Every finding on record at Aviata at the Harbor

Based on record review and interviews, the facility failed to develop and implement a baseline care plan within 48 hours of admission to address Advance Directives and person-centered care for one resident (#1) of five sampled residents.Findings included: Record review of Resident #1's clinical record showed an admission date of 04/23/2026 and a discharge date of 05/13/2026. The face sheet identified the resident's primary emergency contact as a family member who was also listed as Guardian Advocate, with a home phone number and email address.Resident #1's diagnoses included: malfunction of continent stoma of urinary tract; muscle weakness; methicillin resistant Staphylococcus aureus infection; neuromuscular dysfunction of bladder; fibromyalgia; chronic pain syndrome; pressure ulcer of left hip, stage 3; pressure ulcer of other site, stage 3; and spina bifida, unspecified. Onset dates for the latter diagnoses were 04/23/2026.Review of the documents scanned into the clinical record showed Letters of Guardian Advocate uploaded on 04/23/2026. The legal document, issued by the Circuit Court of the Sixth Judicial Circuit, [Name of County] County, Florida, Probate Division, dated 10/21/2025, verified that the listed family member had been appointed Guardian Advocate for Resident #1 with authority that included consent for medical treatment.Review of the electronic care plan system revealed no advance directives care plan for Resident #1.On 06/10/2026 at 4:52 p.m., a phone interview was conducted with Resident #1's family member, who stated she had been appointed Guardian Advocate in 10/2025. She reported that she provided the appointment documents to the Admissions Director at the time of admission. The family member stated she called the facility repeatedly to obtain updates regarding Resident #1's condition but did not receive return calls.On 06/10/2026 at 2:07 p.m., an interview with the Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC) revealed the NHA had reviewed the guardian documentation at admission but stated, I thought we needed an incapacity decision. The NHA confirmed the facility had access to a legal department for assistance with document interpretation but stated he did not contact them for guidance in this case.On 06/10/2026 at approximately 3:08 p.m., an interview with the Minimum Data Set (MDS) Coordinator, Registered Nurse, revealed Resident #1 had discharged prior to completion of the comprehensive care plan. Review of the electronic care plan confirmed no advance directives focus area. The MDS Coordinator stated Social Services was responsible for developing the advance directives care plan and verified that the baseline care plan, which would contain the information, was not available in the system.During an interview on 06/10/2026 at 4:16 p.m., the NHA stated the facility had not been able to locate Resident #1's baseline care plan.Review of the facility's Plans of Care policy (N 1015), effective 11/30/2014, documented that an individualized person centered plan of care is to be developed by the interdisciplinary team with the resident and/or representative. The policy required staff to develop and implement a person centered baseline care plan within 48 hours of admission that includes initial goals and information from admission orders, physician orders, dietary orders, therapy services, social services, PASRR recommendations (if applicable), and other areas needed to ensure effective and appropriate care until the comprehensive care plan is completed.

Based on interview and record review, the facility failed to ensure the legally appointed Guardian Advocate was notified of and involved in health care decisions, including the use of psychotropic medications, for one resident (#1) of five sampled residents.Findings included:On 06/10/2026 at 4:52 p.m., a phone interview was conducted with Resident #1's family member. The family member stated they had been appointed Guardian Advocate in 10/2025 and had provided a copy of the appointment letter to the Admissions Director at the time of admission. They reported repeatedly calling the facility for updates on the resident's condition but never received a return call. They stated they did not sign any informed consent forms for psychotropic medications. The family member reported that a visitor had expressed concerns about Resident #1's care. On 05/13/2026, upon visiting the facility, the family member found the resident lethargic and not at baseline. They requested the resident be sent to the hospital, and the resident was subsequently transferred. The family member reported that Resident #1 is now in a supported living setting with significantly improved communication and care.Record review revealed Resident #1 was admitted on [DATE] and discharged on 05/13/2026. The face sheet listed the same family member as the #1 Emergency Contact/Guardian, with phone number and email. The resident's emergency contact listed the same family member identified in the guardianship paperwork as the #1 contact/guardian, with both phone number and email provided. The diagnosis list included multiple conditions, including malfunction of urinary tract stoma, neuromuscular dysfunction of the bladder, fibromyalgia, chronic pain syndrome, and pressure ulcers (all onset dated 04/23/2026).Review of the Guardianship paperwork scanned into the electronic chart on 04/23/2026 revealed the court documents from the Sixth Judicial Circuit, [Name of County] County, appointed the family member as Guardian Advocate with the authority to consent to medical treatment, ordered 10/21/2025.Review of the Consent to Treat dated 04/23/2026 showed the resident's name written in the resident signature field, an illegible facility representative signature, and a blank responsible party section.Review of psychotropic medication informed consent forms dated 04/23/2026 for: Buspar (anti anxiety), Seroquel (antipsychotic), and Trazodone (antidepressant)revealed each form was signed in person by the resident. No guardian signature was present on any form.Review of Medication Administration Record (MAR) showed: Ativan 2 mg/mL IM given on 04/28/2026 and again on 05/13/2026 without informed consent in the record. Hydroxyzine 50 mg administered on 05/04, 05/05, 05/08, and 05/10 without informed consent in the record.During the survey, the facility was unable to produce completed informed consent forms for Ativan or Hydroxyzine, despite request.On 06/10/2026 at 1:20 p.m., the Registered Nurse Consultant (RNC) stated that informed consent for psychotropic medication is typically required from a resident's guardian.On 06/10/2026 at 2:07 p.m., during an interview with the Nursing Home Administrator (NHA) and the RNC, the NHA stated he had reviewed the guardianship paperwork at admission but believed an incapacity decision was required before involving the guardian. When asked if he consulted the facility's legal department, the NHA stated, No, I did not.Review of the facility's Medication Management - Psychotropic Medications policy (revised 04/28/2025) states that risks and benefits must be reviewed and consent completed prior to initiating psychotropic medication.The Advance Directives policy (revised 11/14/2018) requires the facility to honor all properly executed directives provided by the resident or representative.

