Based on record review and staff interview, the facility failed to ensure the resident's right to formulate an advanced directive. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #111 and #65. Facility Census: 3. Findings included: a) Resident #111 On 06/16/25 at 02:38 PM, Advanced Directives were not found on the electronic chart for Resident #111. The resident was coded as a Full Code. On 06/17/25 at 9:42 AM, the Interim Administrator confirmed there was no Advanced Directive completed on the medical chart. The Interim Administrator reported without an advanced directive; the resident is automatically made a full code. b) Resident #65 On 06/16/25 at 4:14 PM, Advanced Directives were not found on the electronic chart for Resident #65. The resident was coded as a Full Code. On 06/17/25 at 09:42 AM, the Interim Administrator confirmed there was no Advanced Directive completed on medical chart. The Interim Administrator reported without an advanced directive; the resident is automatically made a full code.

Based on resident interview, staff interview and record review the facility failed to provide treatment in accordance with professional standards of practice by not passing medications at their scheduled administration times. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #70. Facility Census 113. Findings include: a) Resident #70 During the initial interview on 06/16/25 at 11:17 AM, Resident #70 stated, Sometimes I have to wait a long time on my medicine. Our medications are never on time. A record review on 06/18/25 AT 11:30 AM, of Resident #70's Medication Administration Audit Report (MAAR) revealed the following: -04/06/25 Lyrica Capsule 50 Milligrams (MG) was to be given at 6:00 AM and was not administered until 8:16 AM -04/07/25 Lasix oral tablet 20 MG was to be given at 12:00PM and was not administered until 2:27 PM. -04/24/25 Cholecalciferol Oral Capsule 1.25 MG was to be given at 8:00 AM and was not administered until 2:20 PM -04/30/25 Potassium Chloride 10 MEQ, Sennosides-Docusate Sodium Tablet 8.6 to 50 MG, Wixela Inhub Inhalation Aerosol Powder Breath, Calcium Carbonate Oral Tablet, Allopurinol Oral Tablet 100 MG, Tylenol extra strength oral tablet 500 MG, and Apixaban oral tablet 5 MG was all to be given at 8:00 AM and was not administered until 12:34 PM. -06/18/25 Ipratropium-Albuterol Inhalation Solution 3 MG/3ML was to be given at 12:00AM and was not administered until 1:30 AM. During an interview on 06/18/25 at 3:13 PM, Unit Manager Registered Nurse (UMRN) #15 stated, I can answer for April 30, The nurse had a family emergency and had to leave, so we had to have another nurse come in to give the meds that is why they were late that day. There is a note, where the doctor was notified. The other days I do not know, and do not have an answer for. UMRN #15 further confirmed that the medications were late and not administered within the (1) one hour window. A review on of the policy titled {Medication Administration Policy}, under Medication Administration, 14. Reads as follows: Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at meal times or in the dining room unless specifically ordered with meals.

Based on observation, record review and staff interview the facility failed to ensure catheter had proper drainage during a transfer. This was a random opportunity for discovery during the Long-Term Care survey and had the potential to affect a minimal number of residents. Resident Identifier: #104 Facility Census: 113 Findings Include: During an observation on 06/19/25 at 10:55 AM the surveyor observed therapy staff transferring Resident #104 from their wheelchair to stretcher. While transferring the catheter bag was hooked to the transfer belt staff was using to transfer Resident #104. The transfer belt was placed above the waste and not allowing proper drainage that can allow for the possibility for a UTI. Interview with the Director of Nursing (DON) on 06/19/25 at 11:30 AM confirmed the catheter back should have been below the waste to maintain proper flow stating, I have already educated staff when i heard this had happened.

Based on observation, staff interview and record review, the facility failed to ensure refrigerator temperatures in a resident's room were maintained and logged in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: 36. Facility Census: 113. Findings included: a) On 06/17/25 at 09:04 AM, the Refrigerator/Freezer Temperature Log for Resident # 36's personal refrigerator for June 2025 was reviewed and the following temperature and dates were recorded on the log: Temperatures recorded: 06/05/25 - 45 degrees 06/06/25 - 45 degrees 06/09/25 - 48 degrees 06/10/25 - 46 degrees No temperatures were recorded for 06/03/25, 06/04/25, 06/07/25, and 06/08/25. On 06/17/25 at 9:00 AM, Nursing Assistant #1 confirmed the missing dates, and the temperatures recorded on the Refrigerator/Freezer Temperature Log. b) The facility's policy and procedure for 'Refrigerators: Patient In-Room' stated, 4.1 A Refrigerator/Freezer Temperature Log will be maintained for every patient refrigerator. 4.2 Nursing will observe and record temperatures of the refrigerator on a daily basis using the Refrigerator/Freezer Temperature Log. 4.3 If temperature falls outside of the acceptable range, notify the Maintenance Department. According to the facility's In-Room Refrigerator/Freezer Temperature Log, the acceptable range for the refrigerator is 32-40 degrees F.

Based on record review and staff interview, the facility failed to ensure a correct and complete medical record was maintained for residents. This was true for two (2) of thirty (30) residents reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: # 65 and # 111. Facility census: 113. Findings included: a) On 06/17/25, Advance Directives were not located for Resident # 65 and Resident #111 on the electronic medical chart. On 06/17/25 9:42 AM, the Interim Administrator confirmed there were no advanced directives for Resident #65 and #111 on the medical record The facility's policy and procedure purpose for Code Status Orders is To ensure that the patient's desired resuscitation wishes are documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview and staff interview the facility failed to provide a safe, clean, comfortable home like environment by not taking reasonable care to protect residents personal property from loss, and by not ensuring comfortable temperatures in the dining area. This failed practice was found true for (1) one of (3) three residents reviewed for personal property and was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #108. Facility census 113. Findings Include: a) Resident #108 During the initial interview on 06/16/25 at 12:19 PM, Resident #108 stated, I came here in march and some of my stuff is still missing. They say the washing machine is broken and that it will be down for 6 months. They say they are looking for my stuff, but how long do I have to wait? A review of the Grievance Log on 06/17/25 at 8:30 AM, revealed a grievance filed by Resident #108 dated 06/05/25 and reads that Resident #108 was missing the following items: Size large red polo golf shirt, Short sleeve large charcoal shirt, Gray t-shirt short sleeve size large, 3 pairs of shorts size large black, navy blue, and brown. All Boxer briefs, Reebok brand, and white [NAME] crew socks. The grievance read that the issue would be resolved by 06/10/25. During an interview, on 06/17/25 at 9:30 AM, Social Service Specialist (SSS) #72 stated, We looked for his things. No we have not replaced them yet, because the washer has been down and we were so backed up in laundry we were waiting for it to get caught up to see if it was in there. The SSS further confirmed that the grievance was to be resolved by 06/10/25 and had not.

Based on observation and staff interview, the facility failed to respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #48. Facility Census: #115 Findings included: a) Resident #48 On 11/13/23 at 08:00 AM, observation was made of Nurse Aid (NA) #91 assisting Resident #48 with his breakfast meal. NA #91 was standing while feeding him. This was confirmed immediately with NA #91. Her response was, I can't, I didn't know that? According to the Genesis Procedure: Feeding a patient/resident revision date 06/01/21 states 6. Sit in chair at eye level with the patient . This was confirmed with the Administrator on 11/13/23 at 09:15 AM, who agreed that NA #91 should be sitting down while feeding the Resident and stated she will re-educate the NA. No additional documentation was provided prior to exiting the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a Pre admission Screening and Resident Review (PASARR) for new diagnosis of Bipolar disorder. This was true for 1 of 2 residents reviewed for PASARR. Resident identifier: #22. Facility Census 115. Findings Include a) Resident #22 A record review on 11/13/23 at 10:00 AM, revealed that Resident #22 received a new diagnosis of Bipolar Disorder on 05/09/22. The Resident was admitted to the facility on [DATE]. A record review on 11/13/23 at 10:00 AM found Resident #22's initial PASARR upon admission did not indicate a diagnosis of Bipolar Disorder. A record review on 11/13/23 at 10:00 AM, of Resident #22 admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/13 did not indicate an active diagnosis of Bipolar Disorder. A record review on 11/13/23 at 10:00 AM, of Resident #22 last MDS which was a Significant change with an ARD of 10/06/23 revealed that Section I for Psychiatric/mood disorder section 15900 is marked for Bipolar Disorder. During and interview on 11/13/23 at 11:30 AM with Social Worker (SW) #101 she stated, We usually do a new PASARR when they have a mental disorder typically with a diagnosis of Schizoaffective. The Surveyor asked if she believed that Bipolar Disorder was considered a mental disorder? SW #101 stated, Yes A record review on 11/13/23 at 11:45 AM, of this facility's Social Services Policies and Procedures Titled Pre-admissions screening for Mental Disorder and/or Intellectual Disability Patients, revised on 01/15/21 under Practice Standards 1. reads: { Social services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if there is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or related condition.} On 11/13/23 at 12:12 PM SW #100 was asked if the new PASARR for resident # 22 had been found? Social worker #100 stated, No, it was not in there, I don't guess it was done.

Based on record review, staff interview, resident interview, and observation the facility failed to properly secure Resident #23's indwelling urinary catheter device. This was true for one (1) of one (1) Residents reviewed for catheter care and had the potential to affect only a limited number of Residents. Resident identifier: #23. Facility census:115. Findings included: a) Resident #23 During observation of catheter care on 11/13/23 at 1:05 PM, Resident #23's urinary indwelling Foley catheter was found to not have an catheter securement device in use. The tubing going to the bed side drain bag was stretched tight across the Residents right leg, pulling at the Resident's penis causing tension. A previous adhesive catheter secure device was attached to the drain tubing, but not to Resident's leg. Resident #23 was asked if he preferred to wear an anchoring device for his catheter and he stated, I had one, but it came off. I would wear it if I had it The resident further stated he liked the straps that wrapped around his leg better like the hospital had but he will take what he can get. ied Nurse Aide (NA) # 143 stated, I will get him [Resident #23] one [catheter secure device] when I am done cleaning him up. Resident was noted to have urethral erosion to the right side of the penis. On 11/13/23 at 1:00 PM the Administrator informed Surveyor they have now placed a secure device on the Resident's leg for his catheter. Record review of the facility's policy titled, Catheter, Indwelling Urinary - Care Of date 02/02/23, showed that catheter tubing should be secured and free from kinks. Position catheter for straight drainage. Allow slack in the catheter so that movement does not create tension on it.

Based on record review and staff interview the facility failed to maintain acceptable parameters of nutritional status by not completing weights/re-weights appropriately. This was true for one (1) of three (3) Residents reviewed for nutrition. Resident identifier: #58 Facility Census: #115 Findings Included: a) Resident #58 On 11/13/23 at 02:20 PM record review shows the following documented weights: 11/13/2023 14:44 150.2 Lbs Wheelchair 11/07/2023 14:12 153.0 Lbs Standing 10/03/2023 13:48 196.5 Lbs Standing 9/25/2023 12:35 199.6 Lbs Standing 9/21/2023 22:33 157.0 Lbs Mechanical Lift 9/26/2023 15:29 Correction The above documentation shows a 43.5 pound weight loss from 10/03/23 until 11/07/23. admission records from the hospital states Resident #58 weighed 162 pounds on 09/12/23. Re-weight on 11/13/23, during the survey, shows the Resident weighs 150.2 pounds. The facility Clinical System Process - Weights and Vitals dated 04/02/20 states If the re-weight verifies that the first weight (discrepant weight) was accurate, both entries will remain as entered in Point Click Care (PCC). During an interview on 11/13/23 at 03:41 PM with the Administrator, based on the above weights, it is believed that the weights on 09/25/23 and 10/03/25 were incorrect and the staff failed to re-weigh the resident as required by the facility Clinical System Process - Weights and Vitals Policy. She also stated if there is a weight fluctuation of 5 (five) pounds plus or minus, nursing is to obtain a re-weight, and document as a correction if appropriate.

b) Resident #97 During an observation on 11/13/23 09:02 AM Resident # 97 was not in her room. The tube feeding was hanging on the pole unhooked from the resident A record review on 11/13/2023 at 9:30AM found orders for Resident #97 dated 11/01/23 which reads {One time a day Jevity 1.5 @ 20ML/HR with 50ml/hr H20 flush 18 hours} under Routine 1 on the order it reads {One time every day at 4pm for 18 hours} A record review on 11/13/23 at 9:30 AM of resident #97 Medication Administration record (MAR) reveals that on the evening of 11/12/13 the tube feeding was started per orders. During an interview on 11/13/23 at 9:41 with Unit Manager employee # 27 she states Tube feeding was not given and it should have been, It appears it was not given. During an observation on 11/13/23 at 9:50 AM, another full bottle of the same tube feeding ordered was found in the room. During an interview on 11/13/23 at 10:00AM DON stated, I read her report on the monitor of the tube feeding and it shows 271ml of the Jevity and 360ml on water flushes According to the order she should of gotten 360ml of the Jevity and 900ml of the water. During and interviw on 11/13/23 at 2:49PM Unit Manager Employee # 27 stated, I called the night shift nurse (employee #39) and she said that she did unhook Resident # 97 tube feed to go to therapy this morning. Unit Manager employee #27 verified that the tube feeding was not given per orders. Based on record review, observation and staff interview the facility failed to provide care in accordance with professional standards of practice to prevent complications of enteral feeding for Resident #96 and Resident #97. This was true for two (2) of two (2) residents reviewed for the care area of feeding tube during the long term care survey. Resident Identifier: #96 and #97. Facility Census: 115 Findings Included: a) Resident #96 A review of Resident #96's medical record found the following two (2) orders related to Resident #96 enteral feeding tube: -- Enteral Feed Order: Every 4 (four) hours water flush 240 ML (Milliliters), PEG (Percutaneous Endoscopic Gastrostomy) every 4 (four) hours after each bolus. -- Enteral Feed: Flush Tube with 30 ml of water before and after each medication pass. Flush Tube with a least 15 ml of water between each medication. An observation beginning 12:07 pm and concluding at 12:27 pm on 11/13/23 found Licensed Practical Nurse (LPN) #37 administered Resident #96 his 10:00 am medication. The residents received the following medications during this medication pass: -- Aspirin 81 milligram one (1) tablet via PEG tube. -- Depakote Sprinkles Oral Capsules Delayed Release 125 mg via PEG tube. -- Diltiazem 30 mg via PEG tube. -- Eliquis Oral Tablet 5 mg via PEG tube -- Jevity 1.5 237 ml (1 carton) -- Metoprolol Tartrate Oral Tablet 100 mg 1 tablet via PEG tube. -- Senna Oral Liquid 10 ml via PEG tube. -- Vitamin B12 oral Tablet Extended Release 1000 MCG via PEG tube. During the medication administration LPN #37 administered all seven (7) medications individually to the resident via his PEG tube. Between each medication LPN #37 flushed the tube with five (5) ML of water instead of the 15 ml as ordered. Also LPN #37 flushed the PEG tube with 30 ml of water after the bolus of Jevity instead of the ordered 240 ml of water. An interview with LPN #37 at 1:07 pm on 11/13/23 confirmed she gave 5 (five) ML of water between each medication. She was asked to review the order and confirmed she did get the required 15 ml of water between each medication. LPN #37 was asked when she administered the 240 ml flush of water which should have been given after the bolus of Jevity. She stated, I gave it kind of cumulative with the feeding. When asked if this was the water she was mixing with the Jevity, LPN #37 stated it was. When asked how much water she gave after the Jevity as administered she stated, I flushed it with 30 ml not 240 ml.

Based on record review and staff interview the facility failed to ensure all Pharmacy recommendations were answered with a rationale and in a timely manner. This was true for two (2) out of five (5) Residents reviewed for unnecessary medication. Resident identifiers: #56, and #25. Facility census 117. Findings included: Facility Policy titled, LTC Facility's Pharmacy Services and Procedures Manual revision on 08/17/23. * Facility should alert the Medical Director where MRR's are not addressed by the attending physician in a timely manner. a) Resident #56 During of Resident #56's medical records revealed a pharmacy recommendation from 04/11/23. The pharmacist made recommendations concerning the multiple antidepressants. The facility physician accepted the recommendation on 09/15/23. During an interview 11/15/23 at 10:16 AM, the Administrator was asked for a policy for Medication Regimen Review (MRR). The Administrator agreed that took a long time for a response from the facility physician. b) Resident #25 A record review found Resident #25 received a recommendation from the pharmacist to discontinue Hydroxyzine on 06/13/23. The attending physician did not respond to this request until 09/15/23. It was also discovered that on 02/13/23 the pharmacy made a recommendation to taper the Remeron with a goal to discontinue. The attending physician responded on 05/18/23 with only a check mark for declining the recommendation, failing to provide a rationale. The above concerns were discussed with the Director of Nursing (DON) on 11/15/23 at 12:43 PM. DON agreed there was not a rationale and it was not a timely response. No additional information was provided at the conclusion of the survey.

Based on record review and staff interview the facility failed to obtain a consent for Physician ordered psychotropic drugs. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #42 Facility Census: 115 a) Resident #42 On 11/14/23 at 01:32 PM record review shows that Resident #42 has an order for Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 2 tablet by mouth one time a day for Depression and Buspirone HCl Oral Tablet 5 MG (Buspirone HCl) Give 1 tablet by mouth at bedtime for Generalized Anxiety Disorder (GAD.) Resident #42 has an active diagnosis for generalized anxiety disorder and major depressive disorder. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (Sertraline) (iii) Anti-anxiety; and (Buspirone) (iv) Hypnotic Upon record review on 11/14/23 at 02:00 PM, there were no consents available for the two (2)psychotropic drugs Resident #42 is receiving. It is required that the facility provide informed consent to resident or healthcare decision maker for psychotropic medications the Resident is receiving. This was confirmed with the Director of Nursing on 11/15/23 at 10:37 AM. She agreed that there should be a consent for each psychotropic medication ordered.

Based on observation, staff interview, and resident interview, the facility failed to ensure safe and sanitary storage, handling, and consumption of food by not having up to date temperature logs for resident personal refrigerators. This was a random opportunity for discovery. This failed practice was true for 3 of 3 residents. Resident Identifiers #22, # 69, # 42. Facility census: 115. Findings Included: a) Resident #22 An observation on 11/12/23 at 11:45 AM, revealed that resident #22 had a personal refrigerator in her room with a Temperature log sheet filled out until 09/18/23. An interview on 11/12/23 at 11:45 AM, with Resident #22, who has a BIMS of 14 stated, They used to do those and then just stopped. During a record review on 11/13/23 at 2:00 PM, of Policy 031 Titled Food: Safe handling for Foods from Visitors #5 Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and have temperature monitored daily for refrigeration < 41 degrees Fahrenheit and Freezer < 0 degrees Fahrenheit. An interview on 11/13/23 at 2:00 PM, with housekeeper #121 stated, House keepers are supposed to do refrigerator temperatures in resident rooms, where I worked at before we did not do that, so I sometimes forget. b) Resident # 69 An observation on 11/12/23 at 11:58 AM, revealed that resident #69 had a personal refrigerator in her room with a Temperature log sheet filled out until the 10 th of the month with no month indicated and one more temperature on the 22nd of the same unidentified month. An interview on 11/12/23 at 11:58 AM with resident #69 found, I have not seen them do that for a while, unless they do it when I am asleep. During a record review on 11/13/23 at 2:00 PM of Policy 031 Titled Food: Safe handling for Foods from Visitors - #5 reads [ Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and have temperature monitored daily for refrigeration < 41 degrees Fahrenheit and Freezer < 0 degrees Fahrenheit. An interview on 11/13/23 at 2:00 PM with housekeeper #121 found, House keepers are supposed to do refrigerator temperatures in resident rooms, where I worked at before we did not do that, so I sometimes forget. b) Resident #42 On 11/12/23 at 01:59 PM observation was made that Resident #42 had a personal refrigerator in his room. There were no temperature log sheet in place. This was confirmed with Licensed Practical Nurse #37 on 11/12/23 at 02:00 PM The facility Safe Handling for Foods, Policy #031 states Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: * Equipped with thermometers * Have temperature monitored daily for refrigeration <41 degrees F and freezer <0 degrees F * Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for > (greater than) seven (7) days. * Clean weekly This was confirmed with the Administrator on 11/15/23 at 12:10 PM.

Based on observation, record review, and staff interview, the facility failed to accurately record the amount of a prescribed snack that was consumed. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: #66, #65, and #39. Facility census 117. Findings included: a) Resident #66 At the time of entering the facility on 11/12/23 at 10:30 AM, it was noted snacks were at the nursing station untouched and undelivered to the residents. The snack for Resident #66 was a cup of mixed fruit dated 11/11/23 labeled third snack. These snacks were seen and witnessed by Registered Nurse #19 at the time of discovery. A review of medical records revealed the staff documented Resident #66 consumed 100 percent of his third snack on 11/11/23. b) Resident #65 On 11/12/23 at 10:30 AM, it was noted that an oatmeal cake was labeled with the name of Resident #65 and dated 11/11/23 and called the third snack. These snacks were seen and witnessed by Registered Nurse #19 at the time of discovery on 11/12/23 at 10:30 AM. A review of medical records revealed the staff documented Resident #65 consumed 100 percent of his third snack on 11/11/23. c) Resident #39 A house shake and a sandwich were labeled for Resident # 39. The snacks were left at the nurse's station. These snacks were dated 11/11/23 and called the third snack. These snacks were seen and witnessed by Registered Nurse #19 at the time of discovery on 11/12/23 at 10:30 AM. A review of medical records revealed the staff documented Resident #39 consumed 100 percent of his third snack on 11/11/23. During an interview with the DON on 11/15/23 at 12:57 PM about the Residents mentioned above, the DON stated the snacks left at the nurse's station were there probably because the residents did not want them. The DON was shown the Medication Administration Record (MAR) where it was documented as being consumed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interviews the facility failed to maintain equipment in safe operating conditions. Two (2) Heating, Ventilation and Air Conditioning (HVAC) units were not in safe operating conditions for room [ROOM NUMBER] and room [ROOM NUMBER]. This had the potential to affect a limited number of residents residing in those rooms. Facility Census: 115. Findings Included: a) room [ROOM NUMBER] During the initial tour on 11/12/23 at 11:56 AM, room [ROOM NUMBER]'s HVAC unit was void of a plastic guard. During an interview on 11/12/23 at 11:57 AM, Resident #85 stated, That heater has been missing the vents forever. During another observation on 11/13/23 at 10:56 AM, room [ROOM NUMBER]'s HVAC unit's plastic guard was not there. During an interview on 11/14/23 at 4:31 PM, the Maintenance Director acknowledged the HVAC plastic guard was missing. The Maintenance Director stated, I will replace the whole unit, I have a new one I will put in. b) room [ROOM NUMBER] During the initial tour on 11/12/23 at 11:42 AM, room [ROOM NUMBER]'s HVAC power cord was woven through the plastic guard instead of the appropriate way under the HVAC unit. The HVAC unit was also set for heat setting and was on. During another observation on 11/13/23 at 10:55 AM, room [ROOM NUMBER]'s HVAC power cord continued to be woven in the plastic guard with the heat on During an interview on 11/14/23 at 4:31 PM, the Maintenance Director acknowledged the HVAC unit cord was not stored properly. The Maintenance Director stated That could have been dangerous if the heat had been on. This surveyor stated the heat has been on the last two days when I observed the HVAC unit.

