**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment over which it had control, Specifically by not ensuring that a P-Tac unit was cleaned and maintained. This was true for one (1) of thirty-two (32) rooms surveyed during the long-term care survey process. This was a random opportunity for discovery. Room Identifier: room [ROOM NUMBER]. Facility Census: 52. Findings Included: a) room [ROOM NUMBER] During an observation of room [ROOM NUMBER] on 01/21/25 at approximately 1:45 PM, lint and debris were observed inside the vent grille of the P-Tac unit. A repeat inspection of the P-Tac unit on 01/22/25 at 1:35 PM revealed that it had still not been cleaned. On 01/23/25 at approximately 10:00 AM, the Director of Nursing (DON) #13 and Corporate Nurse (CN) # 71 were notified of the dirty P-Tac unit. They inspected it and stated that it would be cleaned immediately. At approximately 10:15 AM on 01/23/25, a maintenance worker was observed servicing the P-Tac unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) out of 21 records reviewed during the Long-Term Care Survey Process. Resident identifiers: #46 and #29. Facility census: 52 Findings included: a) Resident #46 During a record review, completed on [DATE] at 2:58 PM, the following discrepancy was found: -A Physician Orders for Scope of Treatment (POST) form, dated [DATE], listed Resident #46 as a Do Not Resuscitate (DNR) -A Physician Order, dated [DATE], read CPR (Cardiopulmonary Resuscitation). During an interview on [DATE] at 11:03 AM, the Director of Nursing (DON) was asked to explain how nursing staff were trained to determine a resident's code status. The DON demonstrated that staff would click on the Advance Directives hyperlink in the electronic medical record which would take them to the most recent POST form. The DON reported that the Resident #46 was considered a Do Not Resuscitate (DNR). The DON was then asked to pull up Resident #46's active physician order for code status. The DON acknowledged that the code status order entered on [DATE], read CPR. The DON stated that resident had been out to the hospital and had returned to the facility on [DATE]. She noted that LPN #33 had incorrectly entered the code status and immediately corrected the order. All three nursing staff who were responsible for entering orders were immediately re-educated and a whole house audit was completed to verify all code status orders were correct. [DATE] 11:21 AM DON provided information that the staff had been re-educated, there were no other identified issues, and all code status orders were correct in the building. b) Resident #29 On [DATE], at approximately 9:45 AM, a review of the immunization records for a random sample of residents was conducted. The records for Resident #29 included a completed Pneumonia vaccine consent/declination form. The facility indicated that the resident had declined the Pneumonia vaccine; however, the form lacked the resident's name. The documentation on the form stated, Verbal as per [NAME], and it had been signed by two witnesses. This discrepancy was brought to the attention of the Director of Nursing (DON) #13 and Administrator #15 at around 11:15 AM on [DATE]. They confirmed that the facility had failed to enter the resident's name on the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge which included the resident's right to submit an appeal and the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman, was provided to residents/resident representatives for five (5) of five (5) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #20, #52, #12, #21 and #33. Facility census: 52 Findings included: a1) Resident #20 - 07/05/24 Hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a2) Resident #20 - 09/20/24 Hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a3) Resident #20 - 12/04/24 Hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a4) Resident #20 - 01/06/25 Hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a5) Resident #20 - 01/10/25 Hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a6) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. b1) Resident #52 - 01/05/25 Hospitalization A record review completed on 01/22/25 at 6:37 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. b2) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. c1) Resident #12 - 10/22/24 Hospitalization A record review, completed on 01/22/25 at 1:26 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. c2) Resident #12 - 12/05/24 Hospitalization A record review, completed on 01/22/25 at 1:26 PM revealed that resident had been transferred to the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. c3) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. d1) Resident #21 - 01/09/25 Hospitalization A record review completed on 01/22/25 at 7:10 PM revealed that resident had been transferred tp the hospital on [DATE]. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. d2) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. Findings include: e) Resident #33 1) On 12/19/24 Resident #33 was transferred to the local hospital emergency room for evaluation. Review of transfer documentation shows the following required documents were completed as required: Ombudsman notification, bed hold authorization and the E interact transfer form. Review of the Acute Transfer Letter was reviewed and found it did not provide a written notice of transfer/discharge to the resident/resident's representative which included the resident's right to file a grievance. This was confirmed on 01/22/25 3:45 PM with the Director of Nursing. 2) On 12/31/24 Resident #33 was transferred to the local hospital emergency room for evaluation. Review of transfer documentation shows the following required documents were completed as required: Ombudsman notification, bed hold authorization and the E interact transfer form. Review of the Acute Transfer Letter was reviewed and found it did not provide a written notice of transfer/discharge to the resident/resident's representative which included the resident's right to file a grievance. This was confirmed on 01/22/25 3:45 PM with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when the resident experienced a fracture. This was true for one (1) of three (3) residents reviewed for notifications in the complaint survey process. Resident identifier: #43. Facility census: 55. Findings included: a) Resident #43 A medical record review, completed on 07/05/23 at 10:20 AM, revealed the following details: Resident #43 was admitted to the facility on [DATE]. Resident #43 has the following diagnoses: Huntington's Disease; Depression; Dysphagia; Hypothyroidism; Anxiety Disorder; Dementia in Other Diseases Classified Elsewhere, Moderate with Agitation; and Nondisplaced Fracture of Middle Phalanx of Left Little Finger (pinky finger), Initial Encounter for Closed Fracture. A Physician Determination of Capacity, dated 01/25/23, revealed Resident #43 demonstrated incapacity to make medical decisions. The [NAME] Virginia Department of Health and Human Resources (DHHR) was appointed the Legal Guardian and Legal Guardianship Paperwork was on file. A nurses note, dated 06/18/2023 at 10:06 AM, stated, Resident noted to have swelling and a dark purple discoloration to her left 5th finger (pinky). Resident not showing signs of pain when finger is touched or moved at this time. This nurse called and notified MD (Medical Doctor). MD gave telephone order for an x-ray to be done to finger and to tape 4th and 5th fingers together with a paper tape loosely. This nurse called [x-ray company's name] and placed x-ray order. This nurse called and left a message for case worker. A second nurses note, dated 06/18/2023 at 2:25 PM, stated, X-ray result received, there is a fracture of the proximal metaphysis, middle phalanx, fifth finger (pinky finger). This nurse called and notified MD (Medical Doctor). MD gave order to tape fourth and fifth fingers together. Resident not showing any signs of pain or discomfort at this time. There was no evidence in Resident #43's medical chart to indicate resident's legal guardian had been notified of the x-ray results and that Resident #43 had a fractured pinky finger. During an interview on 07/05/23 at 11:30 AM, the Director of Nursing (DON) stated the facility was unable to produce any evidence that the Legal Guardian was notified of x-ray results / fracture. .

. Based on observation and staff interview, the facility failed to honor privacy of resident medical records by leaving a narcotic book open and on top of an unattended medication cart. This was a random opportunity for discovery. Resident identifiers: #9 and #21. Facility census: 52. Findings included: a) Open Narcotic Book Surveyor observation on the 200 Hall, on 01/31/23 at 10:33 AM, found the medication cart unattended. The nurse assigned to the cart had walked down the hallway out of site of the cart and had left the narcotic book open leaving medical records out for public view. In the presence of Corporate Registered Nurse (CRN) #61 by the medication cart at 10:38 AM confirmed the narcotic book had been left open on the medication cart by Licensed Practical Nurse (LPN) #52 and stated, That is a problem. CRN #61 also confirmed that it was readily visible to any passerby that Resident #9 received traMADol [a medication is used to help relieve moderate to moderately severe pain] 50 mg every six hours as needed for pain and Resident #21 received Gabapentin [a medication used to relieve nerve pain] 100 mg three times a day for neuropathy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of two (2) sampled residents for falls. Resident identifier: #44. Facility census: 52. Findings included: a) Resident #44 An electronic medical record review, completed on 01/31/23 at 12:48 PM, revealed Resident #44 had experienced a fall on 01/11/23 at 2:30 AM. Additionally there was a Nurses Noted on 01/12/2023 at 11:54 AM where the Assistant Director of Nursing (ADON) documented, Spoke with NP [Nurse Practitioner] this AM regarding x-ray to shoulder done at [local hospital]. They recommended an immobilizer to be worn to help with proper healing of shoulder. Therapy is aware and will order one. Daughter aware. Awaiting final report to be faxed. The facility received the faxed x-ray results received on 01/12/23 at 12:52 PM. Findings on the x-ray noted, There is a new comminuted proximal left humeral fracture. Review of the facility reportable for the injury found the initial fax reporting form was sent to the appropriate state agencies on 01/19/23, seven (7) days after the facility had knowledge of the serious bodily injury. During an interview on 02/01/23 at 10:10 AM, the Administrator confirmed the x-ray results were faxed to the facility on [DATE] but it was not reported as a serious bodily injury the appropriate state agencies until 01/19/23. The Administrator acknowledged the facility failed to meet the two (2) hour time frame for reporting a serious bodily injury. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for residents with dementia. This is true for two of two residents reviewed for dementia. Resident identifiers: 1 and 15. Facility census: 52. Findings include: a) Resident (R) #1 Review of the medical record revealed R#1's diagnoses include Alzheimer's disease, non-Alzheimer's dementia, anxiety and depression. The quarterly minimum data set (MDS) assessment with an assessment reference date of 01/03/23 notes R#1 displays behaviors not directed towards others four to six days a week. An observation in the dining room on 01/30/23 from 12:00 PM to 12:30 PM, found Resident (R) #1 repeatedly stating I am bored and asking for something to do before lunch arrived. Registered Nurse (RN) #31 repeatedly escorted R#1 back to her table and offered to talk with her. R#1's mood escalated, she refused to stay at the table and her voice got louder as she stated I am [AGE] years old and I can get mad. I do not want to talk, I am bored. R#1 continued to roam the room and complain when staff started to serve trays. R#1 initially refused to eat and threatened to throw the plate on the floor. **No activities other than talking were offered R#1 during this observation. At 12:30 PM on 01/30/23, Registered Nurse (RN) #31, acknowledged there were no activities in the dining room before lunch and agreed she could have turned on the TV or put on some music to try and occupy R#1 during her wait for food. The care plan identifies R#1's diagnoses of Alzheimer's disease, dementia, anxiety and depression, the use of antipsychotic medications and her behaviors including throwing things, anger and hostility towards others and refusing medications. The care plan lacks individualized interventions related to these behavioral symptoms and outburst. The care plan was reviewed with corporate nurse #61 during an interview on 01/31/23 at 02:30 PM, She confirmed R#1's care plan lacks personal non-pharmacological interventions for staff to utilize when R#1 demonstrates behaviors. b) Resident (R) #15 Review of the medical record revealed R#15 receives monthly psychiatric reviews and her diagnoses include Alzheimer's disease with late onset, anxiety and depression, and was deemed incapacitated after a recent hospitalization. Her current daily medication regimen includes an antipsychotic, antianxiety and an antidepressant. The care plan identifies the above diagnoses and the administration of psychoactive medications with a long history of psychiatric problems and medication use. There are no non-pharmacological interventions listed to assist the resident with her psychosocial needs as her disease process continues. During an interview on 01/31/23 at 1:16 PM, Licensed Practical Nurse (LPN) #10 acknowledged R#15's diagnoses include Alzheimer's disease with late onset, anxiety and depression. LPN #10 reviewed R#15's care plan and confirmed the care plan identifies R#15's current psychotropic medications and notes the goals are to utilize the lowest dose possible and not display any medication side effects. LPN #10 agreed the care plan focuses on the psychotropic meds and possible side effects and is silent for person centered non-pharmacological interventions to assist R#15 with any symptoms or behaviors related to her Alzheimer's disease process, anxiety and depression. .

. Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored in accordance with current accepted professional practices. The facility failed to ensure medications were not being stored for use after the Manufacturer's discard date for use. This was true for medications stored in one (1) of two (2) medication carts inspected. This practice had the potential to affect a limited number of residents. Resident identifier: Resident #35. Facility census: 52. Findings included: An observation, of the 200 Medication Cart, on 01/31/23 at 09:06 AM, revealed a vial of Novolog Insulin for Resident #35, with the opened date of 12/31/22 verifying when the medication was put into use. An interview, on 01/31/23 at 09:06 AM, with LPN #52, revealed the Novolog insulin for Resident #35 should have been discarded and was still in the medication cart available for use. A review of manufacture's discard date for Novolog Insulin is to discard after 28 days of use. An interview, with the DON, on 01/31/23 at 09:30 AM, confirmed it is facility policy to abide by the manufacturer's direction to discard after 28 days of use for the Novolog insulin. The DON stated further, the insulin should not have been stored in the medication cart for use. .