Based on record review and interviews, the facility failed to ensure the rights of a resident representative, appointed as the Guardian Advocate and authorized to consent to medical treatment, were honored related to communication of health status for one resident (#1) of five sampled residents.Findings included: On 06/10/2026 at 4:52 p.m., a telephone interview was conducted with Resident #1's family member. She reported that she had been appointed as the resident's Guardian Advocate in October 2025 and had provided the appointment paperwork to the Admissions Director at the time of the resident's admission. She stated she repeatedly contacted the facility for health updates but never received a return call. She reported that she had not signed any informed consents for psychotropic medications. She stated that a visitor went to the facility and shared concerns about the resident's care. On 05/13/2026, she personally went to the facility, found the resident lethargic and not at baseline, and requested the resident be transferred to the hospital. The resident was subsequently transferred and received care. She stated the resident now lives in a supported living program where communication is consistent and the resident is receiving better care than she had in any nursing home.A review of Resident #1's clinical record showed an admission date of 04/23/2026 and discharge on [DATE]. The face sheet identified the same family member as Emergency Contact #1 and Guardian, with a phone number and email listed. Resident diagnoses included malfunction of a continent urinary stoma, muscle weakness, MRSA infection, neuromuscular bladder dysfunction, fibromyalgia, chronic pain syndrome, stage 3 pressure ulcers, and spina bifida. Guardianship paperwork was scanned into the record on 04/23/2026. The Letters of Guardian Advocate from the Sixth Judicial Circuit, [Name of county] County, appointed the family member as Guardian Advocate with the authority to consent to medical treatment. The document was ordered and signed on 10/21/2025.A review of the Care Plan revealed no advance directive care plan for Resident #1.A review of nursing progress notes dated 04/23/2026 through 05/12/2026 showed no documentation of communication with the Guardian Advocate regarding multiple refusals of wound care, medications, assessments, or episodes of behavioral changes. Notes documented repeated refusals of care, wound care, routine medications, vital signs, labs, and evaluations. On 05/01/26, 05/02/26/ 05/03/26, 05/04/26, 05/05/26 and 05/12/2026, staff documented frequent behavioral episodes, including screaming, refusing care, refusing medications, and combativeness. The Director of Nursing (DON) was informed, and the resident was evaluated by in house Advanced Practical Registered Nurse (APRN) and wound care APRN. A request was made for a psychiatric evaluation, which was not completed that shift. The resident refused transfer to the emergency room when offered. There was no evidence that the Guardian Advocate was notified at any time regarding these changes or concerns.During an interview on 06/10/2026 at 2:07 p.m. with the Nursing Home Administrator (NHA) and the Registered Nurse Consultant, the NHA stated that he had reviewed the guardian paperwork at admission but believed the facility needed a determination of incapacity. When asked whether he contacted the facility's legal department for guidance, he stated he had not. A review of the facility's policy titled Advance Directives, SS 124, last revised 11/14/2018, states that the center will abide by state and federal laws regarding advance directives and will honor all properly executed advance directives provided by the resident or resident representative.

Based on observation, record review, and staff interviews, the facility failed to develop and implement a comprehensive, person centered care plan addressing hearing impairment and hearing aid management for one resident (#2) out of five residents sampled.Findings included: On 06/10/2026 at 9:32 a.m., Resident #2 was observed sitting on the side of her bed, partially through her breakfast meal, and wearing a hospital gown. The resident stated she had lost both hearing aids-one had been missing a while and the second was now gone. A landline telephone was on her bedside table. The resident could not recall when either hearing aid went missing.Record review showed that Resident #2 was admitted on [DATE]. Her face sheet listed a family contact. Diagnoses included muscle weakness, hypothyroidism, glaucoma, and hypertension. The personal effects inventory dated 01/01/2026 documented one pair of hearing aids.A review of the care plan on 06/10/2026 identified a focus area related to altered self care performance due to emphysema, glaucoma, and dementia, with interventions requiring assistance for personal hygiene and upper body dressing. However, the care plan contained no focus area or interventions addressing the resident's hearing impairment, hearing aid use, or related staff support.On 06/10/2026 at approximately 11:50 a.m., the Nursing Home Administrator (NHA) stated they were responsible for grievances but were unaware the resident's hearing aids were missing.On 06/10/ 2026 at 12:09 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A (LPN) reported being familiar with Resident #2 but stated, I do not perform that function regarding placing hearing aids in the resident's ears. Staff A believed CNAs (Certified Nursing Assistants) usually assisted but was unaware the devices were missing until asked by the Administrator approximately 25 minutes earlier. Staff A then initiated a grievance.On 06/10/2026 an 12:41 a.m., Staff B (CNA) stated he was assigned to Resident #2 on the 7 a.m.-3 p.m. shift. He said the resident stayed in bed frequently but sometimes got up for music or activities. He confirmed the resident had hearing aids but stated, I do not put them in. The staff from the 11 p.m.-7 a.m. shift put them in. He reported he did not know they were missing. The hearing aid case on the bedside table was observed to be empty.On 06/10/2026 at 1:30 p.m., a phone interview with the resident's family member revealed that the resident had told him a couple of days prior that one hearing aid was missing. He stated that, as far as he knew, she had both hearing aids before that time. During an interview and review on 06/10/2026 at 3:08 p.m., the MDS Coordinator reviewed the care plan and MDS assessments stating as follows: 01/13/26 admission MDS: highly impaired hearing, no hearing aids 01/27/26 quarterly MDS: highly impaired hearing, no hearing aids 04/29/26 quarterly MDS: highly impaired hearing, yes to hearing aidsThe MDS Coordinator stated that the hearing related care plan did not trigger because the full assessment did not capture the presence of hearing aids. She confirmed that the resident's chart listed Special Instructions stating: Please remove and charge hearing aids every night. She stated nurses were responsible for this task, but the clinical record contained no documentation that nurses performed it. She also stated that hearing aid support was not included in CNA task lists. A review of the facility's Plan of Care Policy (N 1015, effective 11/30/2014) showed an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/ or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. The Procedure showed an expectation to: -Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Review, update or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA (Omnibus Budget Reconciliation Act) MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to ensure temperature logs were completed daily, the microwave in the nutritional room was kept clean and sanitary, and the kitchen reach-in refrigerator was not over packed with food items to keep cold foods at an appropriate safe temperature. Findings included: An observation, during the kitchen initial tour, on 07/29/24 at 9:06 a.m., revealed the walk-in refrigerator was not in service. During an interview on 07/29/24 at 9:07 a.m., Staff I, [NAME] stated the walk-in refrigerator quit working on 07/28/24 and this was reported to administration. Staff I, [NAME] stated all the food from the walk-in refrigerator was moved to the three-door reach-in refrigerator. During an interview on 07/29/24 at 9:08 a.m., Staff C, Interim Dietary Manager (IDM) stated Staff D, Dietary Manager (DM) just started today and was currently doing the morning rounds in the nourishment rooms. Further observations in the kitchen area on 07/29/24 at 9:20 a.m. revealed the following logs were not completed: - A Freezer Temperature Log showed no temperatures for the dates of 07/27/24 and 07/28/24. Photographic evidence obtained. - The reach-in Refrigerator Temperature Log showed no temperatures for the dates of 07/27/24 and 07/28/24. Photographic evidence obtained. - The Three Compartment Sink Log showed no temperatures for the dates of 07/27/24 for breakfast time and no dates for 07/28/24. Photographic evidence obtained. During an interview on 07/29/24 at 9:23 a.m., Staff D Dietary Manager (DM) stated he would have expected all temperature logs to be completed daily. An observation on 07/29/24 at 9:25 a.m. showed a three-door reach-in refrigerator with food packed inside with no additional space left on the shelves to put any other food items inside. An observation on 07/29/24 at 9:44 a.m. revealed a microwave located in the 200 Hallway Nourishment room. The microwave was opened and showed a sticky brown substance covering all over the inside of the microwave. Photographic evidence obtained. During an interview on 07/29/24 at 9:45 a.m., Staff F, Certified Nursing Assistant (CNA) confirmed the microwave was dirty and should have been cleaned. Staff F, CNA stated that it is the nursing staff who are responsible for cleaning the microwave daily with dietary staff who come daily, usually in the mornings, to ensure the nourishment rooms are clean and in good condition. Staff F, CNA stated the dietary staff must not have made their morning rounds yet or they should have caught the microwave being so dirty. An observation, during follow-up in the kitchen, on 07/30/24 at 11:10 a.m., revealed Staff I, [NAME] beginning to do holding food temperature checks. The food temperatures were as follows: Hot Foods: - Hamburger: 172 degrees Fahrenheit (F) - Tater Tots- 165 degrees (F) - Puree hamburger- 169 degrees (F) - Mashed Potatoes- 142 degrees (F) - Mechanical soft meat- 181 degrees (F) Cold foods: - Tuna- 45 degrees (F) - Pasta salad- 53 degrees (F) - pureed cold vegetables- 60 degrees (F) During an interview on 07/30/ 24 at 11:15 a.m., Staff I [NAME] stated all the cold foods that were taken out of the three-door reach-in refrigerator had temperatures above 41 degrees (F). Staff I [NAME] stated they could always put the cold food back in to the three-door reach-in refrigerator to see if we can get them back to under 41 degrees (F). During an interview on 07/30/24 at 11:15 a.m., Staff D, DM stated because the walk-in refrigerator was out of order all the cold food had been placed in the three-door reach-in refrigerator, so the refrigerator was packed not allowing the air to properly circulate and keep the food inside properly cooled. The DM stated the cold food that had temperatures over 41 degrees (F) will need to be discarded and made brand new again prior to serving. Review of the facility policy Food Storage: Cold Foods, revised date 09/2017, showed the following: Policy Statement: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the [Food Drug Administration] FDA Food Code: .2. All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. Review of the facility's policy Preventing Foodborne Illness-Food Handling, revised date July 2014, showed the following: Policy Interpretation and Implementation. 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; Inadequate cooking and improper holding temperatures; .c. Contaminated equipment and d. Unsafe food sources . .5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirements. .9. All food service equipment and utensils will be sanitized according to current guidelines and manufactures' recommendations.