Based on record review, staff interview, and resident interview, the facility failed to consider the views of resident council and act promptly upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. This failed practice had the potential to affect more than a limited number of residents. Facility census: 115. Findings included: a) During the resident council meeting on 11/13/23 at 1:00 PM, numerous residents stated they do not feel that their grievances and concerns are being taken care of. We complain here, and no one does anything about it. Review of the council meeting minutes from 06/06/23, 07/05/23, 08/01/23, 09/05/23,10/03/23, and 11/07/23 had multiple resident concerns which included the following: -TV channels are messed up -food is not hot and cold food is not cold - floors need swept and mopped better, floors are sticky -personal clothes are not coming back timely -not getting showers, call lights not answered timely There was no documentation to indicate a response from any departments had been made to address the concerns from the Resident Council. Resident council concerns documented in the minutes were not signed off by staff and did not have a resolution. During an interview on 11/13/23 at 2:30 PM, the Activity Director (AD) was asked how the concerns were investigated and resolved for the resident council? The AD stated, I give them to the departments and they give them to social services. During an interview on 11/13/23 at 2:40 PM, with Social Services employee # 101 she stated, We do not keep them in here, I am not sure where they are at. No further information was provided prior to the close of the survey.

c) Resident #73 Record review on 11/14/23 at 10:00 AM, found the following order: Humulin R 100 units, 1 ml, inject 8 units subcutaneously after meals for Diabetes Mellitus (DM) type II with hyperglycemia. Notify provider of glucose less than 70 or greater than 400 Review of the MAR found the following occasions when the Resident's blood glucose reading was more than 400: 11/04/23 at 6:00 PM, 431, 11/05/23 at 1:00 PM, 432, and at 6:00 PM 432, 11/07/23 at 1:00 PM 524 and at 6:00 PM, 476, 11/13/23 at 1:00 PM, 407. There is no documentation to show that the physician had been notified of these blood sugars. During an interview on 11/14/23 at 10:15 AM, unit manager #27 stated, If the blood sugar is over 400 we should be notifying the physician. On 11/14/23 at 10:45 AM, the DON stated, The notes for the days that his blood sugar was over 400 are not in his chart, they should be. b) Resident #42 On 11/13/23 at 02:08 PM, record review shows on 09/01/23 at 06:00 PM, the Resident's blood glucose was elevated at 422. Review of the Physicians order is as follows: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously after meals for DM type II with hyperglycemia Notify provider of glucose less than 70 or greater than 400. There was no available documentation indicating the Physician was notified of the elevated blood glucose. This was confirmed with the Administrator on 11/14/23 at 09:10 AM. No additional information was provided prior exiting the survey. Based on record review and staff interview, the facility failed to notify the physician of an elevated blood glucose level. This was true for three (3) of five (5) residents reviewed for unnecessary medication. Resident identifiers: #56, #42, and #73. Facility census 117. Findings included: a) Resident #56 Medical record review revealed there were multiple times the Residents blood glucose levels were greater than 400. The order from the facility physician stated to call if blood sugars were greater than 400. A review of the Medication Administration Record (MAR) found the following times the blood glucose levels were over 400 and the physician was not notified or the physician was not notified timely: 09/30/23 at 4:30 PM, blood glucose was 488. No note about notifying the physician. 10/06/23 at 4:30 PM blood glucose was 504. The physician was notified at 6:08 PM. 10/07/23 at 6:30 AM blood glucose was 428. No note about notifying the physician. 10/07/23 at 4:30 PM blood glucose was 484. The physician was notified at 6:43 PM. 10/09/23 at 4:30 PM blood glucose was 486. The physician was notified at 6:43 PM. 10/14/23 at 4:30 PM blood glucose was 435. No note about notifying the physician. 10/16/23 at 11:30 AM blood glucose was 401. No note about notifying the physician. 10/22/23 at 4:30 PM blood glucose was 496. The physician was notified at 6:45 PM. 11/09/23 at 4:30 PM blood glucose was 432. No note about notifying the physician. On 11/13/23 at 3:31 PM, the Director of Nursing (DON) was informed of the above and confirmed there was not consistent notification to the physician and when it was reported it was more than two (2) hours later.

m) Resident #57 On 11/12/23 at 12:49 AM, observation was made of Resident #57's mattress and it was heavily soiled. The bed was occupied by Resident #57. The mattress was bare with no sheets or blankets. Resident stated, I don't want sheets or blankets, I like it this way because of my skin breaking out. The mattress had what appeared to be white/cream colored dried flakes of skin outlining his body. A dried liquid substance was running down the left and right side of the mattress, and the surface of the mattress at the Resident's midsection was covered with a dried white substance and food particle. The soiled mattress was verified by Licensed Practical Nurse (LPN) #27. LPN #27 stated, I'll let someone know it needs cleaned. During observation of care on 11/13/23 9:52 AM, Resident #57's mattress was found to be soiled and dirty. Nursing Aide (NA) #143 stated, Yell, that needs cleaned, we have to use a special cleaning solution because of his skin allergies. On 11/14/23 at 10:39 AM, observation was made in the presence of the Administrator of Resident #57's soiled bed mattress. Piles of what appeared to be dry flaked off skin surrounded the body. The mattress had dark brown dried substances running off the side of the mattress on the left right and bottom, and various other spots of dried substances all over the mattress. Resident #57 agreed to get up and set in chair for mattress to be cleaned. The Administrator stated, I'll make sure that gets cleaned today. f) Resident #56 During the initial interview with Resident #56 on 11/12/23 at 11:36 AM, it was noted there were three (3) pillows on the bed that were heavily stained. The pillows had many yellow, brownish rings on them. Also, there were not any pillow covers on the pillows. On 11/13/23 at 2:29 PM, the Administrator was asked to look at the pillows Resident #56 had on her bed. The administrator told the resident they will wash her pillows and get covers for them. Resident #56 thanked the administrator and said she would appreciate that. g) Wheelchairs and lift equipment in the hallway On 11/12/23 at 10:30 AM, when entering the facility, it was noted the equipment in the North Hall was heavily soiled with a very thick layer of dust/dirt on the lifts/scales. On 11/13/23 at 1:10 PM, the equipment on the North Hall was still heavily soiled. On 11/13/23 at 2:30 PM the Administrator was shown the equipment in the hall and the wheelchair Resident #56 was sitting in. The administrator agreed the equipment and wheelchairs should be cleaned. h-1) Resident #99 During an interview on 11/12/23 at 12:12 PM, resident #99 stated, My string is broken on my over the bed light. I have reported it. It has been like this for a few days. I cannot reach the string to pull it myself. I hope they can figure it out before I go to bed. Observation on 11/12/23 at 12:15 PM, revealed Resident # 99's switch for his over the bed light is broken and prevents him from turning it on and off. During an interview on 11/13/23 at 12:45 PM, Nurse Aide (NA) #91 stated, can push up on it and then pull this little string and get it to work. I reported it yesterday to try and get it fixed. On 11/13/23 at 1:40 PM, the Maintenance director observed the light switch and stated, I was not aware of it no one had reported it to me, I will fix it as soon as I can. h-2) Resident #99 An observation on 11/12/23 at 1:00 PM, of resident # 99's room revealed that the wardrobe doors were taken off and replaced with a wooden rod and a curtain. On 11/13/2023 at 3:00 PM, the Maintenance director stated, Those curtains were here when I started working here a couple months ago. I don't know who put them up. I have not heard that we are getting new wardrobes. i) Resident #69 An observation on 11/12/23 at 1:15 PM, of resident # 69's room revealed that the wardrobe doors were taken off and replaced with a wooden rod and a curtain. During an interview on 11/13/2023 at 3:00 PM, the Maintenance director stated, Those curtains were here when I started working here a couple months ago. I don't know who put them up. I have not heard that we are getting new wardrobes. j) Resident #82 An observation on 11/12/23 at 1:25 PM, of resident # 82's room revealed that the wardrobe doors were taken off and replaced with a wooden rod and a curtain. During an interview on 11/13/2023 at 3:00 PM, the Maintenance director stated, Those curtains were here when I started working here a couple months ago. I don't know who put them up. I have not heard that we are getting new wardrobes. k) Resident #7 An observation on 11/12/23 at 1:40 PM, of resident #7's room revealed that the wardrobe doors were taken off and replaced with a wooden rod and a curtain. During an interview on 11/13/2023 at 3:00 PM, the Maintenance director stated, Those curtains were here when I started working here a couple months ago. I don't know who put them up. I have not heard that we are getting new wardrobes. l) Resident #366 An observation on 11/12/23 at 1:55 PM, of resident #366's room revealed that the wardrobe doors were taken off and replaced with a wooden rod and a curtain. During an interview on 11/13/2023 at 3:00 PM, the Maintenance director stated, Those curtains were here when I started working here a couple months ago. I don't know who put them up. I have not heard that we are getting new wardrobes. Based on observation, resident interview, and staff interview, the facility failed to ensure the resident environment was clean and in good repair. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #34, #16, #21, #47, #56, #99, #69, #82, #7, #366 and #57. Facility Census: 115. Findings Included: a) Resident #34 An observation of Resident #34's room on 11/12/23 at 11:48 am, found the door was missing on the wardrobe. The door was replaced with a wooden rod and a curtain. A tour conducted with the Nursing Home Administrator (NHA) on 11/14/23 which concluded at 10:07 am, confirmed the the door needed repaired. b) Resident #16 An observation of Resident #16's room on 11/12/23 at 12:06 PM, found the door was missing on the wardrobe and was replaced with a wooden rod and a curtain. The handles on the wardrobe were also broken and were hanging down to one side. A tour conducted with the Nursing Home Administrator (NHA) on 11/14/23 which concluded at 10:07 am confirmed the above areas needed repaired. c) Resident #21 An observation of Resident #21's room on 11/12/23 at 11:43 am, found the wall behind is bed was soiled, the plastic bed guard was dislodged from the wall. The handle on nightstand was broken and hanging down to the side. The nightstand was also dirty. A tour conducted with the Nursing Home Administrator (NHA) on 11/14/23 which concluded at 10:07 am, confirmed the above areas were in need of repair and/or cleaning. d) Resident #47 An observation of Resident #47's room on 11/12/23 at 11:52 AM, found the wardrobe door was missing and was replaced with a wooden rod and a curtain. A tour conducted with the Nursing Home Administrator (NHA) on 11/14/23 which concluded at 10:07 am confirmed the above areas were in need of repair. e) East Shower Room by Nurses Station An initial tour of the East shower room by the nurses station on 11/12/23 at 12:15 PM, found an accumulation of hair gathered in the shower drain and a black substance with the appearance of mold in the lower corner of the shower stall. A tour conducted with the Nursing Home Administrator (NHA) on 11/14/23 which concluded at 10:07 am, confirmed the above areas were in need or repair and/or cleaning.

Based on observation, record review, resident interview and staff interview the facility failed to provide care to residents that was required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. This is true for four (4) of eight (8) reviewed for ADL care area during the Long Term Care Survey Process (LTCSP). Resident Identifiers: #24, #61, #1, and #66. Facility Census: 115. Findings Included: a) Resident #24 During an interview on 11/12/23 at 11:44 AM, Resident # 24 stated I don't get showers or bed baths. Observation revealed Resident #24's hair was disheveled and sticking up everywhere. During an interview on 11/13/23 at 10:35 AM, Resident # 24 stated, The night shift (Nurse Aide (NA) #76's name) left me shitty since two (2) AM, and I am still not changed, and I still have not gotten a shower or bed bath. This surveyor asked Resident # 24 to turn on the call light at 10:37 AM. The Administrator in Training (AIT) #97 came into the room at 10:39 AM and stated I saw your call light on what do you need? Resident # 24 stated, I have not been cleaned since two (2) AM that (Nurse Aide (NA) #76's name) never cleaned me up and I have been lying in shit since then. I want her fired. All she does is sit at the nurses station all night and don't help no one. The AIT #97 acknowledged the resident needed a bath and needed to be changed. During an interview on 11/13/23 at 12:13 PM, the Administrator stated a grievance was started and was reported. The NA was suspended. Resident # 24 is care planned for refusal of care. During a record review on 11/13/23 at 1:13 PM, the facility shower schedule reflected Resident # 24 shower days were Monday and Thursday on the 7 AM to 7 PM shift. During a record review on 11/14/23 02:27 PM, Resident #24 medical record revealed the following care plan: (typed as written) Focus: Resident has self care deficit due to muscle weakness and multiple disease processes. Goals: Resident will participate in ADL's daily and have a neat, clean, well groomed appearance daily through the next quarterly review Interventions included: Bed baths daily with showers two(2) times a week and as needed (PRN). Resident prefers showers on Monday and Thursday. Resident usually performs substantial/maximal assist for dressing. Resident usually performs dependent assist for bathing. During an interview on 11/14/23 at 10:45 AM, the Administrator presented evidence the alleged allegation was reported to the required State authorities. b) Resident #61 During an interview on 11/12/23 at 11:32 AM with Resident #61, she stated she wasn't getting her bed baths as scheduled. Her hair appeared to be unclean. On 11/13/23 at 10:00 AM record review shows her showers are scheduled for Wednesday and Saturday on day shift. Her care plan states Bed baths daily with showers 2 x's a week and PRN (as needed). A review of her daily task sheet for baths and showers for the past 30 days shows the following: 10/16/23 bed bath 10/17/23 no bed bath or shower 10/18/23 received scheduled shower 10/19/23 no bed bath or shower 10/20/23 bed bath 10/21/23 shower scheduled, received (rec'd) bed bath 10/22/23 no bed bath or shower 10/23/23 Refused 10/24/23 bed bath 10/25/23 received scheduled shower 10/26/23 no bed bath or shower 10/27/23 no bed bath or shower 10/28/23 shower scheduled, rec'd bed bath 10/29/23 no bed bath or shower 10/30/23 bed bath 10/31/23 no bed bath or shower 11/01/23 received scheduled shower 11/02/23 no bed bath or shower 11/03/23 bed bath 11/04/23 received scheduled shower 11/05/23 no bed bath or shower 11/06/23 no bed bath or shower 11/07/23 bed bath 11/08/23 Refused 11/09/23 no bed bath or shower 11/10/23 no bed bath or shower 11/11/23 received scheduled shower 11/12/23 Refused 11/13/23 no bed bath or shower 11/14/23 no bed bath or shower Eight (8) showers should have been provided during this time period. The Resident received five (5) showers. She refused (once) and received a bed bath instead of a shower on two (2) days. She missed one shower. However bed baths were due on each additional day. There were twenty two (22) opportunities for a bed bath from 10/16/23 through 11/14/23. She received eight (8) bed baths of the 22 (twenty two) opportunities. This was confirmed with the Administrator on 11/13/23 at 02:22 PM. No additional documentation was provided prior to exiting the survey. c) Resident #1 During an interview on 11/12/23 at 11:46 AM, Resident #1 said she is supposed to get a shower on Tuesdays and Thursdays. She also said she does not like getting a shower late at night, and when they offer one at 10:00 PM or 11:00 PM, I say no, but they do offer me one the next day. Resident # 1 is documented as being total dependent for bathing. A review of the shower records provided by the Administrator revealed Resident # 66 has received zero (0) showers in the last 14 days. On 11/15/23 at 9:56 AM, the Administrator reviewed the shower schedule and acknowledged there were no refusals documented. d) Resident # 66 On 11/12/23 at 11:57 AM, Resident #66 said he does not always get showers like he wanted. Resident #66 is documented as being total dependent for bathing. A review of the shower records provided by the Administrator revealed Resident # 66 has received three (3) showers in the last 22 days. On 11/15/23 at 9:56 AM, the Administrator was shown the facility form by the surveyor. NO further information was provided before the close of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #22 An observation on 11/12/23 at 11:30 AM revealed that resident #22's TV has lines going through it at the top, middle and bottom. 11:30 AM Resident # 22 stated, I go to activities on occasion but only when they don't have Covid. I enjoy watching TV, but I decided not to watch it because it gets on my nerves with the lines through it. Sometimes it makes a noise depending on what channel you are on. I have complained but it hasn't been fixed yet, she thinks they have ordered a part. An observation on 11/13/23 at 1:00 PM revealed that resident # 22 TV continued to have the lines going through it. During an record review on 11/13/23 at 1:15 PM of resident # 22 Activity Participation records for the months of October and November revealed that resident is marked watching TV everyday as an Individual activity. During a record review on 11/13/23 at 1:15 PM resident #22 Recreation Comprehensive Assessment question 15 is marked that it is very important for resident #22 to watch the news on TV. Question 18 is marked that it is very important for resident # 22 to watch TV in general. During a review on 11/13/23 at 2:00 PM of the grievance and concern forms dated 10/03/23 reads as follows T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have pictures. The action taken to resolve this concern reads, We are having (name of tv provider) to come and rewire the bad wires going through the gutters. During an interview on 11/13/23 at 2:20 PM the maintenance director stated, The part has been ordered for the TV'S and should be here today. These TVs have been like this for as long as I have been here at least a couple of months. e) Resident #82 An observation on 11/12/23 at 11:45 AM, revealed that resident #82 TV has lines going through it at the top, middle and bottom. During an Interview on 11/12/23 at 11:45 AM, Resident #82 stated, This TV drives me crazy. It has been like this since I got here, I try to watch some of my shows, but usually end up turning it off because it's ridiculous An observation on 11/13/23 at 1:00 PM revealed that resident # 82's TV continued to have the lines going through it. During an record review on 11/13/23 at 1:15 PM, of resident # 82 Activity Participation records for the months of October and November revealed that resident is marked watching TV everyday as an individual activity. During a record review on 11/13/23 at 1:30 PM, Resident #82's Recreation Comprehensive Assessment question 15 is marked that it is somewhat important for resident #82 to watch the news on TV. Question 18 is marked that it is very important for resident # 22 to watch TV in general. During a review on 11/13/23 at 2:00 PM of the grievance and concern forms dated 10/03/23 reads as follows T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have pictures. The action taken to resolve this concern reads, We are having (name of tv provider) to come and rewire the bad wires going through the gutters. During an interview on 11/13/23 at 2:20 PM, the maintenance director stated, The part has been ordered for the TV'S and should be here today. These TVs have been like this for as long as I have been here at least a couple of months. f) Resident #73 An observation on 11/12/23 at 12:00 PM, revealed that resident #73 TV has lines going through it at the top, middle and bottom. During an Interview on 11/12/23 at 12:00 PM Resident #73 stated, I don't watch the dang thing anymore, these lines makes it to where I can even hardly see it An observation on 11/13/23 at 1:00 PM, revealed that Resident #73's TV continued to have the lines going through it. During an record review on 11/13/23 at 1:15 PM, of resident # 73 Activity Participation records for the months of October and November revealed that residents is marked watching TV everyday as an Individual activity. During a record review on 11/13/23 at 1:45 PM, Resident #73's Recreation Comprehensive Assessment question 15 is marked that it is very important for resident #73 to watch the news on TV. Question 18 is marked that it is very important for resident # 73 to watch TV in general. During a review on 11/13/23 at 2:00 PM of the grievance and concern forms dated 10/03/23 reads as follows T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have pictures. The action taken to resolve this concern reads, We are having (name of tv provider) to come and rewire the bad wires going through the gutters. During an interview on 11/13/23 at 2:20 PM, the maintenance director stated, The part has been ordered for the TV'S and should be here today. These TVs have been like this for as long as I have been here at least a couple of months. Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for six (6) of six (6) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident Identifier: Resident #85, Resident #62, Resident #96, Resident #22, Resident #82, and Resident #73 . Facility Census: 115. Findings Included: a) Resident #85 During an interview on 11/12/23 at 11:56 AM, Resident # 85 stated there are no activities, I do stuff in my room to keep busy, but they don't do anything. During a record review on 11/15/23 9:30 AM , Resident #85's medical record revealed an recreation comprehensive assessment dated [DATE] with the Resident Preferences coded were listed as follows: -bingo -doing things with groups of people -Social gatherings -Outside for fresh air -Attend Religious services Further record review revealed Resident #85's care plan: Focus: While in the facility, resident states that it is important that she has the opportunity to engage in daily routine that meaningful relative to her preferences Interventions included: I like to participate in socializing and bingo with groups of people I am of the Christian faith and would like to participate in religious services/practices. Further record review revealed an November activity monthly calendar included the following group activities Resident #85's has a preference in. Religious services: 11/01, 11/05, 11/08, 11/11, 11/12, and 11/13 Bingo: 11/02,11/04, 11/06, 11/09, and 11/13 Socials: 11/10 Further record review revealed Resident #85's November activity participation record: -Bingo was void any documenting Resident #85 was invited or refused on the following date: 11/04. -Religious services was void any documentation Resident #85 was invited or refused on the following dates: 11/01, 11/05, 11/08, 11/11, 11/12, and 11/13. -Socials: was void any documentation Resident #85 was invited or refused on the following date:11/10 During an interview on 11/15/23 at 9:44 AM, the Recreation Director (RD)#102 stated sometimes Resident #85 does not like to attend evening activities so we don't invite her, it is not on the care plan. The RD was asked What about the daytime activities and not getting invited? The RD stated, I don't guess we asked her to come to the activities if it's not documented. b) Resident #62 During an interview on 11/12/23 11:36 AM Resident # 62 stated that there is nothing to do here especially on weekends, all we do is sit here and watch the idiot box (TV) During a record review on 11/15/23 8:30 AM , Resident #62's medical record revealed an recreation comprehensive assessment dated [DATE] with the Resident Preferences coded were listed as follows: -Listens to music -doing things with groups of people -Social gatherings -Outside for fresh air -Attend Religious services Further record review revealed Resident #62's care plan: Focus: While in the facility, the resident states that it is important that she has the opportunity to engage in a daily routine that is meaningful relative to her preferences. Goal: Resident will express satisfaction that her daily routines and preferences are accommodated by staff. Interventions includes: I like to participate in social gatherings, church, and bingo with groups of people. It is important for me to engage in my favorite activities: reading, socializing, listening to music, watching television and talking with family. Further record review revealed an November activity monthly calendar included the following group activities Resident #62 has a preference in: Religious services: 11/01, 11/05, 11/08, 11/11, 11/12, 11/13 Bingo: 11/02,11/04, 11/06, 11/09, 11/13 Music: 11/07, Socials: 11/10 Further record review revealed Resident #62's November activity participation record: -Music on 11/07 was void any documentation Resident #62 was invited or refused. -Religious services was void any documentation Resident #62 was invited or refused on the following dates: 11/01, 11/05, 11/08, 11/13. During a interview on 11/15/23 at 9:55 AM the Recreation Director #102 acknowledged Resident #62 was not invited to the activities of her preferences. c) Resident #96 An interview with Resident #96 on 11/12/23 at 1:30 PM, revealed his Television (TV) was not working. He turned on the television to show the surveyor there was lines in the picture and a static sound coming through the speakers. Resident #96 stated, I like to watch television. Watching televisions is all I like to do, but for the last two (2) months he has not been able to watch it because it has been broken. The Maintenance Director entered the room and was checking the beds during this resident interview. The maintenance director was asked if he knew what was going on with the resident's television. He stated, it had been like this for a few months now. He further stated, they just recently ordered a part which they hope will fix the problem. Upon returning to the building on 11/13/23 at 8:00 am, it was discovered the televisions had been fixed. The maintenance director confirmed the part arrived and it has been installed and the problem has been fixed. A review of the grievance and concern forms found the following concern dated 10/03/23 related the televisions on the east hallway made by the resident council. The concern form reads as follows, T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have picture. The action taken to resolve this concern was as follows, We are having (name of TV provider) to come and rewire the bad wires going threw [SIC] the gutters. An interview with the Nursing home administrator on 11/13/23 at 12:58 PM, confirmed she ordered the part to fix the televisions on 11/08/23 and it came in on 11/13/23 and they were able to get the televisions fixed. She confirmed it was an ongoing problem for a few months now and (name of TV provider) had been in a few times but was unable to fix them. She stated, as soon as they told her to order this part she did. When asked to provide evidence the TV provider had been to the facility to address this issue she was unable to locate any evidence. A review of Resident #96's medical record found an activity assessment dated [DATE] which indicated Resident #96 enjoys watching television and prefers independent activities as opposed to group activities. A review of the Resident #96's activity participation log found the resident was marked as watching TV daily for the entire month of October and the first 13 days of November even though his TV was not working and the Resident stated he was unable to watch television because of this. An interview with the Recreational Director on 11/15/23 at 9:57 am confirmed Resident #96 likes to watch TV daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e) Resident #73 Record review on 11/14/23 at 10:00 AM, found the following order: Humulin R 100 units, 1 ml, inject 8 units subcutaneously after meals for Diabetes Mellitus (DM) type II with hyperglycemia. Notify provider of glucose less than 70 or greater than 400 Review of the MAR found the following occasions when the Resident's blood glucose reading was more than 400: 11/04/23 at 6:00 PM, 431, 11/05/23 at 1:00 PM, 432, and at 6:00 PM 432, 11/07/23 at 1:00 PM 524 and at 6:00 PM, 476, 11/13/23 at 1:00 PM, 407. There is no documentation to show that the physician had been notified of these blood sugars. During an interview on 11/14/23 at 10:15 AM, unit manager #27 stated, If the blood sugar is over 400 we should be notifying the physician. On 11/14/23 at 10:45 AM, the DON stated, The notes for the days that his blood sugar was over 400 are not in his chart, they should be. f) Resident #18 On 11/12/23 at 12:21 PM Resident #18 stated, Its kinda like what they say is what goes. Sometimes they take care of my skin, sometimes not. Resident #18 stated he was chapped and raw in his private area, they girls on midnights told him they weren't allowed to put the creams on him, but he needed the cream down there. Resident #18 further stated he didn't understand why some days they looked at his heels and other days no one paid any attention them. Record review showed an order for heel lifter to be used while in bed as resident will allow every day and night shift for redness. Review of the Treatment Administration Record (TAR) showed the order was not completed on 11/06/23 night shift, 11/11/23 day shift, and 11/12/23 day shift. Record review showed an order for cleanse bilateral feet with wound cleaner, pat dry. Apply Aquaphor every day and night shift for 14 weeks dry skin to bilateral feet. Review of the TAR showed the order was not completed on 11/06/23 night shift, 11/11/23 day shift, and 11/12/23 day shift. Record review showed on order to cleanse deep tissue injury left heel with wound cleaner, pat dry. Apply Sure Prep every day and night shift every day. Review of the TAR showed the order was not completed on 11/06/23 night shift, 11/11/23 day shift, and 11/12/23 day shift. Record review showed on order to cleanse deep tissue injury to right heel with wound cleaner, pat dry. Apply Sure Prep every day and night shift every day Review of the TAR showed the order was not completed on 11/06/23 night shift, 11/11/23 day shift, and 11/12/23 day shift. Record review showed on order to monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable. Review of the TAR showed the order was not completed on 11/06/23 night shift, 11/11/23 day shift, and 11/12/23 day shift. g) Resident #86 During an interview on 11/12/23 at 12:58 PM Resident #86 stated, They are inconsistent at taking care of my heel. Some days I have to ask for the stuff to be rubbed on. I don't want it to get broke down again. Record review showed on order to cleanse boggy left heel with wound cleaner, pat dry. Apply Sure Prep daily every day shift. Review of the TAR showed the order was not completed on 11/02/23, 11//11/23, 11/12/23. Record review showed on order to cleanse deep tissue injury (unopened) to right hill heel with wound cleanser, pat dry. Apply Sure Prep every day and night shift daily. Review of the TAR showed the order was not completed on 11/6/23 night shift, 11/11/12 dayshift, 11/12/23 dayshift. During an interview on 11/14/23 at 10:00 AM, The Administrator stated, I don't understand why these treatments weren't done, I have hired an extra wound care nurse to help out. h) Resident #28 On 11/12/23 at 12:13 PM observation was made of the Residents inhaler medication laying on his over the bed table, unattended by staff. Resident was isolation room with door closed for diagnosis of Covid-19. Licensed Practical Nurse (LPN) #36 came to Resident's room door and stated, No it shouldn't be in there, I left it in there when I set his breathing treatment up this morning. The LPN told Surveyor, Reach it to me and I'll take it with me. LPN #36 had her hands full of a cup of water and mediation what appeared to be a cup of medication. LPN #36 nodded her head downward and had surveyor drop the Resident's inhaler into her right uniform pocket. The inhaler was then placed back into the medication cart with other mediations without disinfecting it. Record review showed the following orders: -Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (Fluticasone-Salmeterol). inhale one (1) puff orally two times a day for Chronic Obstructive Pulmonary Disease (COPD). -Rinse mouth with water after use of corticosteroid, do not swallow every day and night shift. -Droplet contact isolation every shift for COVID positive until 11/17/2023. Record reviewed indicated Resident #28 did not have an order to self-administer mediations. During an interview on 11/12/23 at 3:00 PM, LPN #36 was asked if she was present when the Resident used the inhaler that was left in the room, and did she instruct the Resident to rinse his mouth afterwards? LPN #36 stated, No, I have no idea if he had a chance to use it or not. He should know to rinse his mouth. Record review of the facility's policy and procedure titled, Medication Administration: Metered Dose Inhaler, revised date 06/01/21, showed that when inhaled corticosteroids are administered instruct the patient to rinse and gargle with water and then to expectorate after each dose. The following Residents were indicated to have the potential to wander into Resident #28's room and have access the inhaler mediation that was left unattended: Resident #5, #105, #17, #87, #3, #75, #14, #8, 53, #70, #24, #93. #59, #55, #83, #45, #6, #58, #73, #47, #16, #109, #96. Based on record review and staff interview, the facility failed to follow Physicians orders in the areas of neurological checks, medication administration, and skin/wound treatments. Resident identifiers: #42, #67, #1, #56, #73, #86, #18 and #28. Facility Census: 115 Findings Included: a) Resident #42 1) Record review on 11/14/23 at 01:04 PM shows resident #42 had an unwitnessed fall on 08/08/23 at 12:45 PM. Status post of the fall he complained of right leg and back pain. He was sent to the local emergency room for X-rays, which were negative, and he returned to the facility on [DATE] at 06:50 PM. Facility policy NSG204 Neurological Evaluation, revision date of 06/01/21 states: Neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: Every 15 minutes X two (2( hours, then Every 30 minutes X two (2) hours, then Every 60 minutes X four (4) hours, then Every eight (8) hours until at least 72 hours has elapsed. Further record review and an interview on 11/14/23 at 02:30 PM with the Administrator, found there were no neurological evaluations performed for this unwitnessed fall. 2) On 11/13/23 at 02:08 PM record review shows on 09/01/23 at 06:00 PM Resident #42's blood glucose was elevated at 422. Review of the Physicians order is as follows: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneous after meals for DM type II with hyperglycemia Notify provider of glucose less than 70 or greater than 400 There was no available documentation indicating the Physician was notified of the elevated blood glucose. This was confirmed with the Administrator on 11/14/23 at 09:10 AM. No additional information was provided prior exiting the survey. b) Resident #67 On 11/14/23 at 07:15 AM, record review of the Treatment Administration Record (TAR) for October and November, 2023 found the following: a) numerous skin treatments missed. X13 b) Peripherally inserted central catheter (PICC) line dressing change not completed as ordered. X1 c) neuromuscular checks not completed as ordered. X2 d) Wound monitoring not completed as ordered X 2 Documentation on the October TAR shows: Skin treatment: Cleanse closed surgical incision to Left heel with in house wound cleanser (IHWC), pat dry, apply sure-prep all over cream every day and night shift. The night shift treatment was not documented as being performed on 10/25/23. Documented on the November TAR shows: Change Transparent Dressing to PICC every day shift every Tuesday until 11/20/23. This day shift treatment was not documented as being performed on 11/07/23 Neuromuscular Checks: Check pedal pulse, capillary refill, signs/symptoms of acute pain and swelling. Every day and night shift for Neuromuscular Check of left extremity while in stabilizer. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment: Cleanse bilateral lower extremities with IHWC, pat dry. Apply a liberal amount of Aquaphor to both extremities every day and night shift to protect/heel severely dry skin. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment: Cleanse Incontinence associated dermatitis to bilateral buttock with Remedy Foam, pat dry, apply Calazime every day shift. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment Cleanse left lateral calf incisions X 2 with (X2 stitches each) with IHWC, pat dry. Apply sure prep to the peri wound. Apply Xerofoam and betadine, cover with Telfa. Wrap with Kerlix and ACE every 2 days and as needed (PRN) every day shift every 2 days for left lateral calf incisions X 2 with stitches X2. This day shift treatment was not documented as being performed on 11/07/23. Skin Treatment Cleanse moisture associated skin damage (MASD) under abdominal folds with IHWC, pat dry, apply calezime every day shift for MASD under abdominal folds. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment, cleanse MASD under bilateral breast with IHWC pat dry and apply calezime every day shift for MASD under bilateral breast. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment Cleanse small incision to left inner ankle with IHWC pat dry, apply sure prep to site every day shift. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment cleanse small incisions X 3 to outer left leg with IHWC, pat dry, Apply sure prep every day shift. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Wound(s): Monitor site(s) daily for status of surrounding tissues and wound pain. Monitor for status of dressing(s), if applicable, additional documentation in nurses note if needed. This day shift wound monitoring was not documented as being performed on 11/02/23 and 11/07/23 The above missed treatments were confirmed with Administrator on 11/15/23 at 10:57 AM. She stated they were treatments that were not documentation as being completed. c 1) Resident #1 late medication administration. During a review of the Medication Administration Audit Report (MAAR) Resident #1 received a scheduled medication more than an hour late. The following medications, dates and times are listed below: On 10/02/23 day shift below is a list of medications given by Registered Nurse (RN) #17. -Percocet (pain medication). Give 1 tablet two (2) times a day for pain. Scheduled for 10:00 AM, was given at 12:54 PM. -Lyrica (for neuropathy pain). Give 1 tablet two (2) times a day for pain. Scheduled for 10:00 AM, was given at 12:54 PM. -Wixela inhaler. Give inhalation 1 tablet two (2) times a day for Chronic Obstructive Pulmonary Disease (COPD). Scheduled for 10:00 AM, was given at 12:54 PM. -Keppra. Give 1 tablet two (2) times a day for seizures. Scheduled for 10:00 AM, was given at 12:54 PM. On 10/06/23 day shift medications given by Licensed Practical Nurse (LPN) #43. -Percocet (pain medication). Give 1 tablet two (2) times a day for pain. Scheduled for 10:00 AM, was given at 3:20 PM. -Wixela inhaler. Give inhalation 1 tablet two (2) times a day for Chronic Obstructive Pulmonary Disease (COPD). Scheduled for 10:00 AM, was given at 3:20 PM. On 10/30/23 day shift medications given by LPN #26. -Cipro Dex Otic Suspension instill 4 drops in the left ear two times a day for [NAME] (middle ear infection) Scheduled for 9:00 AM, given at 1:47 PM. On 11/03/23 day shift given by LPN #36 -Insulin Glargine Pen inject subcutaneously two (2) times a day for (blood glucose control). Scheduled for 10:00 AM, given at 2:00PM. c2) Resident #1 missed treatments. A review of records found Resident #1 missed one (1) treatment on 10/14/23. Order read: Skin treatment- Cleanse raised area to top of right pinky finger with wound cleanser, pat dry, apply surprep. On 11/13/23 at 12:45 PM the Administrator stated she was ashamed of give this surveyor the MAR because of the late medication. On 11/14/23 at 3:10 PM Director of Nursing (DON) was asked about the late medications and the missed skin treatment. DON stated she was not sure why the medications were so late and agreed it was more than an hour past due. DON stated she had no explanation for the missed skin treatment. d1) Resident #56 late medicate. On 11/12/23 at 11:30 AM Resident #56 stated the biggest problem she has at the facility is some of the nurses do not give her the medication she needs like insulin and antibiotics for many hours after it was due. Resident #56 said it is mostly night shift, but day shift has been late too. After a review of the MAAR found many medications given beyond the acceptable one (1) hour after the scheduled time. On 08/01/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 12:00 PM, and given at 3:50 PM, by LPN #42. On 08/01/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM not given until 5:39 AM on 08/02/23, by LPN #34. On 08/04/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and give on 08/05/23 at 2:13 AM by LPN #22. On 08/05/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and given on 08/06/23 at 1:22 AM by LPN # 42. On 08/06/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and give on 08/07/23 at 12:39 AM by LPN #42 On 08/07/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and given at 08/08/23 at 12:49 AM by LPN #42. On 09/20/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 AM and given at 09/20/23 at 1:38 PM by LPN #143. On 09/20/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 12:00 PM and given at 09/20/23 at 1:38 PM by LPN #143. Note the two (2) doses for 09/20/23 for 8 AM and 12 PM were combined to one dose at 1:38 PM. On 08/03/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/04/23 at 2:45 AM by RN #17 On 08/04/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/05/23 at 2:13 AM by LPN #32. On 08/05/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/06/23 at 1:22 AM by LPN #34. On 08/06/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/07/23 at 12:49 AM by LPN #32. On 08/07/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/08/23 at 12:49 AM by LPN #32. On 08/10/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/11/23 at 2:45 AM by LPN #32. On 08/11/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/12/23 at 12:48 AM by LPN #32. On 08/15/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/16/23 at 1:59 AM by LPN #32. On 08/16/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/17/23 at 4:14 AM by LPN #32. On 08/18/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/19/23 at 2:06 AM by LPN #32. On 08/19/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/19/23 at 2:10 AM by RN #17. On 08/19/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/20/23 at 1:16 AM by LPN #39. On 08/20/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/20/23 at 12:34 AM by RN #17. On 08/20/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/21/23 at 1:16 AM by LPN #32. On 08/21/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/22/23 at 2:13 AM by LPN #32. On 08/24/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/25/23 at 2:21 AM by LPN #32. On 08/25/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/26/23 at 2:20 AM by LPN #32. On 08/26/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/27/23 at 12:53 AM by LPN #32. On 08/29/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/29/23 at 4:35 PM by RN#17. On 08/30/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/30/23 at 2:46 PM by RN#17. On 08/31/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/31/23 at 12:14 PM by LPN #30. On 09/02/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 09/03/23 at 1:10 AM by LPN #32. On 09/03/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 09/04/23 at 2:04 AM by LPN #32. On 09/04/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 09/04/23 at 12:01 PM by LPN #42. On 08/02/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 4:30 PM not given until 08/02/23 at 7:53 PM by LPN #42. On 08/21/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 11:30 AM not given until 08/21/23 at 2:28 PM by LPN #42. On 08/29/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 11:30 AM not given until 08/29/23 at 4:35 PM by LPN #42. On 08/30/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 11:30 AM not given until 08/30/23 at 7:46 PM by RN #17. On 09/04/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 4:30 PM not given until 09/05/23 at 6:04 AM by LPN #42. On 11/14/23 at 3:34 PM DON reviewed the MAAR and agreed the times mentioned above were not within the standards of nursing practice. d2) Resident #56 missed treatment of wound. A review of the medical records found Resident #56 had an order for a treatment of a wound on the left breast. The order was written as: Irrigate wound to left breast with In-house wound cleanser or normal saline; Pack with iodoform and apply border gaze, every shift. On 10/14/23, 10/19/23, and 10/20/23 nothing was documented for shift 7a. Farther review revealed the treatment for yeast in the folds of the back was written as: Nystatin External Powder, apply to folds to lower back topically every 6 hours yeast. The missed treatments were: 09/07/23 at 6 AM, and 6 PM, 09/09/23 at 6 AM, and 6 PM. 09/10/23 at 6 PM 09/14/23 at 6 AM 09/15/23 at 6 AM 09/17/23 at 12 PM and 6 PM. 09/24/23 at 12 PM and 6 PM. 09/26/23 at 6 AM. 10/01/23 at 6 PM 10/02/23 at 12 AM, and 6 AM 10/03/23 at 12 PM. On 11/13/23 at 12:45 PM the Administrator stated she was ashamed of giving this surveyor the MAAR because of the late medication. On 11/14/23 at 3:10 PM Director of Nursing (DON) was asked about the late medications and the missed skin treatment. DON stated she was not sure why the medications were so late and agreed it was more than an hour past due. DON stated she had no explanation for the missed skin treatment. On 11/13/23 at 3:12 PM LPN #20 (also the wound nurse) was asked about the missed treatment for the yeast infection on Resident #56. LPN #20 stated she gets most of them. This is a 120-bed facility. She was asked if she had time to do the treatments and there was no response. d3) #56 elevated blood glucose not notified to the physician timely. During a review of the medical record of Resident #56 it was revealed there were multiple times the blood glucose levels were greater than 400. The order from the facility physician stated to call them if greater than 400. A review of the Medication Administration Record (MAR) found the following times the blood glucose was over 400 or was not done: 09/04/23 at 4:30 PM no blood glucose was recorded. 09/09/23 at 4:30 PM no blood glucose was recorded. 09/30/23 at 4:30 PM blood glucose was 488. No note about notifying the physician. 10/06/23 at 4:30 PM blood glucose was 504. The physician was notified at 6:08 PM. 10/07/23 at 6:30 AM blood glucose was 428. No note about notifying the physician. 10/07/23 at 4:30 PM blood glucose was 484. The physician was notified at 6:43 PM. 10/09/23 at 4:30 PM blood glucose was 486. The physician was notified at 6:43 PM. 10/14/23 at 4:30 PM blood glucose was 435. No note about notifying the physician. 10/16/23 at 11:30 AM blood glucose was 401. No note about notifying the physician. 10/22/23 at 4:30 PM blood glucose was 496. The physician was notified at 6:45 PM. 11/09/23 at 4:30 PM blood glucose was 432. No note about notifying the physician. On 11/13/23 at 3:31 PM, the Director of Nursing (DON) was informed of the information above and agreed there was not consistent notification to the physician and when it was reported it was more than two (2) hours later.