. Based on review of the concern/grievance log, record review and staff interview, the facility failed to ensure a dental referral was made in a timely manner for a resident who had lost or damaged dentures. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #34 Census: 52. Findings included: a) Resident #34 A review of the Concern/Grievance log for 01/2023, showed Resident #34 was identified as having a concern/grievance of missing dentures, date of notification documented as 01/10/23. There was no indication of a resolution date. The Concern/Grievance Form review showed the date the concern/grievance was made as 01/09/23. An interview with Nursing Assistant (NA) #6, on 02/01/23 at 11:03 AM, revealed Resident #34 had dentures but stated they came up missing a few weeks ago and she did not currently have dentures. An electronic medical record review showed a progress note, dated 1/18/2023 at 10:19, where Registered Nurse (RN) #31 had spoken with a family dentistry group regarding a plan to obtain new dentures. An interview the Social Services Director, on 02/01/23 at 12:33 PM, revealed she was made aware of the lost dentures on 1/10/23, however, staff were aware of the lost dentures on the 01/09/23. The Social Service Director verified a referral for dental services was not made until 01/16/23. Further, the Social Service Director revealed she was not familiar with a time frame requirement for obtaining a dental referral for a resident who had broken or lost dentures. Further review of the electronic medical record, showed lack of evidence showing extenuating circumstances that led to the delay of the dental referral. An interview, with the Administrator, on 02/01/23 at 02:00 PM, revealed no additional information. .

. Based on observation and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to ensure food was labeled and dated. This practice had the potential to affect a limited number of residents. Facility census: 52. Findings included: a) Unlabeled and Undated Food During a tour of the kitchen with the Food Services Manager, on 01/30/23 at 8:05 AM: -In the dry storage area one (1) clear bag of what was identified as egg noodles had been opened and half-used but was not labeled. -In the refrigerator there was a two-quart container of vanilla pudding that was unlabeled and undated. The Food Services Manager stated kitchen staff had failed to follow facility protocol for labeling and dating all open/prepared food items. .

. Based on observation and staff interview, the facility failed to maintain current food handler cards for two (2) of seven (7) employees reviewed in the Dietary Department. This practice had the potential to affect a limited number of residents who receive their nutrients from the kitchen. Facility Census 52. Findings included: a) Food Handlers Cards During a record review on 01/31/23 at 11:09 AM, it was determined that Dietary Worker #5's food handlers card expired on 01/10/23 and was not renewed until after Surveyors entered the building on 01/20/23. Additionally, Dietary Worker #23 did not have an active food handlers card on file. The Food Services Manager stated there had been an oversight in renewing Dietary Worker #5's food handlers card. She also added that Dietary Worker #23 was a PRN [as needed] employee that had not worked since summer. .