Based on observations, interviews, and record review the facility 1) failed to ensure oxygen was delivered according to physician orders for one resident (#91) with a tracheostomy tube out of two sampled residents with a tracheostomy tube, and 2) failed to ensure emergency tracheostomy supplies were readily available at the resident's bedside according to standards of practice for two residents (#91 and #83) out of two residents sampled with a tracheostomy tube. Findings included: 1. Review of Resident #91's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of tracheostomy status, dependence on supplemental oxygen, non-traumatic subarachnoid hemorrhage from left middle cerebral artery, chronic respiratory failure with hypoxia, systemic lupus erythematosus, aphasia, and pulmonary fibrosis. An observation was conducted on 07/29/24 at 10:18 AM of Resident #91. She was observed to be in bed, eyes open, nonverbal, with a tracheostomy tube. She was observed to be receiving oxygen via a tracheostomy (trach) collar. The trach collar was connected to an air compressor with a fraction of inspired oxygen (FIO2) dial set to 80%. An observation was conducted on 07/30/24 at 09:54 AM of Resident #91. She was observed to be in bed, eyes open, and nonverbal. She was observed to have a tracheostomy tube in place. She was observed to be receiving oxygen via a trach collar. The trach collar was connected to an air compressor with the FIO2 dial set to 60%. The air compressor was connected to the oxygen concentrator and the oxygen concentrator was set to 4 liters per minute (LPM). Review of Resident #91's physicians orders revealed an order, with a start date of 7/9/24 and no end date, for Respiratory: Oxygen - continuous 2 Liters via trach every shift. A physician's order, with a start date of 7/2/24 and no end date, for Tracheostomy-6 Shiley. A physician order, with a start date of 7/2/24 and no end date, to keep extra trach tube at bedside. Review of Resident #91's Medication Administration Record (MAR) revealed the physician order with a start date of 7/9/24 for Respiratory: Oxygen- continuous 2 liters via trach every shift was signed off as administered every shift from 7/9/24 through 7/29/24. Review of Resident #91's 3008, dated 5/14/24, revealed a primary diagnosis of malfunction of tracheostomy stoma. Section V. Treatment Devices .Mask Type 28% trach collar Oxygen-Liters 5% Trach Size: 6 fr [French] An interview was conducted on 07/30/24 at 01:35 PM with Staff A, Registered Nurse (RN). Staff A said Resident #91 has a Shiley Tracheostomy tube, size 6. She reviewed the physicians order and said Resident #91 was supposed to be on two liters per minute (LPM) of oxygen via trach collar. She entered the resident's room, confirmed the resident was on five LPM of oxygen. She said she was a little familiar with the FIO2 settings on the air compressor and said Resident #91 should be on 60 or 75% FIO2 but that is not on our MAR, she observed the FIO2 and confirmed Resident #91 was on 60% FIO2. She reviewed Resident #91's medical record and confirmed there was no physician order related to the FIO2 and said she could only find hospital documentation from 5/14/24, when the resident was first admitted that she was supposed to be on five liters of oxygen with 28% FIO2 but she [Resident #91] had gone out to the hospital since then so I'm not sure what she is supposed to have. Staff A, RN said the resident should have an ambu ( bag (bag valve mask), oxygen tank, suction machine, suction supplies, trach ties, trach cleaning kit, and a Shiley size 6 trach at the bedside with extra size 6 inner cannulas as the emergency tracheostomy supplies. Staff A, RN said she did not think there needed to be a smaller trach size at the bedside. While she was in the residents room, she confirmed there was not a size smaller tracheostomy at the bedside and she confirmed the emergency oxygen tank at the bedside was empty. An interview was conducted on 07/30/24 at 01:49 PM with Staff B, Licensed Practical Nurse (LPN), [NAME] Unit Manager, she said residents with tracheostomy's should have a suction set-up, sterile water, extra inner cannulas, an entire tracheostomy the same size as the resident has, an extra trach collar, full portable oxygen tank, and she said she was not sure if there should be an ambu bag at the bedside and she said she did not think there needed to be a smaller tracheostomy size at the bedside. Review of Resident #91's care plans revealed a care plan, with a revision date of 6/10/24, read: [Resident #91] has a tracheostomy r/t [related to] impaired breathing mechanics. The goal revealed [Resident #91] will have minimal s/sx [signs and symptoms] of infection through the review date. The interventions included Ensure that trach ties are secured at all times. Monitor/document for restlessness, confusion, increased heart rate (Tachycardia), and bradycardia. Monitor/document level of consciousness, mental status, and lethargy PRN [as needed]. Suction as necessary. An interview was conducted on 07/31/24 at 09:18 AM with the Director of Nursing (DON). She said Resident #91 came to the facility with a tracheostomy. She said her tracheostomy frequently plugs with mucus and the resident's oxygen levels frequently drop below normal. She said the resident should be on two LPM of oxygen and she said she called the Respiratory Therapist to clarify the FIO2 setting and she said they do not need to have a physician's order for that setting but, I did go ahead and put that in the chart. The DON said the facility does not have a policy on emergency tracheostomy supplies that should be at the bedside but best practice, We make sure we have a whole change out tracheostomy kit at bedside and we did implement oxygen tanks at the bedside, and they should be full. She stated ambu bags are not necessary at the bedside because they are on the crash carts. She stated, We just keep the size of the trach [tracheostomy] at the bedside. An interview was conducted with the DON on 07/31/24 at 11:29 AM. She said Resident #91's oxygen concentrator was supposed to be set on 2 LPM and the oxygen connects to the 50 psi air compressor, and the air compressor has the FIO2 dial connected to it and the trach collar. She said the FIO2 dial should be set to 80% according to the manufacturer guidelines of the air compressor. Review of the facility's High Humidity Set-ups Utilizing Concentrator with Air Compressor guideline, undated, revealed O2 [oxygen] concentrator provides oxygen only. 50 psi Medium Volume Compressor provides aerosol only. Match the pointer with the notch on jet nebulizer dial at 80%. According to the National Library of Medicine (NIH), Tracheostomy Care and Suctioning, dated 2021, When caring for a patient with a tracheostomy tube in the acute care setting, it is important to ensure that proper safety equipment is present at the patient's bedside. there should be spare tracheostomy tubes (same size and one size smaller), lubricant, syringe for cuff inflation, and tracheostomy ties (or means to resecure the tracheostomy tube) if reinsertion is required. A bag valve mask should always be kept at the bedside. https://www.ncbi.nlm.nih.gov/books/NBK593189/ (Photographic evidence obtained). 