Based on observation, medical record review, staff interview and resident interview the facility failed to ensure the environment is free from accident hazards over which it has control. Resident #111's cigarettes were in the room and Resident #28's inhaler was left in the room. This failed practice had a potential to affect more than an isolated number of residents. Resident identifier: Resident #111 and Resident #28. Facility Census: 115. Findings Included: a) Resident #111 During the initial tour 11/12/23 at 11:42 AM, Resident #111 had three (3) cigarettes laying on the over bed tables. There was no lighter found. During another observation on 11/13/23 at 10:55 AM , Resident #111 one (1) cigarette was laying on the over the bed table. During an observation on 11/13/23 at 2:00, Resident #111 had no cigarettes on the over the bed table. During an interview on 11/13/23 at 2:01 PM, Resident # 111 stated I don't smoke here. I am not allowed. During an interview on 11/13/23 at 3:52 PM the Administrator stated there was no smoking evaluation completed because resident #111 does not smoke. The Administrator was asked so no one saw the cigarettes on the over the bed tray on Sunday and Monday? The Administrator stated, I will educate the staff on what to do about the cigarettes and lighter when they find them. During an interview on 11/13/23 at 4:27 PM, Maintenance Director (MD) #107, stated I have seen Resident # 111 smoking in his room. The MD was asked what did you do when you found Resident #111 smoking? The MD stated I took them from him and told him he wasn't allowed to smoke in here. During an interview on 11/13/23 at 4:33 PM the Administrator stated Resident # 111 was found with cigarettes on date 11/10/23 and no notes were documented about the issue. I am going to reeducate the smokers and make them sign a new smoking procedures agreement. Resident #111 also has visitors so we think they are bringing them to him. We called the son but it was not documented anywhere. During an interview 11/14/23 at 8:13 AM the Administrator stated Resident # 111 is on 1:1 at all times. Some of the employees have witness the other residents giving Resident # 111 cigarettes but never did anything or told anyone. We have completed a smoking evaluation on Resident # 111. All the smokers have signed a new agreement. We completed a room sweep, and did not find anything. b) Resident #28 On 11/12/23 at 12:13 PM observation was made of the Residents inhaler medication laying on his over the bed table, unattended by staff. Resident was isolation room with door closed for diagnosis of Covid-19. Licensed Practical Nurse (LPN) #36 came to Resident's room door and stated, No it shouldn't be in there, I left it in there when I set his breathing treatment up this morning. The LPN told Surveyor, Reach it to me and I'll take it with me. LPN #36 had her hands full of a cup of water and mediation what appeared to be a cup of medication. LPN #36 nodded her head downward and had surveyor drop the Resident's inhaler into her right uniform pocket. The inhaler was then placed back into the medication cart with other mediations without disinfecting it. Record review showed the following orders: -Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (Fluticasone-Salmeterol). inhale one (1) puff orally two times a day for Chronic Obstructive Pulmonary Disease (COPD). -Rinse mouth with water after use of corticosteroid, do not swallow every day and night shift. -Droplet contact isolation every shift for COVID positive until 11/17/2023. Record reviewed indicated Resident #28 did not have an order to self-administer mediations. During an interview on 11/12/23 at 3:00 PM, LPN #36 was asked if she was present when the Resident used the inhaler that was left in the room, and did she instruct the Resident to rinse his mouth afterwards? LPN #36 stated, No, I have no idea if he had a chance to use it or not. He should know to rinse his mouth. Record review of the facility's policy and procedure titled, Medication Administration: Metered Dose Inhaler, revised date 06/01/21, showed that when inhaled corticosteroids are administered instruct the patient to rinse and gargle with water and then to expectorate after each dose. The following Residents were indicated to have the potential to wander into Resident #28's room and have access the inhaler mediation that was left unattended: Resident #5, #105, #17, #87, #3, #75, #14, #8, 53, #70, #24, #93. #59, #55, #83, #45, #6, #58, #73, #47, #16, #109, #96.