. Based on record review, facility concern/grievance review, staff interviews and individual interviews, the facility failed to ensure prompt efforts were made to resolve grievances for three (3) of five (5) residents reviewed. Resident identifiers: Resident #3, #21 and #150. Census: 52. Findings included: a) Policy review A review of Policy, NS 1601-00, titled: Resident Grievance, effective date, 01/12/2017,showed under Section 1. a., upon receipt of an oral, written, or anonymous grievance submitted by a resident, the Grievance Official would take immediate action to prevent further potential violations. The policy noted, under Section 4., the grievance review will be completed in a reasonable time frame consistent with the type of grievance. Under Section 5. a., the policy showed upon the completion of the review, the Grievance Officer would complete a written grievance decision that included the following: the date the grievance was received, a summary of the resident's grievance, the steps taken to investigate the grievance, the summary of pertinent findings or conclusions regarding the resident's concern, a statements to whether the grievance was confirmed or not confirmed, whether corrective action was taken and a summary of the corrective action if taken and the date the decision was issued. Under Section 6, the policy showed the Grievance officer would meet with the resident and inform the resident of the results of the investigation and how the grievance was resolved or will be resolved. b) Resident #3 An interview with Resident #3, on 01/30/23 at 09:14 AM, revealed the resident was missing a quilt/blanket she had received as a Christmas gift and this had been reported to staff It was further stated, by Resident #3, the quilt/blanket had been sent to laundry to be labeled and it had not come back. A record review for Resident #3 showed a current assessment noting the residents Brief Interview for Mental Status (BIMS), reflected a score of 15, which indicated the resident had no cognitive impairment. On 01/31/23 at 10:38 AM, an inspection of the laundry area and interviews with the Laundry/Housekeeping Supervisor and HK #48 were conducted. At this time, the surveyor told of the issue with #3 missing a blanket/quilt that was a Christmas gift. In the presence of the surveyor, The Laundry/Housekeeping Supervisor and HK #48 did not locate any blanket/quilt with Resident #3's name on it or one that resembled the description provided by the surveyor to facilty staff. An interview with Resident #3, on 02/01/23 at 08:50 AM, verified the resident had complained to staff repeatedly and the blanket had not been found. During this time, the Housekeeping/Laundry Supervisor entered the room, and it was verified the missing blanket was not in the resident's closet. An interview with the Social Service Director, on 02/01/23 at 11:40 AM , revealed the Laundry/Housekeeping Supervisor brought the missing item to her attention that surveyor had discussed 01/31/23 and provided a copy of the concern/grievance form dated 01/31/23, even though Resident #3 stated she had been complaining to staff for an extended period of time. During the interview, the Social Service Director verified Resident #3 was a reliable historian added she was not happy with the way staff failed to notify her of concerns/grievances in a timely manner. b) Resident #21 An interview with Resident #21, on 01/30/23 at 09:18 AM, revealed this resident also had received a blanket for Christmas, was sent to laundry for labeling and was never returned to her. The blanket was described to the surveyor during tour. On 01/31/23 at 11:42 AM, an inspection of the laundry area and interviews with the Laundry/Housekeeping Supervisor and HK #48 were conducted. At this time, the surveyor told of the issue with #21 missing a blanket/quilt that was a Christmas gift. In the presence of the surveyor, the Laundry/Housekeeping Supervisor and HK #48 was showing the surveyor the labeling process, and the blanket description matched a blanket laying on the shelf with a label with Resident #21's name on it. An interview, with the Housekeeping/Laundry Supervisor on 02/01/23 at 08:30 AM, revealed Resident #21's roommate had told her about the missing blankets and this was told to the Social Services Director no later than January 2023 if not before. An interview with Resident #21 on 02/01/23 at 08:50 AM, revealed no blanket had been returned to her. At this time, Resident #21, requested and gave permission to surveyor to open the closet and check. There was a black and gold Steeler blanket in the closet but not the blanket that was seen in laundry the previous day that was light gray, black and yellow with the resident's name on it. At 09:00 AM, the Laundry/Housekeeping Supervisor and HK #29 entered the resident's room. Hk/Laundry staff verified the blanket was not in the laundry area and confirmed it could not be located in Resident #21's room