48441 2. On 7/31/2024 at 9:50 a.m., during medication administration for Resident #83 with Staff J, Licensed Practical Nurse (LPN), an observation was made of tracheostomy emergency supplies for the resident. Staff J, LPN stated there were supplies in the resident bedside table. Upon observation of each drawer, a bag-valve device (ambu bag), oxygen, or a tracheostomy device one size smaller were not present in the room easily accessible for an emergency. On 7/31/2024 at 3:10 p.m., an observation and interview was conducted with Staff J, LPN and the DON regarding emergency tracheostomy supplies available in the room for Resident #83. The DON stated an ambu bag and oxygen are available on the code carts in the hallway at each wing of the facility for emergencies. An observation was made of Staff J, LPN unable to open code cart to demonstrate the location of the ambu bag. The DON opened the code cart to demonstrate the location of the ambu bag and stated an oxygen tank was on the side of the code cart. On 8/01/2024 at 9:30 a.m., an interview was conducted with the Supply Coordinator in the facility's supply room. The Supply Coordinator stated supplies can easily be provided if notified in advance. An observation was made of four ambu bags in separate plastic bags, numerous size 6 and 8 tracheostomy appliances, and one size 4 tracheostomy appliance. The Supply Coordinator could not locate any sizes of tracheostomy appliance kits between 4 and 6 or between 6 to 8 readily available. The Supply Coordinator stated the supply room is locked at night but the nursing supervisor has a key to access the supply room. A record review of Resident #83 Admission Record had an original admitted [DATE] with a readmitted [DATE]. Resident #83 had a primary diagnosis of aphasia following cerebral infarction and secondary diagnoses include but are not limited to dysphagia unspecified, encounter for attention to tracheostomy and gastrostomy. A review of the physician orders, dated 10/26/2023, shows orders to keep extra trach tube at bedside and tracheostomy size 6. A review of Resident #83 care plan, dated 7/25/2024, shows a focus area of tracheostomy related to stroke-cardiac arrest initiated on 11/08/2023. The goal for this focus is to have clear and equal breath sounds bilaterally and to minimize the risk of abnormal drainage around the trach site through the review date. Interventions include but are not limited to ensure trach ties are secured at all times, respiratory therapy to work with capping, and suction as needed. A review of the Minimal Date Set, dated 4/25/2024, Section O-Special Treatments, Procedures and Programs shows in section E1- Tracheostomy care as checked for Resident #83.

Based on observations, interviews, and record review the facility did not ensure medication was stored safely for one out two medication rooms, two out of three medication carts, one treatment out of two treatment carts and medication properly stored for one resident (#38) out of forty residents sampled. Findings include: On July 29, 2024, at 10:00 a.m., during the initial tour of the east wing an inhaler was observed on Resident 38's bedside table [photograph evidence obtained]. Upon this observation the resident was not in the room to interview. Further observation revealed the inhaler present on the bedside table later during the afternoon. On July 30, 2024, at 8:25 a.m., an observation was made on the east wing of an unlocked treatment cart. The cart was located across from the nurses' station in an area where residents could easily open drawers. In the second drawer were various residents medications for wound care. Staff J, Licensed Practical Nurse (LPN) locked the drawer and stated the drawer was most likely re-stocked last night or early this morning and they forgot to lock the drawer. On July 30, 2024, at 2:00 p.m., an observation was made of the west wing medication room. The floors were grossly contaminated with dried stained rusty brown liquid. The sink was grossly contaminated with brown liquid and fragments of medication needle cap and a medication vial cap. A temperature log outside of the medication refrigerator was documented as complete for all the days of July with temperatures in the thirty Fahrenheit range (30-37). The current temperature for this refrigerator was 52-54 degrees Fahrenheit. Inside the refrigerator hanging from the top was a large solid piece of ice. Staff B, LPN/Unit Manager (UM) and an unnamed nurse agreed to the refrigerator temperature of 52-54 range and verified the large solid piece of conformed ice hanging from inside the top part of the refrigerator. Inside the refrigerator was a small hard plastic box with two red zip ties. Staff B, LPN/UM stated the box was the facility's emergency box (ebox) and the red zip ties indicate to staff and pharmacy the box has been opened and needs replacement. Staff B stated the box was opened yesterday to obtain insulin. An observation was made of a shelf in the medication room of a sticky substance under a medication box [photographic evidence obtained]. When lifting the box, the medication box left remnants of the box on the shelf. Staff B witnessed the sticky substance on the shelf. On July 30, 2024, at 2:30 p.m., an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the refrigerator temperature. The DON stated all medication in the west medication room requiring refrigeration have been moved to the east wing medication room refrigerator until a proper placement can be made to replace the refrigerator. On July 30, 2024, at 2:45 p.m., an observation was made of the west wing medication cart with Staff H, Register Nurse (RN). One vial of Novolog was past its expiration based on it's opening date. Staff H agreed and removed the medication from the medication cart. On August 1, 2024, at 9:50 a.m., an observation was made of the east wing back medication cart with the ADON. One yellow band ring in a small bag not labeled and two labeled hearing aid containers were in one drawer with medication. The ADON stated no personal items should be in the medication carts. The ADON removed these items. An injection pen of Lantus was removed due to no documentation of an opening date and an insulin pen of Novolog was removed due to the manufacturing expiration date of (28 days) past the opening date. The ADON was in agreement with the findings of the medication cart. A record review of Resident #38's Admission Record had an original admitted [DATE] with a readmitted [DATE]. Resident #38 has a primary diagnosis of chronic obstructive pulmonary disease (COPD). Secondary diagnoses include but are not limited to unspecified dementia with unspecified severity without behavioral, psychotic, mood or anxiety disturbances, major depressive disorder, anxiety disorder unspecified, and chronic respiratory failure with hypercapnia. A record review of physician orders for Resident #38 has an order, dated 10/19/2023, for Combivent Respimat inhalation aerosol solution 20-100 MCG/ACT (Ipratropium-Albuterol) to give one puff inhale every six hours as needed for COPD. A physician order, dated 12/24/2023, for Incruse Ellipta inhalation aerosol powder breath activated 62.5 MCG/ACT (Umeclidinium Bromide) One puff inhale orally once daily for COPD. A physician order, dated 3/18/2024, for Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT (Albuterol Sulfate) two puffs inhale orally every four hours as needed for shortness of breath. Resident #38 did not have an order to self-administer medication. A record review of Resident #38's most recent care plan, dated 6/23/2024, has a focus area of cognitive deficit related to a diagnosis of dementia. Resident #38 has a focus area of COPD with a goal for resident to display optimal breathing patterns daily through review date and will be free of signs and symptoms of respiratory infections through review date. Interventions include but are not limited to: give aerosol/nebulizers or bronchodilators as ordered and monitor and document any side effects and effectiveness. Resident #38 did not have a care plan focus area to self-administer medications. On August 1, 2024, at 11:05 a.m., a telephone interview was conducted with the facility's pharmacist. The pharmacist stated he is at the facility at least monthly and will type up a report of his findings regarding medication storage as well as have a discussion of his findings with the DON. The pharmacist stated the ice in the west medication room was in his monthly report. A review of the Monthly Medication Unit Review, dated 7/05/2024, under Drug Storage Labeling, Security- Medication Room shows the following observation from the monthly pharmacist rounds: [NAME] medication room needs a new light and consider defrosting refrigerator, build up in top near freezer area. On August 1, 2024, at 11:27 a.m., an interview was conducted with the DON regarding findings of medication carts, treatment cart, medication rooms and the inhaler found in Resident #38's bedside table. The DON stated the refrigerator in the medication room in the west wing has been replaced and education will be provided on proper labeling of medications The facility did not provide a policy on medication storage upon request.