Based on observation, record review, resident interview and staff interview the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: Resident #85, Resident #266 and Resident #22. Facility Census: 115. a) Test tray On 11/12/23 at 1:08 PM, the temperatures were obtained on the lunch meal tray at the time of service. The following temperatures were obtained by the Dietary Account Manager #108 using her thermometer: -chicken cacciatore: 124 degrees Fahrenheit -mixed vegetables: 110 degrees Fahrenheit -peach slices: 54.5 degrees Fahrenheit -chicken noodle soup: 125 degrees Fahrenheit. During an immediate interview the Dietary Account Manager #108 acknowledged the temperatures were not at the appropriate serving temperatures. And stated the hot foods should be over 120 degrees and the cold foods below 50 degrees. b) Interviews: During an interview on 11/12/23 at 11:56 AM, Resident #85 stated the food is always cold, does not matter which meal it is, it's always cold. During an interview on 11/12/23 at 12:30 PM, Resident #266 stated the food was cold on several occasions since she arrived on 11/08/23. During an interview on 11/12/23 at 1:42 PM, Resident # 22 stated the food is cold most of the time. c) Resident Council minutes During the Resident Council meeting held on 11/13/23 beginning at 1:00 PM the Resident as a group were asked, How is the food? Several residents responded the food is cold. Review of the previous monthly Resident Council Minutes revealed the following: -11/07/23 Food from the kitchen for meals is cold -09/05/23 Food is cold, barely warm some meals d) Test tray audit form A review of a test tray audit form the dietary department on 11/10/23 revealed the following temperatures: Pureed eggs: 100 degrees Pureed meat: 100 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, staff interviews and observations, the facility failed to ensure all staff were competent and there were Sufficient nursing staff relate: to extremely late and omitted medications, Nursing staff failed to notify the physician and/or not done timely when blood glucose levels are not in the set parameter, showers not provided for dependent residents, missed treatment, lacking in meaningful activities, catheter care, care for tube feedings, staff adhering to infection control practices (including residents that are positive for COVID-19), and staff failed to document and dispense night time ordered snacks. Facility census 117. Findings included: I) F677 a) Resident #24 During an interview on 11/12/23 at 11:44 AM, Resident # 24 stated I don't get showers or bed baths. Observation revealed Resident #24's hair was disheveled and sticking up everywhere. During an interview on 11/13/23 at 10:35 AM, Resident # 24 stated, The night shift (Nurse Aide (NA) #76's name) left me shitty since two (2) AM, and I am still not changed, and I still have not gotten a shower or bed bath. This surveyor asked Resident # 24 to turn on the call light at 10:37 AM. The Administrator in Training (AIT) #97 came into the room at 10:39 AM and stated I saw your call light on what do you need? Resident # 24 stated, I have not been cleaned since two (2) AM that (Nurse Aide (NA) #76's name) never cleaned me up and I have been lying in shit since then. I want her fired. All she does is sit at the nurses station all night and don't help no one. The AIT #97 acknowledged the resident needed a bath and needed to be changed. During an interview on 11/13/23 at 12:13 PM, the Administrator stated a grievance was started and was reported. The NA was suspended. Resident # 24 is care planned for refusal of care. During a record review on 11/13/23 at 1:13 PM, the facility shower schedule reflected Resident # 24 shower days were Monday and Thursday on the 7 AM to 7 PM shift. During a record review on 11/14/23 02:27 PM, Resident #24 medical record revealed the following care plan: (typed as written) Focus: Resident has self care deficit due to muscle weakness and multiple disease processes. Goals: Resident will participate in ADL's daily and have a neat, clean, well groomed appearance daily through the next quarterly review Interventions included: Bed baths daily with showers two(2) times a week and as needed (PRN). Resident prefers showers on Monday and Thursday. Resident usually performs substantial/maximal assist for dressing. Resident usually performs dependent assist for bathing. During an interview on 11/14/23 at 10:45 AM, the Administrator presented evidence the alleged allegation was reported to the required State authorities. b) Resident #61 During an interview on 11/12/23 at 11:32 AM with Resident #61, she stated she wasn't getting her bed baths as scheduled. Her hair appeared to be unclean. On 11/13/23 at 10:00 AM record review shows her showers are scheduled for Wednesday and Saturday on day shift. Her care plan states Bed baths daily with showers 2 x's a week and PRN (as needed). A review of her daily task sheet for baths and showers for the past 30 days shows the following: 10/16/23 bed bath 10/17/23 no bed bath or shower 10/18/23 received scheduled shower 10/19/23 no bed bath or shower 10/20/23 bed bath 10/21/23 shower scheduled, received (rec'd) bed bath 10/22/23 no bed bath or shower 10/23/23 Refused 10/24/23 bed bath 10/25/23 received scheduled shower 10/26/23 no bed bath or shower 10/27/23 no bed bath or shower 10/28/23 shower scheduled, rec'd bed bath 10/29/23 no bed bath or shower 10/30/23 bed bath 10/31/23 no bed bath or shower 11/01/23 received scheduled shower 11/02/23 no bed bath or shower 11/03/23 bed bath 11/04/23 received scheduled shower 11/05/23 no bed bath or shower 11/06/23 no bed bath or shower 11/07/23 bed bath 11/08/23 Refused 11/09/23 no bed bath or shower 11/10/23 no bed bath or shower 11/11/23 received scheduled shower 11/12/23 Refused 11/13/23 no bed bath or shower 11/14/23 no bed bath or shower Eight (8) showers should have been provided during this time period. The Resident received five (5) showers. She refused (once) and received a bed bath instead of a shower on two (2) days. She missed one shower. However bed baths were due on each additional day. There were twenty two (22) opportunities for a bed bath from 10/16/23 through 11/14/23. She received eight (8) bed baths of the 22 (twenty two) opportunities. This was confirmed with the Administrator on 11/13/23 at 02:22 PM. No additional documentation was provided prior to exiting the survey. c) Resident #1 During an interview on 11/12/23 at 11:46 AM, Resident #1 said she is supposed to get a shower on Tuesdays and Thursdays. She also said she does not like getting a shower late at night, and when they offer one at 10:00 PM or 11:00 PM, I say no, but they do offer me one the next day. Resident # 1 is documented as being total dependent for bathing. A review of the shower records provided by the Administrator revealed Resident # 66 has received zero (0) showers in the last 14 days. On 11/15/23 at 9:56 AM, the Administrator reviewed the shower schedule and acknowledged there were no refusals documented. d) Resident # 66 On 11/12/23 at 11:57 AM, Resident #66 said he does not always get showers like he wanted. Resident #66 is documented as being total dependent for bathing. A review of the shower records provided by the Administrator revealed Resident # 66 has received three (3) showers in the last 22 days. On 11/15/23 at 9:56 AM, the Administrator was shown the facility form by the surveyor. No further information was provided before the close of the survey. II) F 679 a) Resident #85 During an interview on 11/12/23 at 11:56 AM, Resident # 85 stated there are no activities, I do stuff in my room to keep busy, but they don't do anything. During a record review on 11/15/23 9:30 AM , Resident #85's medical record revealed an recreation comprehensive assessment dated [DATE] with the Resident Preferences coded were listed as follows: -bingo -doing things with groups of people -Social gatherings -Outside for fresh air -Attend Religious services Further record review revealed Resident #85's care plan: Focus: While in the facility, resident states that it is important that she has the opportunity to engage in daily routine that meaningful relative to her preferences Interventions included: I like to participate in socializing and bingo with groups of people I am of the Christian faith and would like to participate in religious services/practices. Further record review revealed an November activity monthly calendar included the following group activities Resident #85's has a preference in. Religious services: 11/01, 11/05, 11/08, 11/11, 11/12, and 11/13 Bingo: 11/02,11/04, 11/06, 11/09, and 11/13 Socials: 11/10 Further record review revealed Resident #85's November activity participation record: -Bingo was void any documenting Resident #85 was invited or refused on the following date: 11/04. -Religious services was void any documentation Resident #85 was invited or refused on the following dates: 11/01, 11/05, 11/08, 11/11, 11/12, and 11/13. -Socials: was void any documentation Resident #85 was invited or refused on the following date:11/10 During an interview on 11/15/23 at 9:44 AM, the Recreation Director (RD)#102 stated sometimes Resident #85 does not like to attend evening activities so we don't invite her, it is not on the care plan. The RD was asked What about the daytime activities and not getting invited? The RD stated, I don't guess we asked her to come to the activities if it's not documented. b) Resident #62 During an interview on 11/12/23 11:36 AM Resident # 62 stated that there is nothing to do here especially on weekends, all we do is sit here and watch the idiot box (TV) During a record review on 11/15/23 8:30 AM , Resident #62's medical record revealed an recreation comprehensive assessment dated [DATE] with the Resident Preferences coded were listed as follows: -Listens to music -doing things with groups of people -Social gatherings -Outside for fresh air -Attend Religious services Further record review revealed Resident #62's care plan: Focus: While in the facility, the resident states that it is important that she has the opportunity to engage in a daily routine that is meaningful relative to her preferences. Goal: Resident will express satisfaction that her daily routines and preferences are accommodated by staff. Interventions includes: I like to participate in social gatherings, church, and bingo with groups of people. It is important for me to engage in my favorite activities: reading, socializing, listening to music, watching television and talking with family. Further record review revealed an November activity monthly calendar included the following group activities Resident #62 has a preference in: Religious services: 11/01, 11/05, 11/08, 11/11, 11/12, 11/13 Bingo: 11/02,11/04, 11/06, 11/09, 11/13 Music: 11/07, Socials: 11/10 Further record review revealed Resident #62's November activity participation record: -Music on 11/07 was void any documentation Resident #62 was invited or refused. -Religious services was void any documentation Resident #62 was invited or refused on the following dates: 11/01, 11/05, 11/08, 11/13. During a interview on 11/15/23 at 9:55 AM the Recreation Director #102 acknowledged Resident #62 was not invited to the activities of her preferences. c) Resident #96 An interview with Resident #96 on 11/12/23 at 1:30 PM, revealed his Television (TV) was not working. He turned on the television to show the surveyor there was lines in the picture and a static sound coming through the speakers. Resident #96 stated, I like to watch television. Watching televisions is all I like to do, but for the last two (2) months he has not been able to watch it because it has been broken. The Maintenance Director entered the room and was checking the beds during this resident interview. The maintenance director was asked if he knew what was going on with the resident's television. He stated, it had been like this for a few months now. He further stated, they just recently ordered a part which they hope will fix the problem. Upon returning to the building on 11/13/23 at 8:00 am, it was discovered the televisions had been fixed. The maintenance director confirmed the part arrived and it has been installed and the problem has been fixed. A review of the grievance and concern forms found the following concern dated 10/03/23 related the televisions on the east hallway made by the resident council. The concern form reads as follows, T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have picture. The action taken to resolve this concern was as follows, We are having (name of TV provider) to come and rewire the bad wires going threw [SIC] the gutters. An interview with the Nursing home administrator on 11/13/23 at 12:58 PM, confirmed she ordered the part to fix the televisions on 11/08/23 and it came in on 11/13/23 and they were able to get the televisions fixed. She confirmed it was an ongoing problem for a few months now and (name of TV provider) had been in a few times but was unable to fix them. She stated, as soon as they told her to order this part she did. When asked to provide evidence the TV provider had been to the facility to address this issue she was unable to locate any evidence. A review of Resident #96's medical record found an activity assessment dated [DATE] which indicated Resident #96 enjoys watching television and prefers independent activities as opposed to group activities. A review of the Resident #96's activity participation log found the resident was marked as watching TV daily for the entire month of October and the first 13 days of November even though his TV was not working and the Resident stated he was unable to watch television because of this. An interview with the Recreational Director on 11/15/23 at 9:57 am confirmed Resident #96 likes to watch TV daily. d) Resident #22 An observation on 11/12/23 at 11:30 AM revealed that resident #22's TV has lines going through it at the top, middle and bottom. 11:30 AM Resident # 22 stated, I go to activities on occasion but only when they don't have Covid. I enjoy watching TV, but I decided not to watch it because it gets on my nerves with the lines through it. Sometimes it makes a noise depending on what channel you are on. I have complained but it hasn't been fixed yet, she thinks they have ordered a part. An observation on 11/13/23 at 1:00 PM revealed that resident # 22 TV continued to have the lines going through it. During an record review on 11/13/23 at 1:15 PM of resident # 22 Activity Participation records for the months of October and November revealed that resident is marked watching TV everyday as an Individual activity. During a record review on 11/13/23 at 1:15 PM resident #22 Recreation Comprehensive Assessment question 15 is marked that it is very important for resident #22 to watch the news on TV. Question 18 is marked that it is very important for resident # 22 to watch TV in general. During a review on 11/13/23 at 2:00 PM of the grievance and concern forms dated 10/03/23 reads as follows T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have pictures. The action taken to resolve this concern reads, We are having (name of tv provider) to come and rewire the bad wires going through the gutters. During an interview on 11/13/23 at 2:20 PM the maintenance director stated, The part has been ordered for the TV'S and should be here today. These TVs have been like this for as long as I have been here at least a couple of months. e) Resident #82 An observation on 11/12/23 at 11:45 AM, revealed that resident #82 TV has lines going through it at the top, middle and bottom. During an Interview on 11/12/23 at 11:45 AM, Resident #82 stated, This TV drives me crazy. It has been like this since I got here, I try to watch some of my shows, but usually end up turning it off because it's ridiculous An observation on 11/13/23 at 1:00 PM revealed that resident # 82's TV continued to have the lines going through it. During an record review on 11/13/23 at 1:15 PM, of resident # 82 Activity Participation records for the months of October and November revealed that resident is marked watching TV everyday as an individual activity. During a record review on 11/13/23 at 1:30 PM, Resident #82's Recreation Comprehensive Assessment question 15 is marked that it is somewhat important for resident #82 to watch the news on TV. Question 18 is marked that it is very important for resident # 22 to watch TV in general. During a review on 11/13/23 at 2:00 PM of the grievance and concern forms dated 10/03/23 reads as follows T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have pictures. The action taken to resolve this concern reads, We are having (name of tv provider) to come and rewire the bad wires going through the gutters. During an interview on 11/13/23 at 2:20 PM, the maintenance director stated, The part has been ordered for the TV'S and should be here today. These TVs have been like this for as long as I have been here at least a couple of months. f) Resident #73 An observation on 11/12/23 at 12:00 PM, revealed that resident #73 TV has lines going through it at the top, middle and bottom. During an Interview on 11/12/23 at 12:00 PM Resident #73 stated, I don't watch the dang thing anymore, these lines makes it to where I can even hardly see it An observation on 11/13/23 at 1:00 PM, revealed that Resident #73's TV continued to have the lines going through it. During an record review on 11/13/23 at 1:15 PM, of resident # 73 Activity Participation records for the months of October and November revealed that residents is marked watching TV everyday as an Individual activity. During a record review on 11/13/23 at 1:45 PM, Resident #73's Recreation Comprehensive Assessment question 15 is marked that it is very important for resident #73 to watch the news on TV. Question 18 is marked that it is very important for resident # 73 to watch TV in general. During a review on 11/13/23 at 2:00 PM of the grievance and concern forms dated 10/03/23 reads as follows T.V. channels in rooms channels don't come in some channels pictures rolls some channels no sound but have pictures. The action taken to resolve this concern reads, We are having (name of tv provider) to come and rewire the bad wires going through the gutters. During an interview on 11/13/23 at 2:20 PM, the maintenance director stated, The part has been ordered for the TV'S and should be here today. These TVs have been like this for as long as I have been here at least a couple of months. III) F 684 a) Resident #42 1) Record review on 11/14/23 at 01:04 PM shows resident #42 had an unwitnessed fall on 08/08/23 at 12:45 PM. Status post of the fall he complained of right leg and back pain. He was sent to the local emergency room for X-rays, which were negative, and he returned to the facility on [DATE] at 06:50 PM. Facility policy NSG204 Neurological Evaluation, revision date of 06/01/21 states: Neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: Every 15 minutes X two (2( hours, then Every 30 minutes X two (2) hours, then Every 60 minutes X four (4) hours, then Every eight (8) hours until at least 72 hours has elapsed. Further record review and an interview on 11/14/23 at 02:30 PM with the Administrator, found there were no neurological evaluations performed for this unwitnessed fall. 2) On 11/13/23 at 02:08 PM record review shows on 09/01/23 at 06:00 PM Resident #42's blood glucose was elevated at 422. Review of the Physicians order is as follows: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneous after meals for DM type II with hyperglycemia Notify provider of glucose less than 70 or greater than 400 There was no available documentation indicating the Physician was notified of the elevated blood glucose. This was confirmed with the Administrator on 11/14/23 at 09:10 AM. No additional information was provided prior exiting the survey. b) Resident #67 On 11/14/23 at 07:15 AM, record review of the Treatment Administration Record (TAR) for October and November, 2023 found the following: a) numerous skin treatments missed. X13 b) Peripherally inserted central catheter (PICC) line dressing change not completed as ordered. X1 c) neuromuscular checks not completed as ordered. X2 d) Wound monitoring not completed as ordered X 2 Documentation on the October TAR shows: Skin treatment: Cleanse closed surgical incision to Left heel with in house wound cleanser (IHWC), pat dry, apply sure-prep all over cream every day and night shift. The night shift treatment was not documented as being performed on 10/25/23. Documented on the November TAR shows: Change Transparent Dressing to PICC every day shift every Tuesday until 11/20/23. This day shift treatment was not documented as being performed on 11/07/23 Neuromuscular Checks: Check pedal pulse, capillary refill, signs/symptoms of acute pain and swelling. Every day and night shift for Neuromuscular Check of left extremity while in stabilizer. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment: Cleanse bilateral lower extremities with IHWC, pat dry. Apply a liberal amount of Aquaphor to both extremities every day and night shift to protect/heel severely dry skin. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment: Cleanse Incontinence associated dermatitis to bilateral buttock with Remedy Foam, pat dry, apply Calazime every day shift. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment Cleanse left lateral calf incisions X 2 with (X2 stitches each) with IHWC, pat dry. Apply sure prep to the peri wound. Apply Xerofoam and betadine, cover with Telfa. Wrap with Kerlix and ACE every 2 days and as needed (PRN) every day shift every 2 days for left lateral calf incisions X 2 with stitches X2. This day shift treatment was not documented as being performed on 11/07/23. Skin Treatment Cleanse moisture associated skin damage (MASD) under abdominal folds with IHWC, pat dry, apply calezime every day shift for MASD under abdominal folds. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment, cleanse MASD under bilateral breast with IHWC pat dry and apply calezime every day shift for MASD under bilateral breast. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment Cleanse small incision to left inner ankle with IHWC pat dry, apply sure prep to site every day shift. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Skin Treatment cleanse small incisions X 3 to outer left leg with IHWC, pat dry, Apply sure prep every day shift. This day shift treatment was not documented as being performed on 11/02/23 and 11/07/23. Wound(s): Monitor site(s) daily for status of surrounding tissues and wound pain. Monitor for status of dressing(s), if applicable, additional documentation in nurses note if needed. This day shift wound monitoring was not documented as being performed on 11/02/23 and 11/07/23 The above missed treatments were confirmed with Administrator on 11/15/23 at 10:57 AM. She stated they were treatments that were not documentation as being completed. c 1) Resident #1 late medication administration. During a review of the Medication Administration Audit Report (MAAR) Resident #1 received a scheduled medication more than an hour late. The following medications, dates and times are listed below: On 10/02/23 day shift below is a list of medications given by Registered Nurse (RN) #17. -Percocet (pain medication). Give 1 tablet two (2) times a day for pain. Scheduled for 10:00 AM, was given at 12:54 PM. -Lyrica (for neuropathy pain). Give 1 tablet two (2) times a day for pain. Scheduled for 10:00 AM, was given at 12:54 PM. -Wixela inhaler. Give inhalation 1 tablet two (2) times a day for Chronic Obstructive Pulmonary Disease (COPD). Scheduled for 10:00 AM, was given at 12:54 PM. -Keppra. Give 1 tablet two (2) times a day for seizures. Scheduled for 10:00 AM, was given at 12:54 PM. On 10/06/23 day shift medications given by Licensed Practical Nurse (LPN) #43. -Percocet (pain medication). Give 1 tablet two (2) times a day for pain. Scheduled for 10:00 AM, was given at 3:20 PM. -Wixela inhaler. Give inhalation 1 tablet two (2) times a day for Chronic Obstructive Pulmonary Disease (COPD). Scheduled for 10:00 AM, was given at 3:20 PM. On 10/30/23 day shift medications given by LPN #26. -Cipro Dex Otic Suspension instill 4 drops in the left ear two times a day for [NAME] (middle ear infection) Scheduled for 9:00 AM, given at 1:47 PM. On 11/03/23 day shift given by LPN #36 -Insulin Glargine Pen inject subcutaneously two (2) times a day for (blood glucose control). Scheduled for 10:00 AM, given at 2:00 PM. c2) Resident #1 missed treatments. A review of records found Resident #1 missed one (1) treatment on 10/14/23. Order read: Skin treatment- Cleanse raised area to top of right pinky finger with wound cleanser, pat dry, apply surprep. On 11/13/23 at 12:45 PM the Administrator stated she was ashamed of give this surveyor the MAR because of the late medication. On 11/14/23 at 3:10 PM Director of Nursing (DON) was asked about the late medications and the missed skin treatment. DON stated she was not sure why the medications were so late and agreed it was more than an hour past due. DON stated she had no explanation for the missed skin treatment. d1) Resident #56 late medicate. On 11/12/23 at 11:30 AM Resident #56 stated the biggest problem she has at the facility is some of the nurses do not give her the medication she needs like insulin and antibiotics for many hours after it was due. Resident #56 said it is mostly night shift, but day shift has been late too. After a review of the MAAR found many medications given beyond the acceptable one (1) hour after the scheduled time. On 08/01/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 12:00 PM, and given at 3:50 PM, by LPN #42. On 08/01/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM not given until 5:39 AM on 08/02/23, by LPN #34. On 08/04/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and give on 08/05/23 at 2:13 AM by LPN #22. On 08/05/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and given on 08/06/23 at 1:22 AM by LPN # 42. On 08/06/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and give on 08/07/23 at 12:39 AM by LPN #42 On 08/07/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 PM and given at 08/08/23 at 12:49 AM by LPN #42. On 09/20/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 8:00 AM and given at 09/20/23 at 1:38 PM by LPN #143. On 09/20/23 Cleocin (an antibiotic) ordered to be given four (4) times a day for a dental abscess. Scheduled for 12:00 PM and given at 09/20/23 at 1:38 PM by LPN #143. Note the two (2) doses for 09/20/23 for 8 AM and 12 PM were combined to one dose at 1:38 PM. On 08/03/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/04/23 at 2:45 AM by RN #17 On 08/04/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/05/23 at 2:13 AM by LPN #32. On 08/05/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/06/23 at 1:22 AM by LPN #34. On 08/06/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/07/23 at 12:49 AM by LPN #32. On 08/07/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/08/23 at 12:49 AM by LPN #32. On 08/10/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/11/23 at 2:45 AM by LPN #32. On 08/11/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/12/23 at 12:48 AM by LPN #32. On 08/15/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/16/23 at 1:59 AM by LPN #32. On 08/16/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/17/23 at 4:14 AM by LPN #32. On 08/18/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/19/23 at 2:06 AM by LPN #32. On 08/19/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/19/23 at 2:10 AM by RN #17. On 08/19/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/20/23 at 1:16 AM by LPN #39. On 08/20/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/20/23 at 12:34 AM by RN #17. On 08/20/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/21/23 at 1:16 AM by LPN #32. On 08/21/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/22/23 at 2:13 AM by LPN #32. On 08/24/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/25/23 at 2:21 AM by LPN #32. On 08/25/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/26/23 at 2:20 AM by LPN #32. On 08/26/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 08/27/23 at 12:53 AM by LPN #32. On 08/29/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/29/23 at 4:35 PM by RN#17. On 08/30/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/30/23 at 2:46 PM by RN#17. On 08/31/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 08/31/23 at 12:14 PM by LPN #30. On 09/02/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 09/03/23 at 1:10 AM by LPN #32. On 09/03/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 PM not given until 09/04/23 at 2:04 AM by LPN #32. On 09/04/23 Insulin Glargine Pen (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 10:00 AM not given until 09/04/23 at 12:01 PM by LPN #42. On 08/02/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 4:30 PM not given until 08/02/23 at 7:53 PM by LPN #42. On 08/21/23 Insulin Humalog (used to control the level of glucose in the blood) to be given two (2) times a day. Scheduled for 11:30 AM not given until 08/21/23 at 2:28

Based on observation, facility document review, and staff interview the facility failed to post a staff posting that included the census, total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was true for the last quarter and currently. These failed practices had the potential to affect all residents. Facility census 117. Findings included: a) Staff postings On 11/12/23 at 10:30 AM it was noted the staff posting located at the front lobby of the facility did not contain the information of a daily census, number of nurse aides, number of nurses, and the total hours worked per day. On 11/12/23 at 11:00 AM, the staff posting for the last week and every weekend of the last quarter was requested from the person in charge Registered Nurse #19. On 11/13/23 at 9:00 AM, the above was requested again to the Administrator. On 11/14/23 at 12:30 PM, again the staff postings were requested. On 11/14/23 at 2:20 PM, the Administrator provided the staff postings; however, they did not contain the information needed, such as the daily census, number of licensed and unlicensed nursing staff with the total of hours worked per resident. On 11/15/23 at 10:10 AM, the Administrator called a sister facility to get the correct form to use for the daily staff postings. The Administrator stated she did not know it was not being completed correctly since July of 2023.

Based on record review and staff interview, the facility failed to review and update the Facility Assessment Tool as required. This has the potential to affect all Residents at the facility. Facility Census: 115. Findings Included: a) Facility On 11/12/23 the Facility Assessment Tool was provided by the Director of Nursing. Upon review, it was noted that the information on the Assessment Tool was incorrect and had not been updated since 06/21/22. According to the regulation, the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The Facility Assessment Tool provided stated the following: Date of assessment or update is 06/21/22 Date(s) assessment reviewed with QAA/QAPI 06/24/22 CED (Previous CED name) CNE (Previous CNE name) Medical Director (Current) RED (Current) CQS (Current) The above information was confirmed with the Administrator on 11/13/23 at 03:00 PM, at which time she agreed the assessment was not up to date. She is aware it is to be updated at least yearly and was due to be updated 06/20/23. In an interview on 11/15/23 at 09:27 AM, the Administrator stated she didn't know her staff provided the facility assessment on 11/12/23. It had been obtained from the survey ready book and she was currently updating the facility assessment tool.

Based on observation and staff interview, the facility failed to maintain a safe and sanitary environment to help prevent the development and transmission of diseases, including Covid-19, during an active Covid-19 outbreak. Linens were not handled appropriately within the laundry room or during transport. Medication administration for Covid-19 positive Resident was not done correctly to prevent the possible spread of Covid-19. Personal Protective Equipment (PPE) was not appropriately worn and discarded after Resident care. Continual Infection Surveillance was not completed for evaluation of proper hand hygiene performance. These failed practices had the potential to affect all residents. Resident identifiers: #28, #167. Facility census: 115. Findings included: a) Laundry Room Record review of the facility's policy titled Infection Control Policies and Procedures, Linen Handling, revised on 05/01/23, showed direction for facility staff to keep clean linen covered and keep clean storage area separate from other soiled areas. During tour of the office/clean linen storage area of the laundry room on 11/14/23 at 3:02 PM, a soiled yellow binder labeled MSDS was found in a linen cart buried within the layers of clean Resident clothing. A separate cart (that was to go back to therapy department) containing various clean Resident care items such as heel protectors, hospital gowns, and non-skid socks had a brown handbag belonging to staff, positioned down within the items on the cart. Both carts containing clean Resident care items and clothing were not covered. Laundry Aide (LA) #124 stated, Its hard to keep this stuff separate, we use this an office too. At 3:10 PM on 11/14/23 observation of the dryer section of the laundry room revealed staff's personal belongings laying in a cart of clean bed linens that were not covered. Laying on top of the clean linens was a cell phone and individual packs of breath mints. LA #124 stated, Sorry let me get my that, those are mine. I know I shouldn't have laid them there. b) Improper Handling of Medications Resident #28 On 11/12/23 at 12:13 PM observation was made of the Resident's inhaler medication (Advair Diskus device) laying on his over the bed table, unattended by staff. Resident was isolation room with door closed for diagnosis of Covid-19. Licensed Practical Nurse (LPN) #36 came to Resident's room door and stated, No it shouldn't be in there, I left it in there when I set his breathing treatment up this morning. The LPN told Surveyor, Reach it to me and I'll take it with me. LPN #36 had her hands full of a cup of water and mediation what appeared to be a cup of medication. LPN #36 nodded her head downward and had surveyor drop the Resident's inhaler into her right uniform pocket. The inhaler was then placed back into the medication cart with other mediations without disinfecting it. LPN #36 was not observed using any hand hygiene after placing the inhaler back into the drawer. Record review showed the following orders: -Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (Fluticasone-Salmeterol). inhale one (1) puff orally two times a day for Chronic Obstructive Pulmonary Disease (COPD). -Droplet contact isolation every shift for COVID positive until 11/17/2023. During an interview on 11/12/23 at 3:00 PM, LPN #36 was asked if she cleaned the inhaler prior to placing it back in the drawer? LPN #36 stated, No, I forgot. I had those meds to give so I just opened the drawer and threw it in. LPN #36 confirmed she did not use hand hygiene after handling the inhaler before moving onto the next task. c) Donning/Doffing Personal Protective Equipment (PPE) Resident #167 Record review of the facility's policy titled, Infection Control Policies and Procedures, Contact Precautions, review date 05/01/23, showed that staff are to use barrier precautions prior to entering the room. PPE must be worn before contact with the Resident or Resident's environment. Before exiting the room, remove and bag gown and gloves and wash hands upon exiting. On 11/15/23 at 9:20 AM, Licensed Practical Nurse (LPN) # 30 was observed donning a yellow cloth isolation gown and gloves to go in Resident # 167's room to give medications. LPN #30 was asked what the Resident was in isolation was for? LPN #30 replied, CVR or CRE or whatever, I think. Something in the urine. Surveyor walked off out of eyesight of LPN #30. When surveyor returned to Resident's room door, LPN #30 was observed at Resident #167's bedside taking isolation gown off while waiting for Resident to finish taking medications. LPN #30 laid the gown down on the Residents bed. Resident finished taking the medications and handed the med cup to LPN #30 for disposal. LPN #30 took the empty medication cup from Resident and removed her gloves. LPN #30 turned and saw Surveyor observing. LPN #30 then placed the isolation gown in a plastic bag, threw the med cup and gloves into the trash can, and exited the room. LPN #30 did not wash hands or perform hand hygiene prior to leaving the room or after exiting. During an interview on 11/15/23 at 10:30 AM the Administrator stated, The sad thing is Resident #167 isn't even on contact isolation anymore. Yes [LPN #30's first name] didn't use the PPE correctly but she didn't even have to use it at all. And of course, she should always use hand hygiene. Record review showed an order for Resident #167 for Contact Precautions for CRE (carbapenem-resistant Enterobacterales) that had been discontinued on 11/13/23. d) Hand Hygiene Monitoring On 11/15/23 at 11:26 AM, the Director of Nursing stated no hand hygiene audits were present prior to November 2023. The DON further stated she had no idea if they were done or where the documents could be. The facility had been without an Infection Preventionist (IP) since September 2023, and the previous IP must have taken them with her or something. The DON stated when she realized they needed done, she started doing them in November when she can. Review of the facility's infection surveillance documents showed hand hygiene audits were completed for the month of November 2023 only. e) Clean Linen Transport Record review of the facility's policy titled Infection Control Policies and Procedures, Linen Handling, revised on 05/01/23, showed direction for facility staff to transport clean linen in covered carts or bags. During the initial tour of the facility on 11/12/23 at 12:46 PM an observation was made of housekeeping Account Manager #122 pushing a linen cart up the east hallway with no cover. Account Manager #122 stated this cart has the isolation gowns, I am delivering them to the COVID isolation carts. The Surveyor asked housekeeper #122, Where is the cover for the clean linen cart? Account Manager #122 stated That is my bad I forgot to cover the gowns. During an interview on 11/12/23 at 2:05 PM, Account Manager #122 stated I replaced all the gowns, wiped down the cart and placed clean ones in the isolation cart. I just wanted you to know I took care of the issue.

Based on record review and staff interview, the facility failed to develop and implement an antibiotic stewardship program that promoted the appropriate use of antibiotics including a system of tracking and monitoring outcomes. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Finding included: On 11/15/23 at 11:26 AM, the Director of Nursing stated the facility had been without an Infection Preventionist (IP) since September 2023, and there was not anything done with the antibiotic stewardship stuff in October 2023. The DON further stated once she realized they expected her do it, she started keeping track of the antibiotic use again in November 2023. Review of the facility's antibiotic stewardship surveillance log showed no documentation for antibiotic use for the month of October 2023. The DON verified there was possibly twenty-six (26) Residents that were administered antibiotics for the month of October 2023, as evidenced by a report she ran from the Electronic Medical System.

Based on record review and staff interview, the facility failed to designate one or more individual(s) as the infection preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings included: Record review showed no designated IP on the employee roster. During an interview on 11/13/23 at 1:35 PM the Administrator was asked who the infection preventionist was for the facility? The Administrator replied, We don't have one. We have been without one for a while. The administrator further stated she had to terminate the last IP on 09/28/23.

. Based on record review and staff interview, the facility failed to develop and/or implement the care plan for skin care, respiratory complications, mobility and activities of daily living (ADLs). This was true for two (2) of 11 residents reviewed during a complaint survey. Resident Identifier: #115 and #21. Facility Census: 114. Findings Included: a) Resident #115 On 08/30/23 at 10:00 AM, a record review was completed. The review found Resident#115's care plan had not been developed in the following focus areas: --risk for respiratory complications --risk for skin breakdown --mobility --activities of daily living The focus area of risk for respiratory complications did not list specific and complete goals. The focus area of risk for skin breakdown was not complete and did not list specific and complete goals as well as completed interventions. The focus areas of mobility and ADLs did not specify if the resident needed assistance or if the resident was dependent for their needs as well as completed interventions. The focus area of mobility did not list specific and complete goals. On 08/30/23 at 11:45 AM, the Administrator was notified and confirmed the care plan had not been developed under the focus areas mentioned above. b) Resident #21 On 08/30/23 at 10:30 AM, a record review was completed. The review found Resident 21's care plan had not been implemented in the following focus areas: --bathing --bed mobility --personal hygiene The areas of bed mobility and personal hygiene listed the interventions of extensive assistance of 2 (two) for both areas. The area of bathing listed the intervention of total assistance of 2 (two). However, an incident found dated 07/10/23 found only one (1) nurse aide (NA) was providing bed mobility, personal hygiene and bathing when the resident was noted with a fall. On 08/30/23 at 11:50 AM, the Administrator was notified and confirmed the care plan was not implemented as written. No further information was obtained during the survey process. .

