Dressing and personal hygiene was coded as total dependence on staff for assistance. On 12/04/2018 at approximately 12:00 PM, the Resident was observed awake, lying in bed, and head of bed was elevated approximately 45 degrees. The Resident's daughter and son-in-law were visiting. When asked if they had any concerns about the care their mom was receiving, the daughter stated she was concerned about her mom losing weight and thought it was due to her mom's bottom dentures being lost about 4 months ago. The daughter stated her mom was switched to a pureed diet when her teeth were lost and she does not like to eat pureed food. The daughter stated she told the unit manager and the social worker about the missing dentures but they still haven't been replaced. The Resident was then observed with top dentures in her mouth but no bottom dentures. On 12/04/2018 at approximately 4:00 PM, the facility staff was asked to present documentation for any service-related concerns. A Service Concern Report dated 10/29/2018 was presented and reported two pairs of jeans and two coats were missing. The concerns were resolved on 11/13/2018. There was no mention of lost bottom dentures. On 12/05/2018 at 8:20 AM, the Resident was observed sitting up in bed and the head of bed was elevated approximately 45 degrees. The Resident was awake and observed to have her top dentures in but no bottom dentures were visualized. On 12/05/2018 at approximately 9:00 AM, an interview with the Resident's current CNA, CNA B, was conducted. When asked about when oral care was done, CNA B stated it was done before and after meals. When asked if she assisted the Resident with her dentures that morning, CNA B stated that this Resident doesn't wear dentures. CNA B then stated that this Resident may wear dentures and proceeded to look in the bedside table drawer for them but the bottom dentures were not located. The clinical record was reviewed. An initial nutrition note dated 02/07/2016 documented, Resident admitted on a therapeutic RCS (reduced concentrated sweets) diet. Resident wears both upper and lower dentures, no issues chewing. Family brings outside snacks. Family reports patient has poor appetite and will do best with smaller portions and snacks during the day. Patient will often sleep during the day. admission weight documented on 02/06/2016: 104.1 pounds. Weight documented on 11/26/2018: 131 pounds. A physician's order for Regular diet Level 6 - soft & bite sized texture was discontinued on 07/26/2018. A physician's order for Regular diet Level 4 - pureed texture, regular liquids consistency, Ensure pudding with lunch and dinner trays was discontinued on 08/06/2018. A physician's order for Regular diet Level 4 - pureed texture, Level 3 - moderately thick consistency, Ensure pudding with lunch and dinner trays was discontinued on 10/29/2018. An active physician's order for Diabetic diet Level 4 - pureed texture, Level 3 - moderately thick consistency, Ensure pudding with lunch and dinner trays was dated 12/03/2018. A discharge planning note dated 06/27/2018 documented, DDP (discharge planner) and UM (unit manager) met with patient's daughter [name]. Patient lost dentures in May. Patient has had no reported issues with eating meals. Facility has a visiting dentist starting soon. (Daughter) is happy to wait for dentist visit in order to get new impression of bottom dentures. Discharge planning will provide support as needed. A General Consent form signed by the Resident's daughter in July 2018 authorized a specific dental group to deliver treatments as recommended. A dental examination form dated 10/10/2018 was signed by a dentist and indicated Resident received a comprehensive oral evaluation during a nursing home facility visit. No treatments were selected on the form but in the Notes section, the dentist documented, Has upper denture - lost lower - pt keeps falling asleep. N.V. (next visit) 1. Clean denture 2. 1 year visit. A Care Plan Meeting note dated 11/06/2018 documented, Patient participates in speech therapy. At this time therapist recommendation is to continue on current diet and liquid consistency. Dentures would not impact patient's ability to upgrade. Family would like to proceed with procuring dentures for aesthetics. Facility policy for dental service needs was reviewed. Procedure #6 documented, In the event a patient's dentures are lost or damaged the nursing will promptly (sic), within three days, refer the patient for dental services. If the referral does not occur within three days nursing will provide documentation of what has been done to ensure that the resident can still eat/drink adequately while awaiting dental services and will describe reasons for the delay. On 12/06/2018 at approximately 5:15 PM, the Administrator and DON were notified of findings and they presented a Service Concern Report dated 05/23/2018. The details of the report documented, Glasses missing black rimmed, bottom teeth also missing. She sometimes leaves them in the bed. 3 weeks ago for the glass (sic) and 4 weeks of dentures (sic). (Daughter) [name] feels patient will be fine without dentures, but wants glasses so she can read. Action taken documentation Optometry re-order glasses on visit 05/29/2018. Concern was marked as resolved on 06/03/2018 and signed by the Administrator. In summary, the facility staff was aware Resident's bottom dentures were lost since May 2018 and failed to refer Resident for dental services promptly. The Resident still does not have bottom dentures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed, for 1 resident (Resident #17) in the survey sample of 57 residents, to administer medications in a manner to prevent the spread of infection. For Resident #17, the nurse (LPN C) failed to perform proper handwashing technique prior to preparing and administering medications. The Findings included: Resident #17 was a [AGE] year old, who was admitted to the facility on [DATE]. Resident #17's diagnoses included Generalized Muscle Weakness, Unspecified Kidney Failure, Chronic Obstructive Pulmonary Disease, and Epilepsy. The Minimum Data Set which was an Annual Assessment with an Assessment Reference Date of 1/22/18 was reviewed. Resident #17 was coded with a Brief Mental Status Score of 14, indicating that she was cognitively intact. On 12/5/18 an observation was conducted of the medication administration process. Licensed Practical Nurse (LPN C) was present. At 8:25 A.M., LPN C was observed washing her hands. She turned on the water, then put foam soap on her hands. She washed her hands for 6 seconds, then immediately rinsed off the soap. She then used a paper towel to dry her hands, and another paper towel to turn off the water. She then poured and administered the following medications to Resident #17: 1. Prostat 30 Ml in 240 cc of water 2. Gabapentin 200 MG 3. Juven liquid supplement 4. Amlodipine 10 MG 5. NORCO 7.5/325 MG 6. Anastrozole 1 MG In addition, at 8:40 A.M. LPN C washed her hands in the same manner for only 6 seconds and then immediately rinsed the soap off. When asked about the proper amount of time to wash her hands prior to rinsing off the soap, LPN C stated, I was nervous. I should have washed my hands for 30 seconds. When asked about the importance of proper handwashing technique, LPN C stated, It's important because we shouldn't pass bacteria and germs to the residents. The facility Director of Nursing (Employee B) was present after the handwashing. LPN C informed the DON that she had not washed her hands adequately. On 12/5/18 a review was conducted of facility documentation, revealing a handwashing policy. It read, Revised 12/26/17. All staff are trained on proper technique upon hire, annually, and PRN (as needed), and are monitored for proper handwashing practices. Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections. The policy described the handwashing technique, which included the following, Work lather over hands and wrists. Scrub for at least 15-20 seconds. Rinse hands and wrists thoroughly under running water. No further information was received.