Based on observations, interviews, and record review, the facility failed to serve food at an appetizing temperature for five residents ( #90, #95, #29, #51 and #18) of five residents sampled for food services. Findings included: 1. During an interview on 07/29/2024 at 10:15 a.m., Resident #90 stated he was frustrated with the food in the facility. He said that no fresh fruits or vegetables are ever given, and the food is over processed. He said he feels like he is losing weight. The resident stated he often orders a salad as a substitute from the Always Available Menu because he feels the food the facility is serving is not healthy. He said, This past weekend I wanted a chicken salad from the Always Available Menu and I was told there was no salad because they did not have any lettuce or tomatoes. The resident said the food is always the same and the facility never changes the menu. He stated he often has no breakfast meat. He said he has told the facility many times, but nothing has changed. An interview on 07/30/2024 at 2:20 p.m. revealed Resident #90 was upset and stated, The food today was terrible. The pork chop was so dry it was like leather. The food was cold. It had the white sauce on it and I couldn't stomach it, so I turned the tray away. He further said he declined an alternative choice because he had already lost his appetite. During an interview on 07/31/2024 at 9:17 a.m. Resident #90 stated the night before he requested a salad for dinner from the Always Available Menu. He said when he received his tray the diet slip was marked by the kitchen that they had no lettuce and no tomatoes for a salad (the resident did not save the diet slip from the tray). The resident stated a family member brought cereal to him for dinner. During an interview on 08/01/2024 Resident #90 said the Kitchen Manager has visited him the prior evening and asked the resident about his opinion of the food in the facility. The resident said, I let him have it. I told him exactly what has been happening with the food and how unhappy everybody is with it. I know almost everybody in this building, and nobody likes the food. The resident continued, Then this morning I get eggs for breakfast. I got cold scrambled eggs and two hard boiled eggs. That was it. No toast. Nothing else. The aide was nice enough to get a yogurt for me. Resident #90 showed a photograph, with date and time, of the breakfast he was served on this day. The resident stated the scrambled eggs are always cold. Review of Resident #90's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include peripheral vascular disease, Type 2 Diabetes Mellitus, and morbid obesity. Review of Resident #90's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. 2. During an interview on 07/29/2024 at 12:30 p.m., revealed Resident #95 expressed how he was very unhappy with the food in the facility. The resident stated he is diabetic and he is not receiving a proper diabetic diet. He said the food has a chemical taste, never smells good and is cold. The resident stated he feels like he has lost a lot of weight and has developed acid reflux since his admission to the facility, because of the food. Review of Resident #95's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Chronic Kidney Disease Stage 3, Gastro-Esophageal Reflux Disease. Review of Resident #95's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a BIMS score of 15, which indicated intact cognition. Review of Resident #95's physician orders revealed the resident's current diet order was Consistent Carbohydrates, Regular Texture, Regular/Thin Liquids, Consistent Carbohydrate 75 mg (milligrams). Review of Resident #95's weights revealed monthly weights of: May 179.0 lb, June 180.2 lb, July 173.6 lb. Resident has a weight loss from June to July was 6.6 lbs total. The resident weighed on 07/05/2024 and his weight was 172.0 lbs. Resident's weight is currently being done twice monthly. 3. During an interview on 07/29/2024 at 12:00 p.m., Resident #18 stated, the food here is really bad and what is on the menu isn't always what is available. The hot food is cold and the cold food is hot. Review of Resident #18's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease with Dyskinesia, Muscle Wasting and Atrophy, Osteoporosis, Vitamin D Deficiency, Gout, Chronic Kidney Disease. Review of Resident #18's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a BIMS score of 15, which indicated intact cognition. 4. During an interview on 07/29/2024 at 10:46 a.m., Resident #29 expressed how unhappy she was with the food in the facility. The resident stated she is diabetic and never gets the proper diet. The resident said, What is on the menu is hardly ever what you get. The food is burned, the kitchen is always running out of food and food dishes are broken. The resident said the food is never the correct temperature and the hot food is always cold. Review of Resident #29's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus without Complications, Morbid (Severe) Obesity Due to Excess Calories, Essential Hypertension, Gout, Chronic Kidney Disease. Review of Resident #29's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a BIMS score of 15, which indicated intact cognition. 5. During an interview on 07/20/2024 at 9:29 a.m., Resident #51 stated the food in the facility is terrible and it doesn't taste good sometimes. She said, It doesn't look good and it's always the same. Review of Resident #51's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Essential Primary Hypertension, Chronic Viral Hepatitis C. Review of Resident #95's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a BIMS score of 15, which indicated intact cognition. On 07/31/2024 at 9:30 a.m. a test tray was requested to be placed on the last tray cart leaving the kitchen for the lunch meal. The tray was to be delivered to the [NAME] Dining Room. Per the facility tray delivery schedule, the trays were to be delivered to the [NAME] Dining at 12:40 p.m. During an interview on 07/31/2024 at 10:44 a.m., Staff H (RN) stated whenever a resident tells him about a food complaint he tells the kitchen staff and they handle the issue. On 07/31/2024 at 1:00 p.m. the lunch trays were not yet delivered to the [NAME] Dining Room as indicated by the facility tray delivery schedule. At this time Staff J, Registered Nurse (RN) was interviewed and she verified the lunch trays were late. An observation in the [NAME] Dining Room on 07/31/2024 at 1:09 p.m. revealed the trays were delivered and after the last trays were delivered it was determined the test tray had been delivered to the conference room directly from the kitchen and not to the [NAME] Dining Room as requested. During an interview on 07/31/2024 at 1:12 p.m., Staff F, Food Service Director (FSD), stated the thermometer had been calibrated and was ready to take food temperatures. Staff F, FSD stated he expected food to be served at 140 degrees Fahrenheit (F) from the kitchen. The test tray lunch was encrusted pork loin, southern style pinto beans, braised cabbage, chocolate cake with peanut butter frosting and corn bread. The test tray food temperatures were completed, and results were as follows: -Pork Loin 123 degrees F -Pinto Beans 124 degrees F -Cabbage 117 degrees F -Cornbread 99 degrees F After the food temperatures were taken by FSD, Staff F stated he felt 123 degrees F was an appropriate temperature for the pork loin and he would eat it. An observation on 07/31/2024 at 1:12 p.m., showed no steam from the plate of hot food when the plate cover was removed. The state surveyor felt the pork loin and the pinto beans with finger and both food items were cool to the touch and not hot. On 07/31/2024 at 1:20 p.m. the Nursing Home Administrator (NHA) was interviewed and stated the test tray food was not palatable, attractive and at appetizing temperatures. He stated he would not eat it.