. Based on record review and staff interview, the facility failed to revise a care plan for Resident #115's pressure ulcers and alteration in comfort care plan and Resident #21's actual fall and alteration in comfort care plan. This was true for two (2) of 11 residents reviewed during a complaint survey. Resident Identifiers: #115 and #21. Facility Census: 114. Findings Included: a) Resident #115 A record review was completed for Resident #115. The review found the care plan had not been revised regarding the development of a deep tissue injury (DTI) on the right fifth digit and right lateral foot as well as the left heel. An admission documentation note dated 07/21/23 did not list any skin issues. A skin check dated 07/31/23 noted the resident had new skin wounds and no previously noted skin injuries or wounds. These were listed as the left heel, right fifth digit and lateral foot. An incident report regarding the DTI to the left heel dated 07/28/23 was reviewed. The incident report indicated the resident had been having pain for two to three days prior the incident report and also stated the heel was hurting and sore at the time of the incident report which was documented as 8:18 PM. An additional incident report dated 07/30/23 was also reviewed. The incident report is regarding scabbed areas to the second and third toe of the right foot as well as dark purplish discoloration to the fifth toe. The time of this incident report was noted as 10:33 AM. Further review of the care plan found nothing listed regarding the pain or alteration in comfort for the documented DTIs. The resident no longer resides at the facility. On 08/30/23 at 11:45 AM, the Administrator was notified and confirmed the care plan had not been revised to indicate the resident had actual skin breakdown and continued to have pain or an alteration in comfort. b) Resident #21 A record review was completed for Resident #21. The review found the care plan had not been revised regarding an actual fall on 07/10/23 or alteration in comfort regarding the pain from the fall. The resident was sent to a local acute facility for further evaluation due to continued pain to the head, right shoulder and right leg. No fractures were noted. However, the resident was noted with edema and bruising to the right orbital area and the right forehead. The resident, also, was noted with bruising to the right arm. An interview was held with Resident #21 on 08/29/23 at 4:35 PM. The resident confirmed the fall did happen on 07/10/23 and the pain continues especially in the right shoulder. The resident stated I hit my head on the oxygen concentrator when I slid out of bed, my right shoulder and my right leg got scuffed up and continue to hurt. On 08/30/23 at 11:50 AM, the Administrator was notified and confirmed the care plan had not been revised to indicate the resident had an actual fall and continued to have pain or an alteration in comfort. .

. Based on record review and staff interview, the facility failed to prevent the development of pressure ulcers for Resident #115. This was true for one (1) resident of 11 reviewed during the complaint survey. Resident Identifier: #115. Facility Census: 114. Findings Included: a) Resident #115 On 08/29/23 at 2:30 PM, a record review was completed for Resident #115. The review found the resident had development of a deep tissue injury (DTI) described as a dark purplish discoloration to the right fifth toe and right foot (measuring 4.76cm (centimeters) x 1.73cm x UTD (unable to determine) as well as the left heel measuring 3.46cm x 2.86cm x UTD. Scabbed areas were found on the second and third toe of the right foot. An admission documentation note dated 07/21/23 did not list any skin issues. A skin check dated 07/31/23 noted the resident had new skin wounds and no previously noted skin injuries or wounds. These were listed as the left heel, right fifth digit and lateral foot. An incident report regarding the DTI to the left heel dated 07/28/23 was reviewed. The incident report indicated the resident had been having pain for two to three days prior to the incident report and also stated the heel was hurting and sore at the time of the incident report which was documented as 8:18 PM. An additional incident report dated 07/30/23 was also reviewed. The incident report is regarding scabbed areas to the second and third toe of the right foot as well as dark purplish discoloration to the fifth toe. The time of this incident report was noted as 10:33 AM. On 08/30/23 at 11:45 AM, the Administrator was notified and confirmed the development of the DTIs noted to the right fifth toe, right foot, left heel and scabbed areas to the second and third toe. On 08/29/23 at 3:00 PM, the Administrator was notified and confirmed the resident did have development of pressure ulcers while admitted to the facility.

. Based on record review and staff interview, the facility failed to follow physician's orders regarding medication administration for Resident #18, #66, #19 as well as wound care for Resident #35. This was true for four (4) of 11 residents reviewed during the complaint survey. Resident Identifiers: #18, #66, #19 and #35. Facility Census: 114. Findings Included: a) Resident #18 On 08/30/23 at 2:00 PM, a record review was completed for Resident #18. The Medication Administration Audit Report was reviewed from 08/15/23 through 08/29/23 and found the following medications and accuchecks for blood glucose administered late: --08/15/23 Accuchecks twice daily scheduled at 4:00 PM, completed at 6:23 PM, which is 2 hours and 23 minutes late --08/15/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/16/23 at 2:41 AM, which is 5 hours and 41 minutes late --08/15/23 Clonidine 0.1mg two times daily scheduled at 9:00 PM, administered on 08/16/23 at 2:40 AM, which is 5 hours and 40 minutes late --08/15/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/16/23 at 2:40 AM, which is 5 hours and 40 minutes late --08/15/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/16/23 at 2:41 AM, which is 5 hours and 41 minutes late --08/15/23 House Supplement daily scheduled at 9:00 PM, administered on 08/16/23 at 2:40 AM, which is 5 hours and 40 minutes late --08/15/23 Cymbalta 30mg scheduled at 9:00 PM, administered on 08/16/23 at 2:41 AM, which is 5 hours and 41 minutes late --08/15/23 Mucinex ER 600mg every 12 hours scheduled at 9:00 PM, administered on 08/16/23 at 2:41 AM, which is 5 hours and 41 minutes late --08/15/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/16/23 at 2:41 AM, which is 5 hours and 41 minutes late --08/15/23 Ipratropium-Albuterol 3mg/3ml inhalation every 6 hours scheduled at 12:00 AM, administered on 08/15/23 at 7:45 AM, which is 7 hours and 45 minutes late --08/16/23 Ipratropium-Albuterol 3mg/3ml inhalation every 6 hours scheduled at 12:00 AM, administered on 08/16/23 at 2:40 AM, which is 2 hours and 40 minutes late --08/16/23 Accuchecks twice daily scheduled at 4:00 PM, completed at 6:37 PM, which is 2 hours and 37 minutes late --08/16/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/17/23 at 3:39 AM, which is 6 hours and 39 minutes late --08/16/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/17/23 at 3:38 AM, which is 6 hours and 38 minutes late --08/16/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/17/23 at 3:38 AM, which is 6 hours and 38 minutes late --08/16/23 House Supplement daily scheduled at 9:00 PM, administered on 08/17/23 at 3:38 AM, which is 6 hours and 38 minutes late --08/16/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/17/23 at 3:40 AM, which is 6 hours and 40 minutes late --08/16/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/17/23 at 3:38 AM, which is 6 hours and 38 minutes late --08/16/23 Mucinex ER 600mg every 12 hours scheduled at 9:00 PM, administered on 08/17/23 at 3:38 AM, which is 6 hours and 38 minutes late --08/16/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/17/23 at 3:39 AM, which is 6 hours and 38 minutes late ----08/17/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 House Supplement daily scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 Mucinex ER 600mg every 12 hours scheduled at 9:00 PM, administered on 08/18/23 at 1:33 AM, which is 4 hours and 33 minutes late --08/17/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/18/23 at 1:33 AM, which is 3 hours and 33 minutes late --08/17/23 Ipratropium-Albuterol 3mg/3ml inhalation every 6 hours scheduled at 12:00 AM, administered on 08/17/23 at 3:38 AM, which is 3 hours and 38 minutes late --08/18/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 House Supplement daily scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 Mucinex ER 600mg every 12 hours scheduled at 9:00 PM, administered on 08/19/23 at 12:19 AM, which is 3 hours and 19 minutes late --08/18/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/19/23 at 12:19 AM, which is 2 hours and 19 minutes late --08/19/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/12/23 at 4:24 AM, which is 7 hours and 24 minutes late --08/19/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/20/23 at 4:24 AM, which is 7 hours and 24 minutes late --08/19/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/20/23 at 4:23 AM, which is 7 hours and 23 minutes late --08/19/23 House Supplement daily scheduled at 9:00 PM, administered on 08/20/23 at 4:23 AM, which is 7 hours and 23 minutes late --08/19/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/20/23 at 4:24 AM, which is 7 hours and 24 minutes late --08/19/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/20/23 at 4:24 AM, which is 7 hours and 24 minutes late --08/19/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/20/23 at 4:24 AM, which is 6 hours and 24 minutes late --08/20/23 Ipratropium-Albuterol 3mg/3ml inhalation every 6 hours scheduled at 12:00 AM, administered on 08/20/23 at 4:23 AM, which is 4 hours and 23 minutes late --08/20/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/21/23 at 6:57 AM, which is 9 hours and 57 minutes late --08/20/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/21/23 at 6:58 AM, which is 9 hours and 58 minutes late --08/20/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/21/23 at 6:57 AM, which is 9 hours and 57 minutes late --08/20/23 House Supplement daily scheduled at 9:00 PM, administered on 08/21/23 at 6:57 AM, which is 9 hours and 57 minutes late --08/20/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/21/23 at 6:57 AM, which is 9 hours and 57 minutes late --08/20/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/21/23 at 6:57 AM, which is 9 hours and 57 minutes late --08/20/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/21/23 at 6:58 AM, which is 8 hours and 24 minutes late --08/21/23 Ipratropium-Albuterol 3mg/3ml inhalation every 6 hours scheduled at 12:00 AM, administered on 08/21/23 at 6:46 AM, which is 6 hours and 46 minutes late --08/21/23 Accuchecks twice daily scheduled at 4:00 PM, completed at 6:15 PM, which is 2 hours and 15 minutes late --08/21/23 Ipratropium-Albuteral Solution 3mg/ml (milligram/milliliter) every 6 hours was scheduled at 12:00 PM, administered at 3:13 PM, which is 3 hours and 13 minutes late --08/21/23 Accuchecks twice daily scheduled at 4:00 PM, completed at 6:15 PM, which is 2 hours and 15 minutes late --08/21/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/22/23 at 7:12 AM, which is 10 hours and 12 minutes late --08/21/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/22/23 at 7:12 AM, which is 10 hours and 12 minutes late --08/21/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/22/23 at 7:11 AM, which is 10 hours and 11 minutes late --08/21/23 House Supplement daily scheduled at 9:00 PM, administered on 08/22/23 at 7:11 AM, which is 10 hours and 11 minutes late --08/21/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/22/23 at 7:11 AM, which is 10 hours and 11 minutes late --08/21/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/22/23 at 7:11 AM, which is 10 hours and 11 minutes late --08/21/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/22/23 at 7:12 AM, which is 9 hours and 12 minutes late --08/23/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/24/23 at 4:47 AM, which is 7 hours and 47 minutes late --08/23/23 House Supplement daily scheduled at 9:00 PM, administered on 08/24/23 at 4:47 AM, which is 7 hours and 47 minutes late --08/23/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/24/23 at 4:47 AM, which is 7 hours and 47 minutes late --08/23/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/24/23 at 4:47 AM, which is 6 hours and 47 minutes late --08/24/23 Tylenol Extra Strength 1000mg scheduled at 2:00 PM, administered at 4:10 PM, which is 2 hours and 10 minutes late --08/24/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/25/23 at 2:46 AM, which is 5 hours and 46 minutes late --08/24/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:47 AM, which is 5 hours and 47 minutes late --08/24/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:46 AM, which is 5 hours and 46 minutes late --08/24/23 House Supplement daily scheduled at 9:00 PM, administered on 08/25/23 at 2:46 AM, which is 5 hours and 46 minutes late --08/24/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:46 AM, which is 5 hours and 46 minutes late --08/24/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/25/23 at 2:46 AM, which is 5 hours and 46 minutes late --08/24/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/25/23 at 2:46 AM, which is 5 hours and 46 minutes late --08/25/23 Lantus insulin 40 units twice daily scheduled at 9:00 AM, administered at 2:25 PM, which is 5 hours and 25 minutes late --08/25/23 Lasix 40mg every morning scheduled at 6:00 AM, administered at 8:12 AM, which is 2 hours and 12 minutes late --08/25/23 Potassium 10meq (milliequivalent) daily scheduled at 6:00 AM, administered at 8:12 AM, which is 2 hours and 12 minutes late --08/25/23 Tylenol ES 1000mg three times daily scheduled at 6:00 AM, administered at 8:12 AM, which is two hours and 12 minutes late --08/25/23 Protonix 40mg daily scheduled at 6:00 AM, administered at 8:12 AM, administered at 8:12 AM, which is 2 hours and 12 minutes late --08/25/23 Accuchecks twice daily scheduled at 6:00 AM, completed at 8:12 AM, which is 2 hours and 12 minutes late --08/25/23 Neurontin 200mg twice daily scheduled at 9:00 AM, administered at 2:25 PM, which is 2 hours and 25 minutes late --08/25/23 Breo Ellipta 100-25mcg (microgram) one inhalation daily scheduled at 9:00 AM, administered at 2:25 PM, which is 2 hours and 25 minutes late --08/25/23 Clonidine 0.1mg twice daily scheduled at 9:00 AM, administered at 2:25 PM, which is 2 hours and 25 minutes late --08/25/23 Losartan Potassium 100mg daily scheduled at 9:00 AM, administered at 2:25 PM, which is 2 hours and 25 minutes late --08/25/23 Metoprolol Succinate ER 25mg daily scheduled at 9:00 AM, administered at 2:42 PM, which is 2 hours and 42 minutes late --08/25/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/26/23 at 3:28 AM, which is 6 hours and 28 minutes late --08/25/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/26/23 at 3:27 AM, which is 6 hours and 27 minutes late --08/25/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/26/23 at 3:27 AM, which is 6 hours and 27 minutes late --08/25/23 House Supplement daily scheduled at 9:00 PM, administered on 08/26/23 at 3:27 AM, which is 6 hours and 27 minutes late --08/25/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/26/23 at 3:28 AM, which is 6 hours and 28 minutes late --08/25/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/26/23 at 3:27 AM, which is 6 hours and 27 minutes late --08/25/23 Tylenol ES 1000mg three times daily scheduled at 10:00 PM, administered on 08/26/23 at 3:28 AM, which is 5 hours and 28 minutes late --08/26/23 Tylenol ES 1000mg three times daily scheduled at 10:00 PM, administered on 08/27/23 at 2:22 AM, which is 4 hours and 22 minutes late --08/27/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/28/23 at 7:23 AM, which is 10 hours and 23 minutes late --08/27/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/28/23 at 7:23 AM, which is 10 hours and 23 minutes late --08/27/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/28/23 at 7:23 AM, which is 10 hours and 23 minutes late --08/27/23 House Supplement daily scheduled at 9:00 PM, administered on 08/28/23 at 7:23 AM, which is 10 hours and 23 minutes late --08/27/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/28/23 at 7:23 AM, which is 10 hours and 23 minutes late --08/27/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/28/23 at 7:23 AM, which is 10 hours and 23 minutes late --08/27/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/28/23 at 7:23 AM, which is 9 hours and 23 minutes late --08/28/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/29/23 at 2:43 AM, which is 5 hours and 43 minutes late --08/28/23 Clonidine 0.1mg twice daily scheduled at 9:00 PM, administered on 08/29/23 at 2:43 AM, which is 5 hours and 43 minutes late --08/28/23 Neurontin 200mg twice daily scheduled at 9:00 PM, administered on 08/29/23 at 2:43 AM, which is 5 hours and 43 minutes late --08/28/23 House Supplement daily scheduled at 9:00 PM, administered on 08/29/23 at 2:42 AM, which is 5 hours and 42 minutes late --08/28/23 Basaglar 40 units twice daily scheduled at 9:00 PM, administered on 08/29/23 at 2:42 AM, which is 5 hours and 42 minutes late --08/28/23 Cymbalta 30mg daily scheduled at 9:00 PM, administered on 08/29/23 at 2:43 AM, which is 5 hours and 43 minutes late --08/28/23 Tylenol ES 1000mg three times daily schedled at 10:00 PM, administered on 08/29/23 at 2:43 AM, which is 4 hours and 43 minutes late On 08/30/23 at 3:00 PM, the Administrator was notified and confirmed the medication was administered late and the physician's orders were not followed b) Resident #66 On 08/30/23 at 2:00 PM, a record review was completed for Resident #66. The Medication Administration Audit Report was reviewed from 08/15/23 through 08/29/23 and found the following medications and accuchecks for blood glucose administered late: --08/15/23 Accuchecks twice daily scheduled at 4:00 PM, completed at 6:12 PM, which is 2 hours and 12 minutes late --08/15/23 Ranolazine ER 500mg two tablets twice daily scheduled at 9:00 PM, administered on 08/16/23 at 1:47 AM, which is 4 hours and 47 minutes late --08/15/23 ICaps one capsule twice daily scheduled for 9:00 PM, administered on 08/16/23 at 1:46 AM, which is 4 hours and 46 minutes late --08/16/23 Accuchecks twice daily, scheduled at 4:00 PM, completed at 6:26 PM, which is 2 hours and 26 minutes late --08/16/23 Ketorolac Tromethamine 10mg twice daily scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 Lyrica 150mg twice daily scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 Seroquel 400mg at bedtime scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 Ranolazine ER 500mg 2 tablets scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 Topamax 50mg twice daily scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/16/23 Wixela 100-50mcg inhaler twice daily, scheduled at 9:00 PM, administered on 08/17/23 at 1:59 AM, which is 4 hours and 59 minutes late --08/18/23 Ketorolac Tromethamine 10mg twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 Lyrica 150mg twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 Seroquel 400mg at bedtime scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 Ranolazine ER 500mg 2 tablets scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 Topamax 50mg twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/18/23 Wixela 100-50mcg inhaler twice daily, scheduled at 9:00 PM, administered on 08/19/23 at 12:21 AM, which is 3 hours and 21 minutes late --08/20/23 Lyrica 150mg twice daily scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/20/23 Seroquel 400mg at bedtime scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/20/23 Topamax 50mg twice daily scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/20/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/20/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/20/23 Diclofenac Tablet 25mg twice daily scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM which is 3 hours and 59 minutes late --08/20/23 Wixela100-50mcg twice daily scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/20/23 Ranolazine ER 500mg two tablets twice daily scheduled at 9:00 PM, administered on 08/21/23 at 12:59 AM, which is 3 hours and 59 minutes late --08/24/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Ranolazine ER 500mg 2 tablets scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Wixela 100-50mcg inhaler twice daily, scheduled at 9:00 PM, administered on 08/15/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Lyrica 150mg twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Seroquel 400mg at bedtime scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Topamax 50mg twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/24/23 Diclofenac Tablet 25mg twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM which is 5 hours and 15 minutes late --08/24/23 Wixela100-50mcg twice daily scheduled at 9:00 PM, administered on 08/25/23 at 2:15 AM, which is 5 hours and 15 minutes late --08/25/23 Accuchecks twice daily, scheduled at 4:00 PM, completed at 6:02 PM, which is 2 hours and 2 minutes late --08/25/23 Valium 2mg twice daily scheduled at 6:00 AM, administered at 8:14 AM, which is 2 hours and 14 minutes late --08/25/23 Metformin 500mg daily scheduled at 6:00 AM, administered at 8:14 AM, which is 2 hours and 14 minutes late --08/25/23 Accuchecks twice daily, scheduled at 6:00 AM, completed at 8:13 AM, which is 2 hours and 13 minutes late --08/25/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM, which is 5 hours and 11 minutes late --08/25/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM, which is 5 hours and 11 minutes late --08/25/23 Ranolazine ER 500mg 2 tablets scheduled at 9:00 PM, administered on 08/26/23 at 2:12 AM, which is 5 hours and 12 minutes late --08/25/23 Wixela 100-50mcg inhaler twice daily, scheduled at 9:00 PM, administered on 08/26/23 at 2:12 AM, which is 5 hours and 12 minutes late --08/25/23 Lyrica 150mg twice daily scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM, which is 5 hours and 11 minutes late --08/25/23 Seroquel 400mg at bedtime scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM, which is 5 hours and 11 minutes late --08/25/23 Topamax 50mg twice daily scheduled at 9:00 PM, administered on 08/26/23 at 2:12 AM, which is 5 hours and 12 minutes late --08/25/23 ICaps one capsule twice daily scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM, which is 5 hours and 11 minutes late --08/25/23 Atorvastatin 80mg at bedtime scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM, which is 5 hours and 11 minutes late --08/25/23 Diclofenac Tablet 25mg twice daily scheduled at 9:00 PM, administered on 08/26/23 at 2:11 AM which is 5 hours and 11 minutes late --08/25/23 Wixela100-50mcg twice daily scheduled at 9:00 PM, administered on 08/26/23 at 2:12 AM, which is 5 hours and 12 minutes late On 08/30/23 at 3:00 PM, the Administrator was notified and confirmed the medication was administered late and the physician's orders were not followed. c) Resident #19 Record review on 08/31/23 at 11:00 AM found the following medications were not administered according to the Physicians order nor the Facility Policy #6.2 for Medication administration Times which reads Facility should commence medication administration within sixty (60) minutes after the designated times of administration. The following late administered medications were confirmed with the Administrator on 08/31/23 at 2:00 PM. Medication audit review for 08/14/23 through 08/29/23 7 AM-7 PM Medications: 08/14/23 scheduled for 8:00 AM Administered at 11:58 AM. (2 hours and 58 minutes late) Cymbalta DR 30 mg in the morning 08/14/23 scheduled for 9:00 AM Administered at 11:58 AM. (1 hour and 58 minutes late) Glipizide 2.5 mg two times a day Meclizine HCL 25 mg 0.5 tablet one time a day Diclofenac Sodium EC 50 mg two times a day Bupropion HCL ER 150 mg two times a day BioFreeze Gel 4% to neck/shoulders two times a day Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Allopurinol 100 mg 1 tablet daily Aspirin EC 81 mg daily Hydralazine HCL 25 mg 2 tablets two times a day Mybetriq ER 50 mg 1 tablet daily Omega 3 capsule 1 capsule daily Lidoderm External Patch 5% to lower back daily Calcium Carbonate 500 mg 1 tablet daily Potassium Chloride ER 10 MEQ 1 tablet daily 08/15/23 scheduled for 8:00AM Administered at 10:13 AM. (1 hour and 13 minutes late) Cymbalta DR 30 mg in the morning 08/16/23 scheduled for 8:00AM Administered at 10:16 AM. (1 hour and 16 minutes late) Cymbalta DR 30 mg in the morning 08/19/23 scheduled for 9:00AM Administered at 02:41 PM. (4 hours and 41 minutes late) Lidoderm External Patch 5% to lower back daily 08/21/23 scheduled for 8:00AM Administered at 10:32 AM. (1 hour and 32 minutes late) Cymbalta DR 30 mg in the morning 08/22/23 scheduled for 9:00AM Administered at 11:42 AM. (1 hour and 42 minutes late) Diclofenac Sodium EC 50 mg two times a day Bupropion HCL ER 150 mg two times a day BioFreeze Gel 4% to neck/shoulders two times a day Calcium Carbonate 500 mg 1 tablet daily Allopurinol 100 mg 1 tablet daily Aspirin EC 81 mg daily Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Hydralazine HCL 25 mg 2 tablets two times a day Mybetriq ER 50 mg 1 tablet daily Lidoderm External Patch 5% to lower back daily Potassium Chloride ER 10 MEQ 1 tablet daily Guaifenesin ER 12 hour 600 mg 1 tablet every 12 hours for cough /COVID for 14 days Glipizide 2.5 mg two times a day Meclizine HCL 25 mg 0.5 tablet one time a day Omega 3 capsule 1 capsule daily 08/23/23 scheduled for 8:00AM Administered at 10:39 AM. (1 hour and 39 minutes late) Cymbalta DR 30 mg in the morning 08/23/23 scheduled for 9:00AM Administered at 11:19 AM. (1 hour and 19 minutes late) BioFreeze Gel 4% to neck/shoulders two times a day Lidoderm External Patch 5% to lower back daily 08/24/23 scheduled for 8:00AM Administered at 11:45 AM. (2 hours and 45 minutes late) Cymbalta DR 30 mg in the morning 08/24/23 scheduled for 9:00AM Administered at 11:45 AM. (1 hour and 45 minutes late) Diclofenac Sodium EC 50 mg two times a day Bupropion HCL ER 150 mg two times a day Glipizide 2.5 mg two times a day Meclizine HCL 25 mg 0.5 tablet one time a day Guaifenesin ER 12 hour 600 mg 1 tablet every 12 hours for cough /COVID for 14 days Lidoderm External Patch 5% to lower back daily Potassium Chloride ER 10 MEQ 1 tablet daily Calcium Carbonate 500 mg 1 tablet daily Omega 3 capsule 1 capsule daily Hydralazine HCL 25 mg 2 tablets two times a day Mybetriq ER 50 mg 1 tablet daily Allopurinol 100 mg 1 tablet daily Aspirin EC 81 mg daily Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day 08/25/23 scheduled for 9:00AM Administered at 11:37 AM. (1 hour and 37 minutes late) BioFreeze Gel 4% to neck/shoulders two times a day Lidoderm External Patch 5% to lower back daily 08/29/23 scheduled for 8:00AM Administered at 12:08 AM. (3 hours and 08 minutes late) Cymbalta DR 30 mg in the morning 08/29/23 scheduled for 9:00AM Administered at 12:08 AM. (2 hours and 08 minutes late) Bupropion HCL ER 150 mg two times a day Diclofenac Sodium EC 50 mg two times a day Glipizide 2.5 mg two times a day BioFreeze Gel 4% to neck/shoulders two times a day Lidoderm External Patch 5% to lower back daily Meclizine HCL 25 mg 0.5 tablet one time a day Omega 3 capsule 1 capsule daily Calcium Carbonate 500 mg 1 tablet daily Potassium Chloride ER 10 MEQ 1 tablet daily Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Allopurinol 100 mg 1 tablet daily Aspirin EC 81 mg daily Hydralazine HCL 25 mg 2 tablets two times a day Mybetriq ER 50 mg 1 tablet daily 7 PM-7 AM medications: 08/17/23 scheduled for 9:00 PM Administered at 1:41 AM. (3 hours and 41 minutes late) Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Hydralazine HCL 25 mg 2 tablets two times a day Diclofenac Sodium EC 50 mg two times a day Glipizide 2.5 mg two times a day BioFreeze Gel 4% to neck/shoulders two times a day Guaifenesin ER 12 hour 600 mg 1 tablet every 12 hours for cough /COVID for 14 days Claritin 10 mg 1 tablet at bedtime for nasal drainage/COVID for 14 days Protonix DR 20 mg one time a day Melatonin 3 mg Give 2 tablets at bedtime 08/17/23 scheduled for 10:00 PM Administered at 1:42 AM. (2 hours and 42 minutes late) Sinemet 25-100 mg 1 tablet three times a day Pro-Air HFA inhalation 108 (90 base) MCG/ACT 2 inhalation orally every 8 hours Tylenol extra strength 500 mg 2 tablets three times a day Tramadol HCL 50 mg 1 tablet three times a day 08/19/23 scheduled for 9:00 PM Administered at 00:17 AM. (2 hours and 17 minutes late) BioFreeze Gel 4% to neck/shoulders two times a day Hydralazine HCL 25 mg 2 tablets two times a day 08/19/23 scheduled for 10:00 PM Administered at 00:17 AM. (1 hour and 17 minutes late) Pro-Air HFA inhalation 108 (90 base) MCG/ACT 2 inhalation orally every 8 hours 08/23/23 scheduled for 9:00 PM Administered at 11:37 AM. (1 hour and 37 minutes late) Claritin 10 mg 1 tablet at bedtime for nasal drainage/COVID for 14 days BioFreeze Gel 4% to neck/shoulders two times a day Guaifenesin ER 12 hour 600 mg 1 tablet every 12 hours for cough /COVID for 14 days Glipizide 2.5 mg two times a day Diclofenac Sodium EC 50 mg two times a day Hydralazine HCL 25 mg 2 tablets two times a day Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Protonix DR 20 mg one time a day Melatonin 3 mg Give 2 tablets at bedtime 08/24/23 scheduled for 9:00 PM Administered at 00:02 AM. (2 hours and 02 minutes late) Glipizide 2.5 mg two times a day Diclofenac Sodium EC 50 mg two times a day BioFreeze Gel 4% to neck/shoulders two times a day Guaifenesin ER 12 hour 600 mg 1 tablet every 12 hours for cough /COVID for 14 days Claritin 10 mg 1 tablet at bedtime for nasal drainage/COVID for 14 days Melatonin 3 mg Give 2 tablets at bedtime Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Protonix DR 20 mg one time a day Hydralazine HCL 25 mg 2 tablets two times a day 08/24/23 scheduled for 10:00 PM Administered at 00:02 AM. (1 hour and 02 minutes late) Tramadol HCL 50 mg 1 tablet three times a day Tylenol Extra Strength 500 mg give 2 tablets three times a day 08/28/23 scheduled for 9:00 PM Administered at 00:48 AM. (2 hours and 48 minutes late) Glipizide 2.5 mg two times a day Diclofenac Sodium EC 50 mg two times a day BioFreeze Gel 4% to neck/shoulders two times a day Melatonin 3 mg Give 2 tablets at bedtime Neuron 300 mg 1 capsule two times a day Coreg 25 mg 1 tablet two times a day Protonix DR 20 mg one time a day Hydralazine HCL 25 mg 2 tablets two times a day 08/28/23 scheduled for 10:00 PM Administered at 00:48 AM. (1 hour and 48 minutes late) Tramadol HCL 50 mg 1 tablet three times a day Tylenol Extra Strength 500 mg give 2 tablets three times a day Sinemet 25-100 mg Give 1 tablet three times a day d) Resident #35 On 08/31/23 at 11:00 AM a record review found Resident #35 has an active order dated 07/19/23 for Skin Treatment: Cleanse surgical scar left trochanter with IHWC (in house wound cleanser), pat dry, apply skin protectant and allow to dry. Keep cover