at this time. HK #7 verified the blanket was labeled and was in the laundry yesterday, ( 01/31/23) and verified the blanket was observed on the cart in the clean laundry room and verified it was not there today. HK #7 stated the blanket should have been delivered yesterday because the process was to mark clothes and then deliver them the same day or the next day. An interview with the Social Service Director, on 02/01/23 at 11:40 AM , revealed the Laundry/Housekeeping Supervisor brought the missing item to her attention that surveyor had discussed 01/31/23, but thought Resident #21's blanket had been found. The Social Service Supervisor stated Resident #21's roommate had complained on her behalf regarding the missing blankets. During the interview, the Social Service Director verified Resident #3 and Resident #21 were both reliable historians and stated both ladies have been affected by a prolonged time frame of missing items and the process for grievance/concerns was not a good process. c) Resident #150 A review of the concern/grievance form for Resident #150, showed a concern was submitted to the facility by a family member on 12/23/22. A summary of the concern related to Resident 150's missing items The form showed an investigation was conducted 12/23/22 showed one item listed on the concern had been found and one item had not been found. The Summary/resolution of the concern/grievance dated 12/23/22, showed the confirm was not confirmed with findings of the missing items were not included on the inventory sheet and staff interviews showed 'spoke with staff- staff unable to remember ornament. Under the area of notification to patient or individual of the resolution showed on 12/23/22, the social worker spoke to the family per phone. The concern form was signed by the Grievance Officer on 12/23/22. Further review of the investigation, of the concern of missing ornaments. Showed eight (8) staff statements of the event or incident in question. Two (2) of the eight (8) confirmed the staff verified the ornaments had been seen in Resident 150's room. Additionally, the eight witness statements had been provided on 12/27/22, when the concern/grievance was documented resolved on 12/23/22 and signed off by the Grievance Officer on 12/23/22 confirming the grievance was not confirmed. An interview with the Social Services Director, on 02/01/23 at 11:50 AM, revealed the Social Services Director stated she had not called the resident's family member on 12/23/22 as the form noted to speak about the concern/grievance concern as documented on the complaint/grievance form. The Social Service Director stated at this time, she only investigated the concerns and stopped there. When asked why her name was documented as calling the family, she stated it is what it is. An interview, with the facility administrator, on 02/01/23 at 02:15 PM, verified the concern/grievance form was signed as resolved prior to obtaining the staff statements, stating possibly the incorrect date was documented. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, facility record review and staff interview, the facility failed to provide a meaningful activity prior to lunch in the dining room. This is true one of one reviewed for activities but has the potential to affect all 16 residents eating in the dining room. Resident identifiers: 20, 5, 10, 41, 38, 31, 23, 34, 201, 13, 7, 1, 6, 12, 4, 2. Facility census: 52. Findings include: a) An observation on 01/30/23 at 12:00 PM. found staff escorting residents into the dining room for lunch. No activities or drinks were offered until the food truck arrived at 12:25 PM. During this time, Resident (R) #1 repeatedly stated I am bored and asked for something to do before lunch arrived. Registered Nurse (RN) #31 repeatedly escorted R#1 back to her table and offered to talk with her. R#1's mood escalated, she refused to stay at the table and her voice got louder as she stated I am [AGE] years old and I can get mad. I do not want to talk, I am bored. You better watch out. R#1 continued to roam the room and complain when staff started to serve trays. R#1 initially refused to eat when her lunch was served and again stated, I am mad, you better watch out. R#1 threatened to throw the plate on the floor. At 12:30 PM on 01/30/23, Registered Nurse (RN) #31, acknowledged there were no activities or drinks for the residents while they waited for lunch to be served. RN #31 agreed she could have turned on the TV or put on some music to try and occupy R#1 during her wait for food. The activities calendar notes the following scheduled events for 01/30/2023: Morning cafe at 10:00 AM, Chronicle Trivia at 10:30 AM, Exercise at 11:00 AM and music at 2:30 PM. There are no activities scheduled before lunch. The Director of Nursing and Corporate Nurse #61 agreed there should be an activity in the dining room while residents are waiting for their meals, during an interview on 01/30/23 at 12:45 PM. .