Based on observations, interviews, and record review, the facility 1) failed to ensure an effective infection control program related to Enhanced Barrier Precautions (EBPs) for three residents (#206, #202, and #203) out of four residents observed, and 2) failed to ensure appropriate personal protective equipment (PPE) was utilized during resident care for four residents (#206, #202, #203 and #83) out of four residents observed. Findings included: On 7/29/2024 at 9:40 a.m., an observation and interview was conducted with Resident #203. Resident #203 was conversant and able to state she had a gastrostomy tube for nutrition and medication. Resident #203 stated since her admission she has not witnessed any staff member wear a gown during her care or medication administration via gastrostomy tube. No signage was observed on the outside of Resident #203's door to indicate EBPs were in place and no PPE was observed for staff use. On 7/29/2024 at 10:45 a.m., an observation and interview was made of Resident #202 during the initial tour. Resident # 202 had a Contact Isolation sign on the outside of her room with appropriate PPE supply on the door. When entering room, Resident #202 stated, This is the first time I've seen anyone wear a gown, mask and gloves, since I've been here - no one has done this. Resident #202 stated she does not know why she is on isolation, stating, I think maybe it's because I have an infection in my back. Staff Q, Licensed Practical Nurse (LPN) stated, Both residents have MRSA [Methicillin resistant staph aureus], bed A has it in her wound and bed B has it in her nares. An observation was made of Resident #202 with a peripherally inserted central catheter (PICC), dated 7/22/2024, and a wound vac connected to the resident. Resident #202 stated she had the PICC inserted at the hospital as well as the wound vac which is currently connected to a wound on her bottom. On 7/30/2024 at 10:30 a.m., a second observation was made of no EBPs signage for Resident #203. Resident stated she received her medication via gastrostomy tube this morning but she was hopeful a swallow study due today will let her eat. On 7/30/2024 at 10:55 a.m., an interview was conducted with the Infection Control Preventionist/Assistant Director of Nursing (IPC/ADON). The IPC/ADON stated when placing a resident requiring any form of isolation, she would use the 3008-communication form from the discharging hospital to their facility and obtain an order from the admitting facility physician to continue the isolation. On 7/31/2024 at 8:15 a.m., an observation was made of Staff J, Licensed Practical Nurse (LPN) in Resident #202's room finishing up an intravenous medication without a gown or mask in place as required by Contact Isolation guidelines. On 7/31/2024 at 8:30 a.m., an observation was made of the Assistant Director of Nursing (ADON) entering Resident #202's room wearing a gown, mask, and gloves. On 7/31/2024 at 9:50 a.m., an observation and interview was conducted with Staff J, LPN. Staff J, LPN administered medication via gastrostomy tube for Resident #83 without proper gown and gloves as required by Enhanced Barrier Precautions. Staff J, LPN stated she knew she was supposed to wear a gown and made a mistake. On 7/31/2024 at 10:45 a.m., an observation and interview was conducted with the Activities Director. This surveyor was in Resident #202's room in gown, gloves and mask during an interview. Resident #202 had a newly placed dressing over her PICC line with today's date. The resident stated, Some nurse was in here this morning and changed my dressing. During conversation the Activities Director entered the room without PPE to bring the resident the daily activities calendar. The Activities Director stated, I don't know what I'm supposed to wear, I see you are wearing all the PPE but I thought I did not have to if I was just coming in to talk to the residents. Now I don't know. On 7/31/2024 at 9:20 a.m., a third observation was made of no EBPs signage for Resident #203. On 7/31/2024 at 11:20 a.m., an observation was made of a Staff M, Certified Occupational Therapy assistant assisting Resident #206 out of bed into a wheelchair without a gown. On the outside of the room was a sign for Contact Isolation. Staff M stated she did not see the sign and was assisting the resident because she was getting out of bed On 7/31/2024 at 11:27 a.m., an interview was conducted with the DON, ADON and Regional Nurse Consultant regarding concerns of proper isolation and compliance with staff members. The ADON stated she would have to look at the residents' 3008 and guidelines to determine the proper isolation. The current signage for the Contact Isolation utilized by the facility states gown is to be worn for incontinence care. The Regional Nurse Consultant searched the Centers for Disease (CDC) website and printed the signage for Contact Isolation. A comparison was made of signs and agreed staff should be wearing a gown and gloves upon entering the resident's room. The DON stated Resident #203 was supposed to be on Enhanced Barrier Precaution since admission due to her gastrostomy tube. On 8/01/2024 at 9:50 a.m., the ADON stated one resident #203 was on Contact Isolation and Residents #202 and #206 were on Enhanced Barrier Isolation and not Contact Isolation. A record review of Resident #202's Admission Record has an admitted [DATE] with a primary diagnosis of osteomyelitis of vertebra sacral and sacrococcygeal region. Secondary diagnoses include but are not limited to pressure ulcer of sacral region stage 4, flaccid neuropathic bladder, and paraplegia. A record review of the physician orders for Resident #202 shows an order, dated 7/23/2024, for catheter care every shift and as needed, change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Enhanced Barrier precautions dated 7/31/2024, and wound care to left buttocks cleanse with normal saline apply wound vac to run at 150 every Monday, Wednesday and Friday and as needed dated 7/29/2024. A record review of Resident #202's care plan, dated 7/24/2024, shows a focus area requiring enhanced barrier precautions related to use of indwelling medical device(catheter), chronic wound(s) and is at risk for a CDC MDRO (multisystem drug-resistant organism) infection. The goal is for the resident to have reduced risk of obtaining or transmitting CDC MDRO during the review. Interventions include but are not limited to staff to wear enhanced barrier precaution PPE when providing high contact direct care activities. A review of Resident #206's Admission Record has an admitted [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Secondary diagnoses include but are not limited to cutaneous abscess of buttocks, irritable bowel syndrome with diarrhea, and need for assistance with personal care. A review of Resident #206's physician orders have an order dated 7/31/2024 for Enhanced Barrier Precautions related to wound. A review of Resident #206's care plan, dated 7/23/2024, for enhanced barrier precautions related to a chronic wound(s) requiring a dressing/covering and is a risk for a CDC MDRO infection. The goal is for the resident to have a reduced risk of obtaining /transmitting a CDC MDRO during the review period. Interventions include but are not limited to staff to wear enhanced barrier precaution PPE when providing high contact direct care activities. A review of Resident #203's Admission Record has an admitted [DATE] with a primary diagnosis of pathological fracture left femur subsequent encounter for fracture with routine healing. Secondary diagnoses include but are not limited to encounter for attention to gastrostomy, dysphagia pharyngeal phase and need for assistance with personal care. A review of Resident #203's physician orders have an order dated 7/23/2024 for enteral feed order every shift [NAME] Farms 1.5 (325 milliliters/ml) bolus three times a day for tube feeding and wound care left hip every three days and as needed. A review of Resident #203's care plan, dated 7/23/2024, for enhanced barrier precautions related to use of indwelling medical device (Peg tube) and is at risk for a CDC MDRO infection implemented on 8/01/2024. The goal is for the resident to have a reduced risk of obtaining/transmitting a CDC MDRO during the review period. Interventions include but are not limited to staff to wear enhanced barrier precautions PPE when providing high contact direct are activities. A review of the facility's policies and procedures titled, Enhanced Barrier Precautions, revised August 2022, shows the following: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity as opposed to before entering the room. b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include: a. Dressing b. Bathing and showering c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use (central line, urinary catheter, feeding tube, tracheostomy ventilator, etcetera; and h. Wound care (any skin opening requiring a dressing). . 9. No stop are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