Based on observation and staff interview, the facility failed to maintain a safe and accident-free environment as possible. This was a random opportunity for discovery and had the potential to affect more than an limited number of residents. Facility Census: 114. Findings Included: On 08/29/23 at 12:30 PM, an observation of two unlocked (2) treatment carts were observed sitting by the nurses' station by the lobby at the entrance of the facility. No staff were in the vicinity of the treatment carts. On 08/29/23 at 12:40 PM, the Assistant Director of Nursing (ADON) #2 and Nurse Performance Educator (NPE) #3 witnessed the unlocked carts. The ADON #2 locked the treatment carts immediately. Both the ADON #2 and NPE #3 confirmed the treatment carts should be locked at all times when not attended by staff. No further information was obtained during the complaint survey.

. Based on observation, policy review and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections. These findings were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: Resident #66. Facility Census: 114 Findings Included: a) Facility: On 08/31/23 at 08:18 AM while observing the breakfast meal tray pass on the South Unit (Rooms 100-121), it was observed that no hand hygiene was offered to the residents prior to their breakfast meal. This was confirmed with Certified Nursing Aide #77 at the time of discovery. On 08/31/23 at 09:00 AM, review of Facility Policy #IC 405 and in accordance with standard practice of care found, the staff will perform hand hygiene per the Centers for Disease Control and Prevention (CDC) guidelines and policy to provide hand hygiene prior to each meal. This was confirmed with the Administrator on 08/31/23 at 9:30 AM. b) Medication Administration On 08/30/23 at 8:40 AM, medication administration to Resident #66 was observed. Registered Nurse (RN) #20 failed to use a barrier between an Wixela Inhaler and the over-the-bed table. On 08/30/23 at 8:48 AM, RN #20 stated, I thought I used one .I was nervous. On 08/30/23 at 8:55 AM, the Assistant Director of Nursing (ADON) #2 was notified and confirmed a barrier should be used between the inhaler and the over-the-bed table. No further information was received during the complaint survey. .

Based on record review, staff interview and policy review the facility failed to report a COVID-19 outbreak in their building to their Residents, their Representatives and Families. This failed practice had the potential to effect more than a limited number of residents. Facility Census: #114 Findings Included: a) On 08/31/23 at 01:45 PM a record review shows the facility had a staff member test positive for COVID-19 on 08/07/23. Further testing of staff and residents on the following days found an additional seven (7) staff members and fifteen (15) residents tested positive. The documented positive dates range from 08/07/23 through 08/21/23. During an interview with the Administrator on 08/31/23 at 2:00 PM, she confirmed notification was not complete to notify Residents, their Representatives and Families of the outbreak, other than to the Residents, their Representatives and Families of the positive residents. According to the Facility Infection Control Policy #IC 405, COVID-19 Reporting #32. states COVID-19 date required by Centers for Medicare and Medicare Services (CMS) utilizing Centers for Disease Control and prevention (CDC)'s National Health Safety Network (NHSN) will be electronically reported no less than weekly for each Center. 32.1 Centers must inform patients, their representatives, and families of those residing in the Center by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more patients or Healthcare Compliance Professional (HCP) with new onset of respiratory symptoms occurring within 72 hours of each other. Information must: 32.1.1 Not include personally identifiable information 32.1.2 Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the Center will be altered; and 32.1.3 include any cumulative updates for patients, their representatives, and families at least weekly or by 5:00 PM the next calendar day following the subsequent occurrence of either: 32.1.3.1 Identification of a confirmed infection of COVID-19, or 32.1.3.2 Whenever three or more patients or staff with new onset of respiratory symptoms occur within 72 hours of each other.

. Based on record review and staff interview the facility failed to have a complete and accurate Advance Directive in place to honor the wishes of the residents. This was true for two (2) of five (5) Physicians Orders for Scope of Treatment (POST) forms reviewed during the annual survey. Resident identifiers: #2, and #10. Facility Census 117. Findings included: a) Resident #2 On 6/27/22 at 2:30 PM during a record review it was found Resident #2 had capacity as of 1/11/22 and was in the facility at the time her POST form was initiated. The facility got a verbal signature and failed to get a physical signature on the POST. This was confirmed with Social Worker #111 on 6/28/22 at 9:15 AM. b) Resident #10 On 6/27/22 at 2:10 PM during a record review it was found Resident #10 had a POST form that was not completed in its' entirety. The Patient Information section of the POST does not have identifying information provided. There is no Social Security number, no date of birth , or gender in this section. In addition, the entire second page of the POST is not completed. This was confirmed with Social Worker #111 on 6/28/22 at 9:15 AM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview the facility failed to ensure the resident environment was safe, clean, comfortable, and homelike. This failed practice was true for rooms: 137,135,138,136, 141,133,118,158, 145, and 155. Facility census 117. Findings included: a) room [ROOM NUMBER] Observations on 06/27/22 at 12:07 PM in room [ROOM NUMBER], found a large number of flying insects moving about room [ROOM NUMBER]. There was also many insects resting on the privacy curtain. Resident #29 had a towel on his bedside table which was soiled with a reddish substance. The reddish substance was also on the floor. A lot of insects were landing on the red substance. Licensed Practical Nurse (LPN) #31 was asked to witness the number of insects in this room and the red substance the insects were landing on. LPN #31 said she believes the red substance was some type of a sauce. On 06/28/22 at 3:00 PM, it was noted the soiled towel was still on the bedside table. b) room [ROOM NUMBER] Observations on 06/27/22 at 12:10 PM, found Resident #79 was laying on his bed without any sheets, and covered with a green blanket. Resident #79 was asked if he wanted sheets on his bed. Resident #79 stated well yes, I would like to have sheets on the bed, but I would rather do without instead of having pissy ones on the bed. The room smelled of urine. There was an excessive amount of food, plastic wraps, paper, and empty medication cups scattered through out the room. The fall mats on both sides of the bed were covered in the trash described above. The flying insects were on everything including Resident #79 and this surveyor. Resident #79 stated those bugs drive me crazy. On 06/27/22 at 12:15 PM, LPN #35 was stopped in the hallway and asked why Resident #79 did not have sheets on his bed and to verify the trash around the bed and flying insects. LPN #35 said she would get some sheets and have housekeeping come in. LPN #35 agreed there was a lot of insects. c) room [ROOM NUMBER] During a family interview on 06/27/22 at 11:00 AM, the family member was waiting for the roommate of Resident #65 to finish with care in room [ROOM NUMBER]. The family member said now last week I found there was fecal art on the wall beside of (used first name) Resident #65. I told four (4) different people about it at the nurse's station. They assured me it would be taken care of. Upon entering the room, the family member said, son of a gun they lied to me the same finger art it still there! The wall Resident #65's bed was positioned against, had brown handprints and brown smears about two (2) foot high and three (3) foot wide all along the wall. On 06/27/22 at 11:06 AM, the Administrator was asked to come to the room. The soiled wall was pointed out. The family member told the Administrator he reported it to four (4) staff people last week when he was here. The Administrator said he would send housekeeping in to clean the wall right away. d) room [ROOM NUMBER] On 06/27/22 at 11:30 AM, upon entering room [ROOM NUMBER] it was noted there was a large number of flying insects. There was more than 20 insects resting on the privacy curtain. On 06/27/22 at 11:50 AM, LPN #35 was asked to observe the amount of flying insects in the room. LPN #35 walker over to the curtain and shook it, which caused a swarm of insects. Resident #17 said, those gnats are awful we have been dealing with them for a while now. LPN #35 said she would get Maintenance to help with the insects. e) room [ROOM NUMBER] On 06/27/22 at 12:27 PM, Resident #106 was observed using a fly swatter in her room, Resident #106 was asked if she swats the insects often, she said all day long. It was noted the floors had areas of something smeared and dried on them. Resident #106 was asked if housekeeping comes in the room to clean. She said yes, every other day or so. f) Dining Room On 06/27/22 at 11:49 AM an observation of the dining room tray pass process revealed gnat's flying around Residents and their meals. On 06/27/22 at 12:05 PM during an interview with Dietary Aid #124, she verified that there is an issue with gnats and flies in the kitchen and dining area. g) room [ROOM NUMBER] On 06/27/22 at 3:41 PM during tour observations found gnats in room [ROOM NUMBER] on the beds tray tables, and privacy curtains. On 06/27/22 at 3:41 PM during an interview, Resident #5 stated that there is so many gnats' flying around they get in his face, on his food and everything else in the room. Resident #5 stated, I hate gnats. On 06/27/22 at 3:45 PM during an interview with Nurse Aide (NA) #43 confirmed there were gnats in room [ROOM NUMBER]. He stated that he has saw them through out the facility in multiple rooms. h) room [ROOM NUMBER] On 6/27/22 at 1:46 PM during the initial survey process it was observed that a ceiling tile above Resident #100s' wardrobe was slid to the side of where it belonged. This was confirmed with the Nurse Unit Manager #59 on 6/27/22 at 1:55 PM. i) room [ROOM NUMBER] On 6/27/22 at 2:37 PM during the initial survey process Resident #2 complained that the toilet had overflowed during the night and there was water all over the rest room. Upon observation there was water all over the floor with towels laying over it. The toilet appeared to be clogged with a brown substance which had the appearance and smell of feces. This was confirmed with the Nurse Unit Manager #59 on 6/27/22 at 2:40 PM. j) room [ROOM NUMBER] On 6/27/22 at 2:10 PM it was observed that the divider curtain by the residents bed was soiled. This was confirmed with the Nurse Unit Manager #59 on 6/27/22 at 2:15 PM. .

. Based on observation, record review and staff interview the facility failed to implement the resident care plan for the care area of accidents. This was true for two (2) of 24 sampled residents. Resident identifiers: #100 and #48. Facility Census #117 Findings Included: a) Resident #100 On 6/27/22 at 1:46 PM upon the initial survey interview process it was noted Resident #100's room was extremely cluttered which presents for a high chance of a fall. According to her care plan she is at risk for falls due to impaired mobility, weakness, medications and other co-morbid conditions and the staff is to maintain a clutter free environment in the resident's room and consistent furniture arrangement. The Resident is currently in a semi-private room. Upon the move from her previous room on 3/05/22 some of her clothes were placed in a trash bag where they remain at this time. She has a bed side toilet and a wheel chair in addition to her furniture. This was confirmed with Nurse Unit Manager #59 on 6/27/22 at 1:55 PM. b) Resident #48 Observation of Resident #48 on 06/27/22 at 11:53 am found a floor mat propped up beside his bed on the right side of the bed. An interview Licensed Practical Nurse (LPN) #31 at this time confirmed the fall mat should be laying fat on the floor and not standing on its side propped up against the bed. She said, I will fix it let me go see what side of the bed it is supposed to be on. A record review of Resident #48's care plan on 06/28/22, found the care plan related to Resident #48's risk for further falls contained the following interventions, -- Bed in lowest position. Created on 02/26/21. -- Bilateral fall mats. Created on 03/27/21. -- Device - LAL (Low Air Loss) Mattress, Setting 5. Created 12/20/21. -- Utilize Night light in room/bathroom. Created 12/20/21. An additional observation of Resident #48 with Registered Nurse (RN) #29 on 06/28/22 at 4:17 pm confirmed Resident #48 only had one (1) fall mat on the left side of the bed, the bed was no in the lowest position (Resident #48 was laying in the bed), the residents bed did not have a LAL mattress with setting 5, and there was no night light in his room or bathroom. She agreed the residents fall interventions were not in place. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to ensure discharge planning processes were in place which addresses each resident's discharge goals. They failed to follow their policies, or state law as related to discharges which are Against Medical Advice (AMA) for Resident # 110 and failed to develop a discharge comprehensive care plan for Resident #85. These practices affected two (2) of two (2) resident's care reviewed for discharges during the Long-Term Care Survey Process (LTCSP). Resident Identifiers #110 and #85. Facility census 117. a) Resident #85 During an interview on 06/27/22 at 03:13 PM, Resident #85 stated that the facility will not let him go home. He stated that they will not even give him information on discharge. A medical record review on 06/28/22 revealed, there was no discharge comprehensive care plan addressing Resident #85's discharge goals. During an Interview with the Social Services Specialist #82 on 06/28/22 at 4:18 PM, She verified there was no discharge comprehensive care plan in place for Resident #85. She confirmed it should have been started at admission. She entered the Discharge Care plan at this time. b) Resident #110 A review of Resident #110's on 06/28/10 at 10:15 am found Resident #110 was discharged from the facility on 04/07/22. Contained in the medical record was a Voluntary Discharge Against Medical Advice form that was signed by Resident #110 dated 04/07/22. A review of the facility's policy titled, Discharge Against Medical Advice (AMA) with an effective date 06/01/96, and a revision date 01/31/20 found the following: . Documenting the AMA : . 7. The discharge transition plan will be provided to the patient or resident representative. Efforts will be made to make referrals to community resources and agencies to the extent possible. The Director of Nursing (DON) was asked to provide a copy of the discharge transition plan which was provided to Resident #110 at the time of his AMA discharge on [DATE]. On 06/28/22 at 2:08 pm the DON stated they did not complete a discharge transition plan for Resident #110. She confirmed the facility did not follow their AMA policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to provide care in accordance with professional standards of care to prevent the hospitalization of Resident #112. The facility also failed to provide blood pressure medication to Resident #100 within the parameters set by the physician. This was true for two (2) of 24 sampled residents. Resident Identifiers: #112 and #100. Facility Census: 117. Findings Included: a) Resident #112 A review of Resident #112's medical record on [DATE] found the following nursing notes: Change in condition nursing note dated [DATE] at 4:22 pm indicated the primary care physician was contacted in regard to a critical lab value of potassium being 2.9. The not indicated the primary care provider cave orders for Potassium 20 milliequivalent (meq). Change in condition note dated [DATE] at 6:26 pm indicated the nurse was called to the room because Resident #112 was unresponsive. The nurse documented the following in the Change in condition note: Called to resident room upon arrival resident non - responsive to name, light touch, or aggressive sternal rub. Pupils equal but unreactive to light. Resident noted with shallow RR (Respiration Rate) of 8 and noted with pulse. VS (Vital Signs) obtained and documented per this CIC (Change In Condition), o2 (oxygen) applied via mask, 911 called, IV (intravenous) stick attempted x (times) 2 (two) by this nurse with no success to initiate NS (normal saline), resident sent to (Name of local hospital) by (name of local ambulance company). Nursing note dated [DATE] at 4:41 am read as follows: Called (name of local hospital) at 2042 (8:42 pm) spoke to ED (emergency department) nurse (first name of local Hospital nurse) concerning pt (patient) and notified supervisor that they were looking to admit. Follow - up at 22:05 (10:05 pm) awaiting lab work at (name of local hospital) Still looking to admit. Follow up at 0430 (4:30 am): Pt (patient) deceased at 0151 (1:51 am) per (name of local hospital). Further review of the medical record found a lab result dated [DATE] which had a hemoglobin level of 8.2 which is low. The lab also contained a critically low potassium level of 2.9. Hand written on this lab was the following notes: Stool for occult blood X 3. (this note was written near the section which contained the low hemoglobin level). Give potassium 20 meq po (by mouth) now and then po q d (one time every day) repeat BMP (basic metabolic panel) on Wednesday (this would be on [DATE]. (this was written on the section of the lab near the critically low potassium level). Further review of the medical record found the following orders were entered into the medical record on [DATE]: Gualac stool/occult blood one time only for 3 days with a start date of [DATE]. Potassium 20 meq daily BMP one time only for hypokalmeia for 1 day with a start date of [DATE]. A review of the Treatment Administration Record (TAR) found the BMP was obtained on [DATE] as ordered and on [DATE] one (1) stool sample was obtained as ordered for the Gualac stool/occult blood. The TAR indicated there were no other stool samples obtained on [DATE] or [DATE]. Review of the Bowel Movement report for Resident #112 for the time frame of [DATE] through [DATE] found the resident had one (1) bowel movement on [DATE] and two (2) bowel movements on [DATE]. (Please Note: Resident #112 had bowel movements on [DATE] and [DATE] and the facility could have obtained the additional needed stool samples as ordered, but they did not obtain the samples according to the TAR.) During an interview with the Director of Nursing (DON) at 12:25 pm on [DATE] a copy of the results for the basic metabolic panel and the occult stool X3 was requested. Also evidence to indicate the physician or nurse practitioner was notified of the lab results was requested. A subsequent interview with the DON on [DATE] at 1:39 pm confirmed there was no indication in the medical record to indicate the physician was notified of the BMP results which were obtained on [DATE]. She stated the staff did obtain one (1) stool sample for the occult blooded but there was no information in the medical record to indicate what the results of that sample were. She indicated they did not obtain the other two (2) samples. At 2:38 pm on [DATE] the nurse practitioner was interviewed. She stated the occult stool X3 should have been three separate stool samples. Not three (3) days to obtain them. She stated that it needed to be three separate stool samples. When asked if she was ever notified of the BMP on [DATE] or the occult stool X 3. She indicated she had no way to know if she was notified or not. b) Resident #100 On [DATE] at 2:45 PM while reviewing medical records it was noted that on multiple days in [DATE] the nursing staff failed to follow the Physicians parameters order for holding a blood pressure medication based on the systolic blood pressure (SBP) reading This occurred for a total of seven (7) out of twenty (20) times the medication was given on those five (5) days. This was confirmed with the Director of Nursing on [DATE] at 3:30 PM. The Physicians order was as follows: clonidine tablet 0.1 milligram, Give 1 tablet by mouth every 6 hours for hypertension. Hold for SBP less than 150 and notify provider. On [DATE] her blood pressure was 114/80 on the 12:00 AMdose. On [DATE] her blood pressure was 114/80 on the 6:00 AM dose. On [DATE] her blood pressure was 137/74 on the 12:00 AMdose. On [DATE] her blood pressure was 124/50 on the 12:00 AM dose. On [DATE] her blood pressure was 132/68 on the 6:00 AM dose. On [DATE] her blood pressure was 129/80 on the 12:00 AM dose. On [DATE] her blood pressure was 132/84 on the 6:00 AM dose. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview the facility failed to provide the services, care, and equipment to assure that a Resident maintains, and/or improves to their highest level of range of motion (ROM) and mobility. This was a random opportunity for discovery. Resident Identifier #5. Facility Census: 117. Findings included: a) Resident #5 An observation on 06/27/22 at 3:36 PM found, Resident #5's Left hand and arm had a contracture with no protection in place. A review of Resident #5's medical record on 06/28/22, showed it did not contain physicians' orders for treatment to the left hand and arm contractures. Further review of the resident's medical record showed the care plan did not contain treatment for Contractures. Subsequent medical record review revealed Resident #5's Quarterly 06/13/22 Minimum Data Set (MDS), section O (Special Treatment, Procedures, and Programs) 00400 - 0 minutes in Occupational Therapy (OT)or Physical Therapy (PT). Section 00500 (Restorative Nursing Program) found, 0 Days range of motion of splint or brace assistance. Section S (Functional status) S3100 contractures - coded left hand, wrist, elbow, shoulder, neck, ankle, knee, hip contractures. During an Interview on 06/29/22 at 8:35 AM the Occupational Therapist #143 stated that Resident #5 was cut from therapy services around 04/01/22 and transitioned to the Restorative program. A review of the Rehabilitation Restorative Transition Program form revealed a program designed for the restorative program for splinting and Range of Motion (ROM) on the left hand on Resident #5. Certified Occupasional Therapy Assistant (COTA) #146 trained the restorative program staff on the Instruction for splinting and ROM on 04/01/22. During an Interview on 06/29/22 at 8:46 AM the Assistant Director of Nursing and the Medical Records Director stated that Resident #5 was never on the Restorative Program. She stated that Resident #5 was admitted to the hospital on [DATE] and re-admitted to the facility on [DATE] and the Therapy program should have done a screen. During an Interview with Occupational Therapist #143 she revealed the Interdisciplinary screen form for Resident #5 on 04/05/22 that commented for the Restorative Program to Resume from the 04/01/22 order. .

. Based on observation, record review and staff interview the facility failed to assure the Resident received care and services for the provision of hemodialysis consistent with professional standards of practice. Resident Identifier: #100 Facility Census: 117 Findings Included: a) Resident #100 On 6/27/22 at 1:44 PM it was observed Resident #100 has a dialysis perma-catheter to her right chest. As per Physicians orders there is to be smooth clamps at the bedside and on the patients wheelchair and to be checked every shift. Upon further observation, there were no smooth clamps in the Resident's room. The clamps must be accessible immediately upon an emergency with her perma-catheter. This was verified on 6/27/22 at 1:55 PM with Nurse Unit Manager #59. .

. Based on record review and staff interview the facility failed to promptly notify the ordering physician and nurse practitioner of laboratory results that fall outside of clinical reference ranges. Resident #112's nurse practitioner and/or the physician was not notified the of the of a Basic Metabolic Panel (BMP) results which was obtained on 03/30/22. Resident Identifier: #112. Facility Census: 117. Findings Included: a) Resident #112 A review of Resident #112's medical record on 06/28/22 at 10:44 am, found a physicians order for a BMP laboratory test to be obtained on 03/30/22. The electronic medical record did not contain the results of the BMP test. The medical record did not contain any nursing notes or any other documentation which would indicate the physician and/or nurse practitioner was notified of the lab results. The results of the BMP was requested from facility staff on the morning of 06/28/22. The Director of Nursing (DON) provided a copy of the BMP lab result at 12:25 pm on 06/28/22. A review of the lab report found it was not signed by the physician nor the nurse practitioner. The DON was asked if there was any documentation in the medical record to indicate the nurse practitioner and/or physician was notified of the lab results. She confirmed there was nothing in the record to show the nurse practitioner and/or physician was notified of the lab result. .