. Based on record review and staff interview, the facility failed to maintain an accurate medical record for four (4) of 18 sampled residents reviewed in the Long-Term Care Survey process. Resident identifiers: #3, #4, #11, and #6. Facility census: 52. Findings included: a) Resident #3 A brief record review, completed on 01/30/23 at 2:22 PM, identified resident had a Physician Orders for Scope of Treatment (POST) form on file. The attending physician signed the form on 01/15/22. However, Resident #3 had never signed the form. The 2021 POST Form Guidance instructs the signature section provides a declaration on behalf of the patient related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient must sign and date this section for the form to be legally valid. During an interview on 01/31/23 at 9:32 AM, Social Worker #50 acknowledged the facility had failed to obtain a written signature from Resident #3 stating it must have been an oversight and that it would be addressed. b) Resident #4 A brief record review, completed on 01/30/23 at 11:30 AM, identified resident had a POST form on file. The facility had obtained verbal consent from Resident #4's Health Care Surrogate (HCS) on 04/26/22. The 2021 POST Form Guidance instructs, If the incapacitated patient's MPOA representative or Health Care Surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. During an interview on 01/31/23 at 9:34 AM, Social Worker #50 acknowledged verbal consent had been accepted over nine (9) months ago and the facility had failed to obtain a written signature from the HCS. c) Resident #11 A brief record review, completed on 01/30/23 at 1:15 PM, identified resident had a POST form on file. The facility had obtained verbal consent from Resident #11's Medical Power of Attorney (MPOA) on 04/07/20. During an interview on 01/31/23 at 9:36 AM, Social Worker #50 acknowledged verbal consent had been accepted over a year and nine (9) months ago and the facility had failed to obtain a written signature from the MPOA. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to maintain an effective infection control program. Residents were not given the opportunity to sanitize/wash their hands prior to dining. Isolation rooms were not identified with correct/accurate signage and staff failed to follow hand hygiene practices consistent with accepted standards of practice. This practice has the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: 20, 5, 10, 41, 38, 31, 23, 34, 201, 13, 7, 1, 6, 12, 4, 2, 22, 21. Facility census: 52. Findings included: a) Dining Room An observation of the lunch meal on 01/30/23, found 16 of 16 residents (#20, 5, 10, 41, 38, 31, 23, 34, 201, 13, 7, 1, 6, 12, 4, 2) were not given the opportunity to wash or sanitize their hands prior to eating. Registered Nurse (RN) #31 confirmed all 16 residents were not given a chance to clean or sanitize their hands prior to eating during an interview at 12:30 PM on 01/30/23. During an interview on 1/30/23 at 12:45 PM, the Director of Nursing acknowledged the lack of hand sanitizing before meals is an infection control concern. b) Isolation Room Signage An observation on 01/30/23 at 9:20 AM, revealed personal protective equipment (PPE) on the doors of rooms [ROOM NUMBERS] with no signage indicating the residents were in isolation and the type of personal protective equipment (PPE) required. At 9:35 AM the Infection Preventionist (IP) / Licensed Practical Nurse #34 reported Resident (R) # 22 in room [ROOM NUMBER] was on isolation for Clostridia difficile and R#21 in room [ROOM NUMBER] was in isolation for Extended-spectrum beta-lactamases (ESBL) in the urine. Staff are to don a gown and gloves when entering either room. IP #34 acknowledged neither room was labeled with signage identifying the isolation and the type of PPE staff and visitors are to use upon entering. A follow up observation on 01/30/23 at 10:00 AM, found Isolation signs on both rooms stating Airborne Precautions Keep the door closed and staff are to don gown, respirator mask and gloves on all room entries. An interview with IP #34 at this time confirmed the wrong isolation signs were hung. IP #34 reported both residents are on contact precautions and not airborne. .

. Based on observation, record review and staff interview, the facility failed to change the oxygen tubing per policy. This was true for one (1) of four (4) Residents with oxygen administration. Resident identifier: #14. Facility census: 47. Findings included: a) Resident #14 An observation on 12/06/21 at 11:25 AM found Resident #14 humidifier bottle and oxygen tubing bag dated 10/07/21. Resident #14 was receiving the oxygen through a nasal cannula (NC) connected to the humidifier bottle that connected to an oxygen concentrator. During an interview on 12/06/21 at 11:25 AM in Resident #14 room the Director of Nursing (DON) confirmed that the tubing bag and the humidifier bottle should be changed weekly. Record review of the facility's policy titled Oxygen Concentrator showed Oxygen tubing should be changed weekly, and disposable humidifier bottle should be changed weekly or as needed or as recommended by the maker. .

. Based on observation and staff interview, the facility failed to maintain temperature logs in the kitchen for both the refrigerator and the freezer. This failed practice had the potential to affect a limited number of residents receiving nutrients from the kitchen. Facility Census: 47 Findings included: a) Kitchen temperature logs On 12/06/21 at 10:41 AM the initial tour of kitchen with Dietary Manager (DM) #24 found missing temperatures for both the walk in freezer and the walk in refrigerator on 12/05/21 on the evening shift. The DM agreed that temperatures were not taken and stated, the staff did not do them and I will be addressing the staff on ensuring all temperatures are to be taken. .