Based on interviews and observations, the facility failed to ensure a safe environment, free from potential accidents/hazards for residents in one smoking area out of one smoking area in the facility, Findings included: On 7/30/2024 at 11:05 a.m., an observation and interview were conducted on the smoking patio area of the facility. Two residents were under the smoking gazebo with two family members present. In the center of the gazebo ceiling there were two wooden planks not connected to a foundation beam bowing down onto the smoking patio. Above the table provided for the residents during smoking times were further beams bowing down but appeared to be connected to a foundation beam. There was heavy growth of plant-like substances on numerous beams. The gazebo had three light foundations that were heavy with plant-like substances and one light fixture without a cover. During the observation a visiting family member stated, I'm surprised this whole thing hasn't fallen down already. (Photographic evidence was obtained). On 8/01/2024 at 9:00 a.m., an interview was conducted with the Nursing Home Administrator (NHA) in the smoking area. The NHA stated the gazebo roof had already been addressed. The beams that were hanging during previous observations were cut away as well as another area of beams. The NHA stated the foundation is solid so the roof beams and coverage will be replaced and the light fixtures will be removed. The NHA stated the lawn service provider has been on vacation for two weeks and will return this coming Monday to address the overgrowth of grass. On 8/01/2024 at 2:20 p.m., an observation was made of a drainage area in the center of the gazebo in the smoking area. A metal grate covered the drainage area but an exposed area approximately one to one and one-half inches wide was observed at one end of the grate with an approximate one-inch height. An observation was made of the vertical foundation beams with numerous cracks and splintered wood. (Photographic evidence obtained). A request for facility policy was requested but not obtained during the time of the survey.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for one resident (#83) out of four residents observed. These errors constituted an 11.43% medication error rate. Findings include: On 7/31/2024 at 9:50 a.m., medication administration observations were made with Staff J, Licensed Practical Nurse (LPN) for Resident # 83. The staff member dispensed the following medications: - MiraLAX powder 17 grams -Tizanidine 4 milligram (mg) one tablet -Ipratropium Bromide 0.5 mg and Albuterol sulfate 3 mg (resident's representative refused) -Modafinil 200 mg (100 mg) two tablets -Lyrica 100 mg one tablet -Aspirin 81 mg chewable -Eliquis 5 mg one tablet -Guaifenesin oral 200mg/5 milliliters (ml) give 5 ml -gave 5ml of 200mg/10ml -Multivitamin one tablet -Levetiracetam oral solution 100 mg/ml, 10 ml measured A review of the physician orders for Resident #83 has an order. dated 11/21/2023. for B12 Active oral tablet chewable 1 mg (Methyl cobalamin) to give one tablet via Gastrostomy tube (G-tube) one time a day for vitamin. Staff J, LPN stated the medication was not available in the medication cart. Staff J, LPN stated a request was made for a refill through the facility's electronic charting to the pharmacy on 7/17/2024 but a new request will be placed today as well. Staff J, LPN could not state if the medication was not available prior to today's unavailability. A physician order, dated 10/27/2023, for Lansoprazole oral suspension 3mg/ml to give 3mg/ml via G-tube one a day for Gastro-Esophageal reflux disease (GERD). Staff J, LPN stated the medication was not available in the medication cart. Staff J, LPN, stated a request will be placed to pharmacy today for a refill and could not state if the medication was not available prior to today's unavailability. A physician order, dated 10/26/2023, for Metoprolol Tartrate oral tablet 50 mg to give one tablet via G-tube twice a day for hypertension. Staff J, LPN stated the medication was not available in the medication cart and will look in the medication room to see if medication may be in the overstock bins. Staff J, LPN, returned without the medication and stated a request will be made to pharmacy to refill as soon as possible and could not state if the medication was not available prior to today's unavailability. A physician order, dated 10/26/2023, for Guaifenesin oral liquid 200 mg/5ml to give 5 ml via G-tube four times a day for cough/congestion. Staff J, LPN, pulled a bottle of Guaifenesin labeled with Resident #83's name and the following label: Guaifenesin 200mg/10ml. Staff J stated, the order says 5 ml so I will give 5 ml. On 8/01/2024 at 11:05 a.m., a telephone interview was conducted with the facility's pharmacist. The pharmacy supplier will see the request when nurses request for a medication refill but the pharmacist to the facility does not have the information only the supplier. The pharmacist will contact the pharmacy supplier to inquire about previous requests made for missing medications for this resident. On 8/01/2024 at 11:27 a.m., an interview was conducted with the Director of Nursing (DON), present were the Regional Nurse Consultant and Regional Social Services Consultant. The DON was made aware of the medication error rate of 11.43% and the missing medication concerns. On 8/01/2024 at 9:30 a.m., an interview was conducted with Staff K, LPN. Staff K was assigned to dispense medication for Resident #83. In the medication cart, Metoprolol was available but B12 and Lansoprazole oral suspension 3mg/ml were not available. Staff K stated B12 should come from central supply and could not state why Lansoprazole was missing for day two. The Supply Coordinator was in hallway at time of discussion and stated B12 one milligram is not something central supply has and must be obtained from pharmacy through a prescription, stating, I have all doses of B12 in my supply but this is a prescription. On 8/02/2024 at 2:28 p.m., an email was received from the facility's pharmacy regarding the pharmacy supplier tracking history for Resident #83's request to dispense medication timeline. [photographic evidence obtained] According to the pharmacy supplier Metoprolol 50 mg was delivered on 8/01/2024 with a 10 quantity and last delivery was on 7/17/2024 with a 10 quantity. Lansoprazole was delivered on 7/18/2024 with a thirty-day supply. According to the pharmacist, B12 of all strengths is on the facility's supply list and 1mg is available to order. A review of the facility's policies and procedures titled: Administering Medications revised April of 2019. The policy statement states medications are administered in a safe and timely manner, and as prescribed. . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 6. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the facility's policies and procedures titled: 1.0 Medication Shortages/Unavailable Medications shows a policy statement: When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. A. If a medication shortage is noted at the time of medication administration (Med- Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the Med pass is completed. B. If a medication shortage is noted during normal pharmacy hours: 1. A licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order. Facility link may also be utilized to order or reorder medications and or determine the status of a new or reordered medication. If not ordered, place the order or reorder to be sent with the next scheduled delivery. 2. If the next available delivery results in a delay or missed dose in the customer's medication schedule, take the medication from the emergency stock supply to administer the dose. If ordered medication is not available in the emergency stock, notify the pharmacist that an emergency delivery is required. 3. If medication from emergency stock is utilized- ensure that the pharmacy received the fax information (i.e. customer name, drug, dose) for replacement and appropriate billing. . D. If an emergency delivery is not feasible, a licensed nurse contacts the attending physician to obtain orders or directions which may include: 1. Holding the dose or doses. 2. Use of an alternative medication available from the emergency stock supply. 3. Change in order time of administration or medication. E. If the medication is unavailable and cannot be supplied from the manufacturer, a registered pharmacist informs the licensed nurse and attending physician of the expected date of availability and or a therapeutically equivalent alternative medication. 1. Obtain alternate physician orders, as necessary. Orders may include: a. holding the dose or doses until the medication is available b. use of an alternative medication. 2. If unavailable to obtain a response from the attending physician in a timely manner, notify nursing supervisor and contact the medical director for orders or direction. a. Explain the circumstances of the drug product shortages to obtain an appropriate order.