. Based on observations, staff interview, and record review, the facility failed to provide each resident food and / or drink that was palatable, attractive, and at a safe and appetizing temperature. This was a random opportunity for discovery. This has the potential to affect a limited number of residents. Facility census: 117. Findings Included: a) Second Kitchen Tour On 06/28/22 at 11:11 AM during the second tour in the kitchen found the deviled egg potato salad in the freezer cooling down. Observing the temperature check for the lunch meal found the temperature of deviled egg potato salad to be 141.0 degrees. During the interview on 06/28/22 at 11:12 AM the [NAME] #125 stated that she put the potato salad in the freezer to get it to cool down enough before serving. She stated she would start serving in about 20 minutes at 11:30 AM. On 06/28/22 at 11:58 AM an observation of the dining room tray pass process revealed the deviled egg potato salad was being served to Residents. On 06/28/22 at 12:02 PM the Dietary Manager in Training and [NAME] #126 was asked to retake the temperature of the potato salad. The Temperature was 74 degrees. [NAME] #126 stated that she was serving the potato salad from the edges of the pan where it was cooler. At this time the Dietary Manager in Training verified it should not be served. .

. Based on observation and staff interview the facility failed to complete labeling and dates on freezer items, refrigerator items, dry storage, and complete refrigerator temperature log in accordance with professional standards for food service safety related to storage. This has the ability to affect a limited number of residents that get their nutrition from the kitchen. Facility Census: 117. Findings Included: a) Kitchen tour Observation during the kitchen tour on 06/27/22 10:51 AM found: -- Reach in refrigerator -three (3) pitchers of lemon aid, three (3) pitchers of orange juice, ham lunch meat, and a block cheese with no labeling or dates. --Walk in freezer- One (1) open bag of cinnamon rolls, and one (1) bag of open tater tots with no label or date. -- Dry storage - One (1) bag of Corn Flakes was out of original box and not labeled or dated. During an interview on 06/27/22 at 11:00 AM, the Dietary Manager (DM) in training verified, there was no labeling or dates on the items mentioned and though them away at this time. b) Second Kitchen Tour On 06/28/22 at 11:05, observation during the second tour in the kitchen found, the reach in refrigerator temperature (temp) log was missing the 06/27/22 PM temperature and the 06/28/22 AM temperature. At 11:07 an observation of Dietary Aid #124 writing a temperature on the plastic cover of the reach in refrigerator temp log, without opening the refrigerator to review the thermometer. During an interview on 06/26/22 at 11:08 AM, the Dietary Manager (DM) in training verified, there were missing temps on the reach in log. Based on Observation, staff interview the failed to no labels and dates on foods and failed to log refrigerator temperatures .

. Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. This practice affected one (1) of 24 resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #85. Facility census: 117. Findings included: a) Resident #85 A medical record review revealed a Physicians order: --Full Code (All resuscitation procedures will be provided to keep them alive.) with a start date 05/25/22. A review of Resident #85's care plan revealed the following: Focus: Revision on 05/14/22 -- Do Not Attempt Resuscitation (DNR.) Resident has an established advanced directive DNR, Selective Treatment, no feeding tube. Goals associated included: Created on 06/14/22. --Resident's wishes as expressed in advanced directive will be followed. Interventions included: Date initiated 06/14/22. --Activate residents advanced directive as indicated. A continued review of Resident #85's medical record found an active Physician Order for Scope of Treatment Form (POST Form) with section A. marked Do Not Attempt Resuscitation. Dated 5/13/22. On 06/27/22 at 4:06 PM an Interview with the Medical Records Director, verified the POST form and physician order was contradictory. She stated It will be corrected immediately. No further information was provided prior to the end of the survey on 06/29/22 at 1:30 PM. .

. Based on record review and staff interview, the facility failed to ensure all needed members attended all four quarters of the quality assessment and assurance committee (QAA) meetings. This practice has the potential to affect a limited number of residents currently residing in the facility. Facility census 117. Findings included: On 06/29/22 at 10:28 AM, the Administrator was asked to provide a sign in sheet for each quarter. After a review of the sign in sheets it was found that the medical director did not sign the sign in sheet during the first quarter meeting. Administrator stated he was not here during the first quarter and does not have any sign in sheets that showed the medical director was at any meetings during the first quarter. No additional information was provided at close of the survey. .

. Based on record review and staff interview the facility failed to implement the facility Abuse/neglect policy, by filing allegations of abuse/neglect as a grievance/concern issue instead of reporting them to appropriate state agencies as required. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Resident identifiers: #161, #13, #162, and #103. Facility census 117. Findings included: a) Facility Policy Facility Policy,1.0 Abuse Prohibition Manual Title, Assisted Living Administrative Policies and Procedures Effective date: 03/01/02 Abuse is defined as; the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and includes verbal, sexual, physical, and mental abuse. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Upon receiving information concerning a report of abuse, the Executive Director or designee will: -Report it to appropriate agencies as per state requirements. -Conduct an immediate and thorough investigation which will focus on: -- If abuse or neglect occurred and to what extent. --A clinical examination for signs of injuries --Causative factors. --Interventions to prevent further injury. -The investigation will be thoroughly documented on any state required form, and on the Investigation of Incident Form and Incident log for Quality Improvement, ensure that documents of witnessed interviews is included. --Forms, logs, and statements will be kept confidential in a file in the Executive Director's office. --Assign a representative from social services or designee to monitor the resident's feelings concerning the incident, as well as the resident's involvement in the investigation. The Executive Director or designee will report findings of all completed investigations within five working days of the incident or in accordance with state law, and take all necessary corrective actions depending on the results of the investigations, --The report must include, but is not limited to: * Name of resident *Date and time incident occurred *Circumstances surrounding the incident *Where the incident took place *Name of any witnesses *Name of person(s) charged with committing the act *Recommendations for corrective action *Any other information as appropriate The Executive Director will analyze all occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. b) Resident #161 During a review of the facility Grievance/Concern forms it found Resident #161's daughter had reported on 01/22/22 the following: Documentation of Grievance/Concern: Resident was left in WC (wheelchair) after Therapy in her new room, without leg rests on WC and almost empty O2 (oxygen) tank. Room was disheveled and bed was unmade. Resident had soiled herself and it was unknown how long she had been sitting in it. Resident's legs had turned purple with Petechiae (form when tiny blood vessel called capillaries break open) on both sides. From sitting up in the WC to long. Investigation: Individuals/department designated to take on this concern: -Center Exec.Dir. (Administrator) -Director of Social Services -Center Nurse Exec. (DON) Describe actions taken to investigate grievance/concern: Resident was in bed when staff went to investigate and was on the concentrator (a machine used to concentrate and deliver oxygen). Verbal education provided to staff on making sure oxygen full when taken out of room. Leg rest obtained. Resolution of Grievance/Concern: Was grievance/concern resolved? (This section was blank) Identify the method used to notify the patient/representative of resolution: face to face with resident Dated: 01/27/22 On 06/28/22 at 3:15 PM, the Administrator and the Medical Records Director were asked about the above events. They were also asked if there was any documentation that a nurse, physician and/or provider evaluated this resident for any remaining discoloration on her legs and redness on her buttock from being left in a soiled brief. The Administrator indicated the resident had not been evaluated by a nurse, physician and/or provider. They were then asked there was an investigation completed to determine who had left her there and the issues in her room. The administrator then read the allegation aloud and stated, I can see now why his is an allegation of neglect. He stated he was going to have the Director of Social Services to report this allegation. He confirmed it had not been reported. c) Resident #13 During an interview on 06/27/22 at 11:00 AM, Resident #13 appeared to be upset. Resident #13 said he had waited for over two (2) hours for staff to get him cleaned up after a bowel movement. He stated he asked for help right after breakfast and he just got cleaned up at 11:30 AM. Resident #13 said this happens often that he had told the administrator about this happening a few weeks ago. Resident #13 said that a couple of nights ago he had asked a Nurse Aide (NA) (named first name) NA #62 clean him up after a BM. States NA #62 told him he would be back after he gave someone a shower and took someone else to the bathroom. He said NA#62 said he could help me (Resident #62) after that; however, he never came back to help me that night. Resident #13 also complained about being woke up at 3:00 AM for a bed bath a couple of weeks ago. On 06/27/22 at 11:20 AM, the Administrator was asked to speak with Resident #13. Resident #13 repeated the above to the Administrator. On 06/27/22 at 4:30 PM, the Administrator was asked if he had completed a reportable or a grievance about Resident #13's issues. The administrator stated that when he told him that a few weeks ago they started some call light audits but did not complete any forma. The Administrator stated he would provide the audit forms but at the time of exit he had not provided the forms. On 06/27/22 at 12:12 PM, Social Service (SS) #82 completed a facility grievance/concern form which contained the following information: Incident Description: Resident reported to (named State agency) that call light is not being answered in timely manner. He is not being changed in timely manner and is not provided with bed bath in timely manner. Resident also stated he received a bed bath by NA at 3AM. Immediate action taken: Investigation begun. Statements to be taken from resident after AM care is provided as staff went to interview and he was getting bathed and shaved. Provided on 06/28/22 were 11 staff statements, with five (5) questions on the page as follows: 1. Have you answered resident light in last week? 2. Did you provide care resident needed? If so what care did you provide? 3. If resident needed incontinence care was he slightly soiled/wet? If not describe condition of resident and what type of care provided. 4. If you are assigned resident, do you provide bed bath? 5. Does resident refuse care? If so explain. Of the 11 staff statements five (5) were not assigned to him. Six answer yes to the first four questions and no the the fifth question. On 06/28/22 at 3:25 PM , the Administrator was asked If this was an allegation of neglect? Administrator said yes it sounds like it is now that I have heard you read it aloud. He stated that it should have been reported but was not. d) Resident #162 During a review of the facility Grievance/concern forms it found Resident #162 made an allegation on 01/06/22 of care not being provided in a timely manner. The Grievance/Concern form contained the following information: Documentation of Grievance/Concern (Named Resident #162) said that she turned her call light on at 8PM on 01/05/22 and no one came to change her for three (3) hours. Resident #162 said they laid in poop for three (3) hours. Report taken by: Director of Social Services (DSS) Investigation: SS (Social Services) interviewed resident and staff. Resident was changed prior to 8PM and again between 9:30-9:45 PM. Per conversation with resident, she will be placed on a three (3) hour checks and task updated. The facility obtained four statements, two from Resident #162 and two from Staff. Witness Statement: SS (Social Services) spoke with resident during meal pass regarding her concern. Resident was asked if she felt she had been abused or neglected. She stated no your staff, well some of them are just for a paycheck. Resident was asked if she put her light on or if any staff came in her room during the time frame of needing to be changed. She stated, I really don't remember. Resident was asked if we could put her on q two (2) hour checks and she stated, NO I don't want to be bothered. When asked what we could do to make things better she stated, nothing it's your staff's attitude. When asked what she meant she again said, They are here for a pay check. Signed by Director of Social Services Dated: 01/06/22 Witness Statement: Spoke with resident regarding concern from 01/05/22. (Named) Resident #162 stated she turned her call light on around 8 AM or a little after. She stated her call light was answered around 10 PM. Resident states she does not feel like she was abused or neglected. She says she just wants everyone to take their jobs seriously. Resident unable to give details on staff members. Offered two (2) hour checks, resident declined but accepted a three (3) hour check. Resident stated she just wants everyone to get together and talk to them (staff) about taking job seriously. Discussed with resident staff education and call light audits, she stated this would be good. Signed by Registered Nurse # 110 (DON). Witness Statement I changed resident brief around 7:30 PM because she had a bowel movement. I asked her if sheet needed changed, it did so I changed sheet pulled cover up gave her remote and made sure she had ice water. I went in room again about 9:45 PM/10 PM, and she said one of the other girls had changed her. She told me she had diarrhea. Signed by Nurse Aide #89. Dated 01/06/22 Witness Statement I was helping (Name of Nurse Aide #215) on his round. I went in to change her roommate (Resident #162's). (Named) Resident #162 voiced her concern of when she was going to be changed. I asked her how long she been waiting. She said since the last time I was in there at 6:45 PM. So I changed her and gave her a new draw sheet as the old one was soiled due to the saturation of the brief. Signed by Unable to read signature Dated 01/06/22 On 06/28/22 at 3:26 PM, the above information was reported to the Administrator and Medical Record Manager (MRM) #97. They agreed this was not reported. e) Resident #103 During a review of Grievance/Concern forms it found that numerous staff reported seeing the then Activities staff (now nurse aide) #27 receiving money from Resident # 103. There was not any record of NA #27 making any purchases for Resident # 103 or how much money he had given NA#27. This was reported to the facility, and it was handled as a concern only. Facility Grievance/ Concern Form Patient Name: (Used first and last Name of) Resident #103 Date received: 01/24/22 Individual presenting concern: Nurse Aide #99 (Used first and last name) Documentation Describe concern: Staff expressed concern about (Used first name) then Activities staff (now nurse aide) #27 getting money from resident. Staff member: (Used first and last name) Social Services #111 Investigation Talk to resident obtain witness statements from all individuals involved. Recommended corrective action: Create log to keep track of which residents give money to activities to purchase items and amount of money given to activities department Resolution of Grievance/Concern Was Grievance/ Concern resolved? Yes, was checked describe resolution: Investigated Written notification provided and date was blank Staff member: This was blank Witness Statement I sometimes give (used First name) then Activities staff (now nurse aide) #27 money to purchase items for me at the store. I have not given (used First name) then Activities staff (now nurse aide) #27 any money in the past couple of days. I have never given (used First name) then Activities staff (now nurse aide) #27 hundreds of dollars at one time. I have a food stamp card to purchase items for me. I have not given anyone my food stamp card in the past couple of days. I have never given (used First name) then Activities staff (now nurse aide) #27 money to purchase a phone for herself. Signed (Used first and Last name) Resident #103 I personally have seen (used first and last name) Resident #103 give (used First name) then Activities staff (now nurse aide) #27 in activities money on multiple occasions, however, I am unsure of amounts. Was always under the assumption (used First name) then Activities staff (now nurse aide) #27 was using money for (Used first name) Resident #103's cigarettes, etc. It was reported to me by (used first and last name) NA#99 that she overheard (used first name) Resident #103 ask (used first name) then Activities staff (now nurse aide) #27, How do you like the new phone I brought you? and (used First name) then Activities staff (now nurse aide) #27 responded good showing him a new iPhone. It was also reported to me that while on break- (used first name) NA #99 was behind (used First name) then Activities staff (now nurse aide) #27 at gas station and saw (used First name) then Activities staff (now nurse aide) #27 using an EBT (state food stamp card) card in (used first and last name) Resident #103's name. Signed by: (first and last name) Licensed Practical Nurse #48 dated:01/24/22 Witness statement One day last week I saw (used First name) then Activities staff (now nurse aide) #27 in (used first and last name) Resident #103's room with money in her hand. It was $100.00 dollar bills. Then I heard him ask her if she liked the phone, he bought her, and she said yes and showed him new phone. I also saw her on a different day with a food stamp card with his name on it and when she saw I had seen it she flipped it over really fast and put it in her pocket. I didn't say anything at the time because I didn't want to get anyone in trouble. Signed: via telephone with (used first and last name) NA #99 taken by DON dated: 01/24/22 On 06/28/22 at 3:26 PM, the above information was reported to Administrator and Medical Record Manager (MRM) #97. MRM #97 stated, after they (facility) became aware of the money exchange and no record of the exchanges, they developed a logbook and receipts are kept in the logbook and they (facility) see there is room to improve that system as well. Administrator stated he did not think it was a reportable event. Administrator was informed misappropriations of any resident's money or lack of having a system in place to prevent misappropriation and the allegation of misconduct could be considered misappropriation resident funds. .

. Based on record review and staff interview the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. This failed practice occurred, by filing allegations of abuse/neglect as a grievance/concern issue. This was true for four (4) reisdents. Resident identifiers: #161, #13, #162, and #103. Facility census 117. Findings included: a) Facility Policy Facility Policy,1.0 Abuse Prohibition Manual Title, Assisted Living Administrative Policies and Procedures Effective date: 03/01/02 Abuse is defined as; the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and includes verbal, sexual, physical, and mental abuse. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Upon receiving information concerning a report of abuse, the Executive Director or designee will: -Report it to appropriate agencies as per state requirements. -Conduct an immediate and thorough investigation which will focus on: -- If abuse or neglect occurred and to what extent. --A clinical examination for signs of injuries --Causative factors. --Interventions to prevent further injury. -The investigation will be thoroughly documented on any state required form, and on the Investigation of Incident Form and Incident log for Quality Improvement, ensure that documents of witnessed interviews is included. --Forms, logs, and statements will be kept confidential in a file in the Executive Director's office. --Assign a representative from social services or designee to monitor the resident's feelings concerning the incident, as well as the resident's involvement in the investigation. The Executive Director or designee will report findings of all completed investigations within five working days of the incident or in accordance with state law, and take all necessary corrective actions depending on the results of the investigations, --The report must include, but is not limited to: * Name of resident *Date and time incident occurred *Circumstances surrounding the incident *Where the incident took place *Name of any witnesses *Name of person(s) charged with committing the act *Recommendations for corrective action *Any other information as appropriate The Executive Director will analyze all occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. b) Resident #161 During a review of the facility Grievance/Concern forms it found Resident #161's daughter had reported on 01/22/22 the following: Documentation of Grievance/Concern: Resident was left in WC (wheelchair) after Therapy in her new room, without leg rests on WC and almost empty O2 (oxygen) tank. Room was disheveled and bed was unmade. Resident had soiled herself and it was unknown how long she had been sitting in it. Resident's legs had turned purple with Petechiae (form when tiny blood vessel called capillaries break open) on both sides. From sitting up in the WC to long. Investigation: Individuals/department designated to take on this concern: -Center Exec.Dir. (Administrator) -Director of Social Services -Center Nurse Exec. (DON) Describe actions taken to investigate grievance/concern: Resident was in bed when staff went to investigate and was on the concentrator (a machine used to concentrate and deliver oxygen). Verbal education provided to staff on making sure oxygen full when taken out of room. Leg rest obtained. Resolution of Grievance/Concern: Was grievance/concern resolved? (This section was blank) Identify the method used to notify the patient/representative of resolution: face to face with resident Dated: 01/27/22 On 06/28/22 at 3:15 PM, the Administrator and the Medical Records Director were asked about the above events. They were also asked if there was any documentation that a nurse, physician and/or provider evaluated this resident for any remaining discoloration on her legs and redness on her buttock from being left in a soiled brief. The Administrator indicated the resident had not been evaluated by a nurse, physician and/or provider. They were then asked there was an investigation completed to determine who had left her there and the issues in her room. The administrator then read the allegation aloud and stated, I can see now why his is an allegation of neglect. He stated he was going to have the Director of Social Services to report this allegation. He confirmed it had not been reported. c) Resident #13 During an interview on 06/27/22 at 11:00 AM, Resident #13 appeared to be upset. Resident #13 said he had waited for over two (2) hours for staff to get him cleaned up after a bowel movement. He stated he asked for help right after breakfast and he just got cleaned up at 11:30 AM. Resident #13 said this happens often that he had told the administrator about this happening a few weeks ago. Resident #13 said that a couple of nights ago he had asked a Nurse Aide (NA) (named first name) NA #62 clean him up after a BM. States NA #62 told him he would be back after he gave someone a shower and took someone else to the bathroom. He said NA#62 said he could help me (Resident #62) after that; however, he never came back to help me that night. Resident #13 also complained about being woke up at 3:00 AM for a bed bath a couple of weeks ago. On 06/27/22 at 11:20 AM, the Administrator was asked to speak with Resident #13. Resident #13 repeated the above to the Administrator. On 06/27/22 at 4:30 PM, the Administrator was asked if he had completed a reportable or a grievance about Resident #13's issues. The administrator stated that when he told him that a few weeks ago they started some call light audits but did not complete any forma. The Administrator stated he would provide the audit forms but at the time of exit he had not provided the forms. On 06/27/22 at 12:12 PM, Social Service (SS) #82 completed a facility grievance/concern form which contained the following information: Incident Description: Resident reported to (named State agency) that call light is not being answered in timely manner. He is not being changed in timely manner and is not provided with bed bath in timely manner. Resident also stated he received a bed bath by NA at 3AM. Immediate action taken: Investigation begun. Statements to be taken from resident after AM care is provided as staff went to interview and he was getting bathed and shaved. Provided on 06/28/22 were 11 staff statements, with five (5) questions on the page as follows: 1. Have you answered resident light in last week? 2. Did you provide care resident needed? If so what care did you provide? 3. If resident needed incontinence care was he slightly soiled/wet? If not describe condition of resident and what type of care provided. 4. If you are assigned resident, do you provide bed bath? 5. Does resident refuse care? If so explain. Of the 11 staff statements five (5) were not assigned to him. Six answer yes to the first four questions and no the the fifth question. On 06/28/22 at 3:25 PM , the Administrator was asked If this was an allegation of neglect? Administrator said yes it sounds like it is now that I have heard you read it aloud. He stated that it should have been reported but was not. d) Resident #162 During a review of the facility Grievance/concern forms it found Resident #162 made an allegation on 01/06/22 of care not being provided in a timely manner. The Grievance/Concern form contained the following information: Documentation of Grievance/Concern (Named Resident #162) said that she turned her call light on at 8PM on 01/05/22 and no one came to change her for three (3) hours. Resident #162 said they laid in poop for three (3) hours. Report taken by: Director of Social Services (DSS) Investigation: SS (Social Services) interviewed resident and staff. Resident was changed prior to 8PM and again between 9:30-9:45 PM. Per conversation with resident, she will be placed on a three (3) hour checks and task updated. The facility obtained four statements, two from Resident #162 and two from Staff. Witness Statement: SS (Social Services) spoke with resident during meal pass regarding her concern. Resident was asked if she felt she had been abused or neglected. She stated no your staff, well some of them are just for a paycheck. Resident was asked if she put her light on or if any staff came in her room during the time frame of needing to be changed. She stated, I really don't remember. Resident was asked if we could put her on q two (2) hour checks and she stated, NO I don't want to be bothered. When asked what we could do to make things better she stated, nothing it's your staff's attitude. When asked what she meant she again said, They are here for a pay check. Signed by Director of Social Services Dated: 01/06/22 Witness Statement: Spoke with resident regarding concern from 01/05/22. (Named) Resident #162 stated she turned her call light on around 8 AM or a little after. She stated her call light was answered around 10 PM. Resident states she does not feel like she was abused or neglected. She says she just wants everyone to take their jobs seriously. Resident unable to give details on staff members. Offered two (2) hour checks, resident declined but accepted a three (3) hour check. Resident stated she just wants everyone to get together and talk to them (staff) about taking job seriously. Discussed with resident staff education and call light audits, she stated this would be good. Signed by Registered Nurse # 110 (DON). Witness Statement I changed resident brief around 7:30 PM because she had a bowel movement. I asked her if sheet needed changed, it did so I changed sheet pulled cover up gave her remote and made sure she had ice water. I went in room again about 9:45 PM/10 PM, and she said one of the other girls had changed her. She told me she had diarrhea. Signed by Nurse Aide #89. Dated 01/06/22 Witness Statement I was helping (Name of Nurse Aide #215) on his round. I went in to change her roommate (Resident #162's). (Named) Resident #162 voiced her concern of when she was going to be changed. I asked her how long she been waiting. She said since the last time I was in there at 6:45 PM. So I changed her and gave her a new draw sheet as the old one was soiled due to the saturation of the brief. Signed by Unable to read signature Dated 01/06/22 On 06/28/22 at 3:26 PM, the above information was reported to the Administrator and Medical Record Manager (MRM) #97. They agreed this was not reported. e) Resident #103 During a review of Grievance/Concern forms it found that numerous staff reported seeing the then Activities staff (now nurse aide) #27 receiving money from Resident # 103. There was not any record of NA #27 making any purchases for Resident # 103 or how much money he had given NA#27. This was reported to the facility, and it was handled as a concern only. Facility Grievance/ Concern Form Patient Name: (Used first and last Name of) Resident #103 Date received: 01/24/22 Individual presenting concern: Nurse Aide #99 (Used first and last name) Documentation Describe concern: Staff expressed concern about (Used first name) then Activities staff (now nurse aide) #27 getting money from resident. Staff member: (Used first and last name) Social Services #111 Investigation Talk to resident obtain witness statements from all individuals involved. Recommended corrective action: Create log to keep track of which residents give money to activities to purchase items and amount of money given to activities department Resolution of Grievance/Concern Was Grievance/ Concern resolved? Yes, was checked describe resolution: Investigated Written notification provided and date was blank Staff member: This was blank Witness Statement I sometimes give (used First name) then Activities staff (now nurse aide) #27 money to purchase items for me at the store. I have not given (used First name) then Activities staff (now nurse aide) #27 any money in the past couple of days. I have never given (used First name) then Activities staff (now nurse aide) #27 hundreds of dollars at one time. I have a food stamp card to purchase items for me. I have not given anyone my food stamp card in the past couple of days. I have never given (used First name) then Activities staff (now nurse aide) #27 money to purchase a phone for herself. Signed (Used first and Last name) Resident #103 I personally have seen (used first and last name) Resident #103 give (used First name) then Activities staff (now nurse aide) #27 in activities money on multiple occasions, however, I am unsure of amounts. Was always under the assumption (used First name) then Activities staff (now nurse aide) #27 was using money for (Used first name) Resident #103's cigarettes, etc. It was reported to me by (used first and last name) NA#99 that she overheard (used first name) Resident #103 ask (used first name) then Activities staff (now nurse aide) #27, How do you like the new phone I brought you? and (used First name) then Activities staff (now nurse aide) #27 responded good showing him a new iPhone. It was also reported to me that while on break- (used first name) NA #99 was behind (used First name) then Activities staff (now nurse aide) #27 at gas station and saw (used First name) then Activities staff (now nurse aide) #27 using an EBT (state food stamp card) card in (used first and last name) Resident #103's name. Signed by: (first and last name) Licensed Practical Nurse #48 dated:01/24/22 Witness statement One day last week I saw (used First name) then Activities staff (now nurse aide) #27 in (used first and last name) Resident #103's room with money in her hand. It was $100.00 dollar bills. Then I heard him ask her if she liked the phone, he bought her, and she said yes and showed him new phone. I also saw her on a different day with a food stamp card with his name on it and when she saw I had seen it she flipped it over really fast and put it in her pocket. I didn't say anything at the time because I didn't want to get anyone in trouble. Signed: via telephone with (used first and last name) NA #99 taken by DON dated: 01/24/22 On 06/28/22 at 3:26 PM, the above information was reported to Administrator and Medical Record Manager (MRM) #97. MRM #97 stated, after they (facility) became aware of the money exchange and no record of the exchanges, they developed a logbook and receipts are kept in the logbook and they (facility) see there is room to improve that system as well. Administrator stated he did not think it was a reportable event. Administrator was informed misappropriations of any resident's money or lack of having a system in place to prevent misappropriation and the allegation of misconduct could be considered misappropriation resident funds. .

. Based on record review and staff interview the facility failed to thoroughly investigate alleged violations of Abuse/neglect. This was true for four (4) of Four (4) residents reviewed for the care area of Abuse. Resident identifiers: #161, #13, #162, and #103. Facility census 117. Findings included: a) Facility Policy Facility Policy,1.0 Abuse Prohibition Manual Title, Assisted Living Administrative Policies and Procedures Effective date: 03/01/02 Abuse is defined as; the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and includes verbal, sexual, physical, and mental abuse. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Upon receiving information concerning a report of abuse, the Executive Director or designee will: -Report it to appropriate agencies as per state requirements. -Conduct an immediate and thorough investigation which will focus on: -- If abuse or neglect occurred and to what extent. --A clinical examination for signs of injuries --Causative factors. --Interventions to prevent further injury. -The investigation will be thoroughly documented on any state required form, and on the Investigation of Incident Form and Incident log for Quality Improvement, ensure that documents of witnessed interviews is included. --Forms, logs, and statements will be kept confidential in a file in the Executive Director's office. --Assign a representative from social services or designee to monitor the resident's feelings concerning the incident, as well as the resident's involvement in the investigation. The Executive Director or designee will report findings of all completed investigations within five working days of the incident or in accordance with state law, and take all necessary corrective actions depending on the results of the investigations, --The report must include, but is not limited to: * Name of resident *Date and time incident occurred *Circumstances surrounding the incident *Where the incident took place *Name of any witnesses *Name of person(s) charged with committing the act *Recommendations for corrective action *Any other information as appropriate The Executive Director will analyze all occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. b) Resident #161 During a review of the facility Grievance/Concern forms it found Resident #161's daughter had reported on 01/22/22 the following: Documentation of Grievance/Concern: Resident was left in WC (wheelchair) after Therapy in her new room, without leg rests on WC and almost empty O2 (oxygen) tank. Room was disheveled and bed was unmade. Resident had soiled herself and it was unknown how long she had been sitting in it. Resident's legs had turned purple with Petechiae (form when tiny blood vessel called capillaries break open) on both sides. From sitting up in the WC to long. Investigation: Individuals/department designated to take on this concern: -Center Exec.Dir. (Administrator) -Director of Social Services -Center Nurse Exec. (DON) Describe actions taken to investigate grievance/concern: Resident was in bed when staff went to investigate and was on the concentrator (a machine used to concentrate and deliver oxygen). Verbal education provided to staff on making sure oxygen full when taken out of room. Leg rest obtained. Resolution of Grievance/Concern: Was grievance/concern resolved? (This section was blank) Identify the method used to notify the patient/representative of resolution: face to face with resident Dated: 01/27/22 On 06/28/22 at 3:15 PM, the Administrator and the Medical Records Director were asked about the above events. They were also asked if there was any documentation that a nurse, physician and/or provider evaluated this resident for any remaining discoloration on her legs and redness on her buttock from being left in a soiled brief. The Administrator indicated the resident had not been evaluated by a nurse, physician and/or provider. They were then asked there was an investigation completed to determine who had left her there and the issues in her room. The administrator then read the allegation aloud and stated, I can see now why his is an allegation of neglect. He stated he was going to have the Director of Social Services to report this allegation. He confirmed it had not been reported. c) Resident #13 During an interview on 06/27/22 at 11:00 AM, Resident #13 appeared to be upset. Resident #13 said he had waited for over two (2) hours for staff to get him cleaned up after a bowel movement. He stated he asked for help right after breakfast and he just got cleaned up at 11:30 AM. Resident #13 said this happens often that he had told the administrator about this happening a few weeks ago. Resident #13 said that a couple of nights ago he had asked a Nurse Aide (NA) (named first name) NA #62 clean him up after a BM. States NA #62 told him he would be back after he gave someone a shower and took someone else to the bathroom. He said NA#62 said he could help me (Resident #62) after that; however, he never came back to help me that night. Resident #13 also complained about being woke up at 3:00 AM for a bed bath a couple of weeks ago. On 06/27/22 at 11:20 AM, the Administrator was asked to speak with Resident #13. Resident #13 repeated the above to the Administrator. On 06/27/22 at 4:30 PM, the Administrator was asked if he had completed a reportable or a grievance about Resident #13's issues. The administrator stated that when he told him that a few weeks ago they started some call light audits but did not complete any forma. The Administrator stated he would provide the audit forms but at the time of exit he had not provided the forms. On 06/27/22 at 12:12 PM, Social Service (SS) #82 completed a facility grievance/concern form which contained the following information: Incident Description: Resident reported to (named State agency) that call light is not being answered in timely manner. He is not being changed in timely manner and is not provided with bed bath in timely manner. Resident also stated he received a bed bath by NA at 3AM. Immediate action taken: Investigation begun. Statements to be taken from resident after AM care is provided as staff went to interview and he was getting bathed and shaved. Provided on 06/28/22 were 11 staff statements, with five (5) questions on the page as follows: 1. Have you answered resident light in last week? 2. Did you provide care resident needed? If so what care did you provide? 3. If resident needed incontinence care was he slightly soiled/wet? If not describe condition of resident and what type of care provided. 4. If you are assigned resident, do you provide bed bath? 5. Does resident refuse care? If so explain. Of the 11 staff statements five (5) were not assigned to him. Six answer yes to the first four questions and no the the fifth question. On 06/28/22 at 3:25 PM , the Administrator was asked If this was an allegation of neglect? Administrator said yes it sounds like it is now that I have heard you read it aloud. He stated that it should have been reported but was not. d) Resident #162 During a review of the facility Grievance/concern forms it found Resident #162 made an allegation on 01/06/22 of care not being provided in a timely manner. The Grievance/Concern form contained the following information: Documentation of Grievance/Concern (Named Resident #162) said that she turned her call light on at 8PM on 01/05/22 and no one came to change her for three (3) hours. Resident #162 said they laid in poop for three (3) hours. Report taken by: Director of Social Services (DSS) Investigation: SS (Social Services) interviewed resident and staff. Resident was changed prior to 8PM and again between 9:30-9:45 PM. Per conversation with resident, she will be placed on a three (3) hour checks and task updated. The facility obtained four statements, two from Resident #162 and two from Staff. Witness Statement: SS (Social Services) spoke with resident during meal pass regarding her concern. Resident was asked if she felt she had been abused or neglected. She stated no your staff, well some of them are just for a paycheck. Resident was asked if she put her light on or if any staff came in her room during the time frame of needing to be changed. She stated, I really don't remember. Resident was asked if we could put her on q two (2) hour checks and she stated, NO I don't want to be bothered. When asked what we could do to make things better she stated, nothing it's your staff's attitude. When asked what she meant she again said, They are here for a pay check. Signed by Director of Social Services Dated: 01/06/22 Witness Statement: Spoke with resident regarding concern from 01/05/22. (Named) Resident #162 stated she turned her call light on around 8 AM or a little after. She stated her call light was answered around 10 PM. Resident states she does not feel like she was abused or neglected. She says she just wants everyone to take their jobs seriously. Resident unable to give details on staff members. Offered two (2) hour checks, resident declined but accepted a three (3) hour check. Resident stated she just wants everyone to get together and talk to them (staff) about taking job seriously. Discussed with resident staff education and call light audits, she stated this would be good. Signed by Registered Nurse # 110 (DON). Witness Statement I changed resident brief around 7:30 PM because she had a bowel movement. I asked her if sheet needed changed, it did so I changed sheet pulled cover up gave her remote and made sure she had ice water. I went in room again about 9:45 PM/10 PM, and she said one of the other girls had changed her. She told me she had diarrhea. Signed by Nurse Aide #89. Dated 01/06/22 Witness Statement I was helping (Name of Nurse Aide #215) on his round. I went in to change her roommate (Resident #162's). (Named) Resident #162 voiced her concern of when she was going to be changed. I asked her how long she been waiting. She said since the last time I was in there at 6:45 PM. So I changed her and gave her a new draw sheet as the old one was soiled due to the saturation of the brief. Signed by Unable to read signature Dated 01/06/22 On 06/28/22 at 3:26 PM, the above information was reported to the Administrator and Medical Record Manager (MRM) #97. They agreed this was not reported. e) Resident #103 During a review of Grievance/Concern forms it found that numerous staff reported seeing the then Activities staff (now nurse aide) #27 receiving money from Resident # 103. There was not any record of NA #27 making any purchases for Resident # 103 or how much money he had given NA#27. This was reported to the facility, and it was handled as a concern only. Facility Grievance/ Concern Form Patient Name: (Used first and last Name of) Resident #103 Date received: 01/24/22 Individual presenting concern: Nurse Aide #99 (Used first and last name) Documentation Describe concern: Staff expressed concern about (Used first name) then Activities staff (now nurse aide) #27 getting money from resident. Staff member: (Used first and last name) Social Services #111 Investigation Talk to resident obtain witness statements from all individuals involved. Recommended corrective action: Create log to keep track of which residents give money to activities to purchase items and amount of money given to activities department Resolution of Grievance/Concern Was Grievance/ Concern resolved? Yes, was checked describe resolution: Investigated Written notification provided and date was blank Staff member: This was blank Witness Statement I sometimes give (used First name) then Activities staff (now nurse aide) #27 money to purchase items for me at the store. I have not given (used First name) then Activities staff (now nurse aide) #27 any money in the past couple of days. I have never given (used First name) then Activities staff (now nurse aide) #27 hundreds of dollars at one time. I have a food stamp card to purchase items for me. I have not given anyone my food stamp card in the past couple of days. I have never given (used First name) then Activities staff (now nurse aide) #27 money to purchase a phone for herself. Signed (Used first and Last name) Resident #103 I personally have seen (used first and last name) Resident #103 give (used First name) then Activities staff (now nurse aide) #27 in activities money on multiple occasions, however, I am unsure of amounts. Was always under the assumption (used First name) then Activities staff (now nurse aide) #27 was using money for (Used first name) Resident #103's cigarettes, etc. It was reported to me by (used first and last name) NA#99 that she overheard (used first name) Resident #103 ask (used first name) then Activities staff (now nurse aide) #27, How do you like the new phone I brought you? and (used First name) then Activities staff (now nurse aide) #27 responded good showing him a new iPhone. It was also reported to me that while on break- (used first name) NA #99 was behind (used First name) then Activities staff (now nurse aide) #27 at gas station and saw (used First name) then Activities staff (now nurse aide) #27 using an EBT (state food stamp card) card in (used first and last name) Resident #103's name. Signed by: (first and last name) Licensed Practical Nurse #48 dated:01/24/22 Witness statement One day last week I saw (used First name) then Activities staff (now nurse aide) #27 in (used first and last name) Resident #103's room with money in her hand. It was $100.00 dollar bills. Then I heard him ask her if she liked the phone, he bought her, and she said yes and showed him new phone. I also saw her on a different day with a food stamp card with his name on it and when she saw I had seen it she flipped it over really fast and put it in her pocket. I didn't say anything at the time because I didn't want to get anyone in trouble. Signed: via telephone with (used first and last name) NA #99 taken by DON dated: 01/24/22 On 06/28/22 at 3:26 PM, the above information was reported to Administrator and Medical Record Manager (MRM) #97. MRM #97 stated, after they (facility) became aware of the money exchange and no record of the exchanges, they developed a logbook and receipts are kept in the logbook and they (facility) see there is room to improve that system as well. Administrator stated he did not think it was a reportable event. Administrator was informed misappropriations of any resident's money or lack of having a system in place to prevent misappropriation and the allegation of misconduct could be considered misappropriation resident funds. .

. Based on resident interview, observation, and staff interview the facility failed to provide Activities of Daily Living (ADL) care for a dependent Resident in a timely manner. This was true for Three (3) out of four (4) residents reviewed for the care area of ADL care. Residents identifiers: #13, #39, and #79. Facility Census: 117. Findings included: a) Resident #13 During an interview on 06/27/22 at 11:00 AM, Resident #13 appeared to be upset. Resident #13 said he has waited for over two (2) hours for staff to get him cleaned up after a bowel movement. He stated he asked for help right after breakfast and he just cleaned up at 11:30 AM. Resident #13 said this happens often that he has told the administrator about this happening a few weeks ago. Resident #13 said that a couple of nights ago he asked a Nurse Aide (NA) (named first name) NA #62 clean him up after a BM. States NA #62 told him he would be back after he gave someone a shower and took someone else to the bathroom. He said NA#62 said he could help me (Resident #13) after that; however, he never came back to help me that night. Resident #13 also complained about being woke up at 3:00 AM for a bed bath a couple of weeks ago. On 06/27/22 at 11:20 AM, the Administrator was asked to speak to Resident #13. Resident #13 repeated the above to Administrator. b) Resident #39 Observation on 06/27/22 at 11:30 AM it was noted the call light was on when leaving a room across the hall. Resident #39 was asked if he needed help. Resident #39 stated he had a bowel movement (BM) and wanted someone to clean him up. Resident #39 was asked how long he has been waiting with the call light on. Resident #39 said it has been about 10 minutes. On 06/27/22 at 11:50 AM, Licensed Practical Nurse (LPN) #35 was walking past this room Resident #39 was in with the light on. LPN #35 was called into the room. LPN #35 spoke to Resident #39 asking what he needed. LPN #39 then left the room stated she was going to get help for Resident #39 and said consider the call light answered. On 06/27/22 at 4:30 PM, Administrator was informed of the above information. c) Resident #79 On 06/28/22 at approximately 1:00 PM, another surveyor heard Resident #79 yelling from his bed and his call light was on. Resident #79 was observed yelling from his bed at 1:05 PM, until two Nurse Aides (NA) went in to see what he needed at 2:16 PM. It was NA #13 an NA #84 who helped Resident #79. On 06/29/22 at 11:50 AM, Resident #79 was asked what was happening the day before when he was so upset and yelling. Resident #79 said, I was trying not to shit on myself he then apologized for his language. Resident #79 said he did not make it by the time those two aides came in my room to help me I had already got poop in my boxers and jogging pants. Resident #79 all I wanted was a bedpan. The Medical Power of Attorney (MPOA) was in the room of Resident #79. and said he (Resident #79) called her yesterday and he was crying. She went on to say he has called her every day for the last four days crying. MPOA said yesterday it was because he rung his call light from 1 PM to 2:30 PM for a bedpan. Resident #79 said he was very grateful for the two nurse aides that helped him. Resident #79 is a double below the knee's amputee On 06/27/22 at 4:30 PM, the Administrator was informed of the above information. .

. Based on observation, staff interview, and record review, the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. The hazards found were medication left at bedside, cigarettes at bedside, failure to implement care plan related to keeping the room uncluttered room, failed to implement fall precautions. Residents Identifiers: #160, #37, #100, and #48. Facility census 117. Findings included: a) Resident #160 During an interview on 06/27/22 at 11:42 AM. it was noted Resident #160 had a pack cigarettes on her nightstand. Resident #160 was wearing oxygen at this time and was asking why the facility would not allow her to go smoke. She was asked if she had a lighter as well as the cigarettes. Resident #160 said she has five (5) cigarettes left but no lighter. On 06/27/22 at 12:20 PM, It was reported to LP #65 as the Administrator was walking past. Administrator kept walking and said put the cigarettes in the lock box. LP #65 removed the cigarettes. B) Resident #37 During an interview on 06/27/22 at 12:00 PM, with Resident #37 it was noted there were three (3) medications on the bedside table. Resident #37 was asked about the medication. She said she does not use them. The three medications were: Anoro inhaler, antifungal power, and nasal spray. On 06/27/22 at 12:18 PM, the medication was brought the attention of LPN #65. LPN #65 stated she did not know why they were there, and they would be removed right now. c) Resident #100 On 6/27/22 at 1:46 PM upon the initial survey interview process it was noted Resident #100s' room was extremely cluttered which presents for a high chance of a fall. Per her care plan she is at risk for falls due to impaired mobility, weakness, medications and other co-morbid conditions and the staff was to maintain a clutter free environment in the resident's room and consistent furniture arrangement. She is currently in a semi-private room. Upon the move from her previous room on 3/05/22 her clothes were placed in a trash bag where they remain at this time. She has a bed side toilet and a wheel chair, in addition to her furniture. This was confirmed with Nurse Unit Manager #59 on 6/27/22 at 1:55 PM. d) Resident #48 Observation of Resident #48 on 06/27/22 at 11:53 am found a floor mat propped up beside his bed on the right side of the bed. An interview the Licensed Practical Nurse (LPN) #31 at this time confirmed the fall mat should be laying fat on the floor and not standing on its side propped up against the bed. She said, I will fix it let me go see what side of the bed it is supposed to be on. A record review of Resident #48's care plan on 06/28/22, found the care plan related to Resident #48's risk for further falls contained the following interventions, -- Bed in lowest position. Created on 02/26/21. -- Bilateral fall mats. Created on 03/27/21. -- Device - LAL (Low Air Loss) Mattress, Setting 5. Created 12/20/21. -- Utilize Night light in room/bathroom. Created 12/20/21. An additional observation of Resident #48 with Registered Nurse (RN) #29 on 06/28/22 at 4:17 pm confirmed Resident #48 only had one (1) fall mat on the left side of the bed, the bed was no in the lowest position (Resident #48 was laying in the bed), the residents bed did not have a LAL mattress with setting 5, and there was no night light in his room or bathroom. She agreed the residents fall interventions were not in place. .

. Based on observation and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. During medication pass, proper hand hygiene was not utilized. This was a random opportunity for discovery and had the potential to affect more than a limited number of Residents. Resident identifiers: #72, #66, #401. Facility census: 116. Findings included: a) Resident #72 During medication pass observation on 06/28/22 at 8:02 AM, Licensed Practical Nurse (LPN) #8 administered a Lidocaine patch, by form of application to Resident #72's skin, exited the room and never performed any hand hygiene. LPN #8 proceeded to sign off the mediations and moved on to the next Resident for medication administration. b) Resident #66 During medication pass observation on 06/28/22 at 8:07AM, Licensed Practical Nurse (LPN) #8 entered Resident #66's room, helped to reposition the Resident and then administered oral medications to the Resident. LPN #8 exited the room, proceeded to mediation cart, and signed off the medications without using any hand hygiene. c) Resident #406 During medication pass observation on 06/28/22 at 8:15 AM, Licensed Practical Nurse (LPN) #8 entered Resident #406's room and handed the Resident her drink from her bedside table. LPN #8 then administered the Resident's oral medications, left the room, and never utilized any hand hygiene. At that time LPN #8 was asked if she used any hand hygiene while administering the medication, and LPN #8 stated, Oh no, I didn't I forgot. There is usually a bottle of sanitizer setting here [pointed to medication cart] but it wasn't, and I forgot. d) Director of Nursing Interview During an interview on 06/28/22 at 1:30 PM, the Director of Nursing (DON) stated that she would be providing education on hand hygiene and that LPN #8 could have washed her hands if no hand sanitizer was available. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to ensure each Resident was offered and administered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. This failed practice was true for three (3) of five (5) Residents reviewed for pneumococcal vaccines. Resident identifiers: #13, #80, and #89. Facility cenus: 116 Findings included: a) Resident #13 Record review for Resident #13 showed no documentation that the Resident had ever been offered or received the pneumococcal vaccine. The Resident was admitted to the facility on [DATE]. During an interview on 06/29/22 at 3:30 PM the Infection Preventionist (IP) Nurse verified Resident #13 was not offered or administer the pneumococcal vaccine. b) Resident #80 Record review for Resident #80 showed no documentation that the Resident had ever been offered or received the pneumococcal vaccine. The Resident was admitted to the facility on [DATE]. During an interview on 06/29/22 at 3:31 PM the Infection Preventionist (IP) Nurse verified Resident #80 was not offered or administer the pneumococcal vaccine. The IP Nurse further stated she had just contacted the Resident's Medical Power of Attorney (MPOA) and he consented for the pneumococcal vaccine to be given. c) Resident #89 Record review for Resident #89 showed a signed consent dated 02/24/22 indicating the Resident's MPOA gave consent for and desired the Resident to have the pneumococcal vaccine administered. Furter review showed the pneumococcal vaccine was never administered. Resident #89 was first admitted to the facility on [DATE], then out to the hospital on [DATE] and re-admitted on [DATE]. During an interview on 06/29/22 at 3:35 PM the Infection Preventionist (IP) Nurse verified Resident #89 should have been administered the pneumococcal vaccine per the signed consent, and was not. d) Pneumococcal Vaccination Policy Record review of the facility's policy titled, Pneumococcal Vaccination, revised date 04/01/22, showed that staff are to obtain the Residents pneumococcal vaccination history upon admission and offer the appropriate vaccination following the current recommended schedule. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, Resident interview, record review, and staff interview the facility failed to Maintain an effective pest control program so that the facility is free of pests. This failed practice was true for rooms: 137,135,138, 141,133 ,118, and dining room. Facility census 117. Findings included: a) room [ROOM NUMBER] On 06/27/22 at 12:07 PM, a large number of flying insects and many insects resting on the privacy curtain. Resident #29 had a towel on his bedside table that was covered with a red substance. The red substance was on the floor. A lot of insects were landing on the red substance. LPN #31 was asked to witness the number of insects in this room and the red substance the insects were landing on. LPN #31 said she believes the red substance was some type of a sauce. b) room [ROOM NUMBER] On 06/27/22 at 12:10 PM, there was an excessive amount of food, plastic wraps, paper, and empty medication cups. The fall mats on both sides of the bed were covered in the trash described above. The flying insects were on everything including Resident #79 and this surveyor. Resident #79 stated those bugs drive me crazy. On 06/27/22 at 12:15 PM LPN #35 was stopped in the hallway and asked why Resident #79 did not have sheets on his bed and to verify the trash around the bed and flying insects. LPN #35 said she would get some sheets and have housekeeping come in. LPN #35 agreed there was a lot of insects. c) room [ROOM NUMBER] On 06/27/22 at 12:27 PM, Resident #106 was using a fly swatter in her room, Resident #106 was asked if she swats the insects often, she said all day long. d) room [ROOM NUMBER] On 06/27/22 at 11:30 AM, upon entering room [ROOM NUMBER] it was noted there was a large number of flying insects. Tried to count the number of insects on the privacy curtain and there was more than twenty. On 06/27/22 at 11:50 AM, Licensed Practical Nurse (LPN) #35 was asked to verify the insects. LPN #35 walker over to the curtain and shook it, which caused a swarm of insects. Resident #17 said, those gnats are awful we have been dealing with them for a while now. LPN #35 said she would get Maintenance to help with the insects. e) Interview On 06/27/22 at 12:35 PM, Director-Maintenance (104) approached this surveyor and asked how can he get rid of those Gnats. He said, pest control was at facility on 06/23/22 but did not address fruit fly problem. The Pest control receipts were provided on 06/28/22 and it found the facility called the pest control personal to come back to the facility on [DATE], and the pest control put on fruit fly monitors and block stations on exterior. A review of past visits revealed none of the above treatment were done prior to the date of survey. f) Dining Room On 06/27/22 at 11:49 AM an observation of the dining room tray pass process revealed gnat's flying around Residents and their meals. On 06/27/22 at 12:05 PM during an interview with Dietary Aid #124, she verified that there is an issue with gnats and flies in the kitchen and dining area. g) room [ROOM NUMBER] On 06/27/22 at 3:41 PM during tour an observation of gnats in room [ROOM NUMBER] on the beds tray tables, and privacy curtains. On 06/27/22 at 3:41 PM during an interview, Resident #5 stated that there is so many gnats' flying around that they get in his face, on his food and everything else in the room. Resident #5 stated, I hate gnats. On 06/27/22 at 3:45 PM during an interview with Nurse Aide (NA) #43 confirmed that there were gnats in room [ROOM NUMBER]. He stated that he has saw them through out the facility in multiple rooms. OBS SI RR RI failed to Maintain an effective pest control program so that the facility is free of pests .

. Based on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This failed practice has the potential to affect all residents. Facility census: 117. Findings included: a) Kitchen On 06/28/22 at 02:00 PM a review of training certificate for food handlers found: Dietary Aid #136 - No documentation of Food Handlers Training prior to 06/28/22. Dietary Aid #130 - No documentation of Food Handlers Training prior to 06/28/22. Dietary Aid #135 - No documentation of Food Handlers Training prior to 06/28/22. Dietary Aid #131 - No documentation of Food Handlers Training prior to 06/28/22. Dietary Aid #124 - No documentation of Food Handlers Training prior to 06/28/22. Dietary Aid #132 - No Documentation Provided. Dietary Aid #127 - No Documentation Provided. During an Interview with the Administrator and Dietary Manager in Training on 06/28/22 at 2:20 PM, verified the staff in question did not have Food Handlers Training until this date. .

. Based on record and staff interview the facility failed to ensure the designated Infection Preventionist had completed the required the specialized training in infection prevention and control in order to maintain an infection prevention and control program designed to provide a safe and sanitary environment. This failed practice had the potential to affect all residents residing at the facility. Facility census: 116. Findings included: During an interview on 06/28/22 at 11:01 AM, the Infection Preventionist (IP) Nurse stated she did not have a certificate to show completion of the Infection Control training she participated in online. The IP nurse stated that she IP started in position January 2022. Record review showed the facility did not have documentation to show that the designated IP Nurse had completed the specialized Infection Prevention and control training. During an interview on 06/28/22 at 11:05 AM, the Director of Nursing (DON) stated the IP Nurse had competed the training modules but had not taken the test to get the certificate. The DON verified no other staff was certified in Infection Prevention. .