Based on observations, interviews and record review, the facility failed to ensure resident rooms were maintained in a clean, safe and sanitary manner, and failed to ensure Air Conditioning (A/C) units were maintained in a sanitary manner in 10 out of 10 rooms inspected (rooms #132, 125, 117, 114, 214, 218, 222, 220, 205 and 208) in 4 of 4 halls, and did not ensure 2 of 2 rooms had A/C filters in place (rooms #201 and 203). Photographic evidence was obtained. Findings included: During a facility tour on 05/30/23 from 08:23 a.m. to 10:26 a.m., Air Conditioning (A/C) units filters in residents rooms were observed to be layered with a blanket of dirt, debris, and lint on the surface of the filters. The Rooms affected included rooms #132, 125, 117, 114, 214, 218, 222, 220, 205 and 208. rooms [ROOM NUMBERS] were noted without A/C filters and were noted with dirt, debris and lint collecting inside the unit. On 05/30/23 at 9:56 a.m., rooms 214 was observed with stained floors in the bathroom and stains around the toilet base. On 05/30/23 at 10:20 a.m., room [ROOM NUMBER] was observed with a blanket of dust on the resident's nightstand. On 05/30/23 at 10:26 a.m., room [ROOM NUMBER] was observed with missing baseboards. On 05/30/23 at 10:26 a.m., room [ROOM NUMBER] was observed with stained floors in the bathroom and toilet base. On 05/30/23 at 10:30 a.m., an interview was conducted with Staff C, Housekeeping Aide. She stated she did not clean A/C filters because they were not on her list. She stated her responsibility was to wipe the outside of the unit only. She stated she cleans all rooms as assigned and if a room had a maintenance concern, she would report it to her supervisor. On 05/30/23 at 10:38 a.m., an interview was conducted with Staff D, Housekeeping Aide. She stated housekeeping department wipes the outside of the A/C unit, but they do not check filters. She stated the maintenance department was responsible. She stated if a room had any issues, she would notify the housekeeping supervisor. On 05/30/23 at 10:40 a.m., an interview was conducted with the Housekeeping Supervisor. She stated they clean all residents rooms daily. On 05/30/23 at 11:00 a.m., an interview was conducted with the Director of Maintenance (DOM). He reviewed surveyor's photographic evidence and said, that does not represent our standards. He stated their goal was to clean the A/C units monthly. He stated he had not gotten around it because he was the only one working in the department. He stated he was doing his best since the assistant was let go. The DOM said, I understand, they need to be cleaned. I will get to them. I prioritize emergencies. I will get them cleaned. On 05/30/23 at 1:10 p.m. an interview was conducted with the Nursing Home Administrator (NHA). He presented a log showing the facility cleans filters every month. He stated they were scheduled to clean the A/C units the following morning. The NHA said, a little lint is expected. Do you clean your filters daily? The NHA was notified that the A/C units revealed a heavy, thick blanket of lint in 4 of 4 wings. He said, We will clean them tomorrow, that's all I can tell you. The NHA restated they had a plan to clean them, and it should not be a problem. He stated they did not have a policy for A/C units maintenance. He stated they follow standard procedures and presented a document titled, Clean air filters. A review of a facility document titled, Clean air filters, dated 5/30/23, showed instructions to remove or open access cover. Remove air filter and inspect for cleanliness. If the filter is dirty, either wash or replace depending on the type of filter. If clean reinstall the filter. Reinstall access cover. Close and make sure it is secure. At a minimum air filters are to be replaced or thoroughly cleaned depending on the type of filter every 3 months. Clean evaporator coils if lint buildup is present. Inspect electrical wires. A review of a facility document titled, Housekeeping in-service, dated 1/1/2000 showed a subject 7-step daily washroom cleaning steps. (5). Clean and sanitize commode - The commode includes the tank, seat bowl and the base. (7) use proper mop and germicide solution to disinfect floors. Be sure to run mop along the edges and never push dirt into corners.

Based on observations, interviews and facility policy review, the facility did not ensure the kitchen was maintained in a clean, sanitary manner during two of two visits. (Photographic evidence was obtained.) Findings included: A tour of the kitchen was conducted on 05/30/23 between 8:20 a.m. and 8:51 a.m. Two employees were observed without hairnets. Staff G, Dietary Aide did not have a beard hair net and Staff F, Dietary Aide did not have a hair net. They both proceeded to put them on upon surveyor entering the kitchen. Staff F said, I forgot to put on the hair net. I was in a hurry. I normally would have it on. An observation was made of an employee phone placed on a plate on a food prep area. Staff E, Cook stated this was her phone. She said, I was listening to music. I should not have placed it there. During the tour it was noted a kitchen light above the dishwashing area loose and hanging downwards. Staff E stated maintenance was aware and they might be repairing it. An observation was made of a tray underneath the food steamer full of brown looking oily liquid mixture. Staff E stated the tray was catching the water that was dripping because the steamer had not been working. She stated this had been going on for a while, but they were using it anyway. During the interview staff E stated some of the kitchen equipment did not work. Staff E said, We had to serve biscuits this morning because the toaster was broken. She stated she did not know how long it was broken or when it would be repaired. An observation was made of flying insects in the appearance of flies, flying around the kitchen, landing on food service areas, including food trays. It was noted that a window in the kitchen was open without a screen, allowing flying insects to get into the kitchen. An interview was conducted with Staff E. She stated it was too hot and that's why they opened the window. She stated she had observed the flies in the kitchen and that she would shoo them away. On 05/30/23 at 11:30 a.m., a second tour of the kitchen was conducted with the Kitchen Manager (KM). He stated there should be no flies on resident's food or any service areas. He stated he would notify maintenance to have a screen installed on the window. During this second tour, the basin underneath the Food Steamer was observed full of water draining from the steamer. The KM stated the equipment had not worked for a couple months. He stated they would clean the dirty water. A review of a facility policy titled, Food- Preparation, dated 09/2017, showed all foods are prepared in accordance with the FDA (Food Drug Administration) food code. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use.

Based on observations, interviews, and review of facility policy, the facility did not sure food served to residents was palatable, attractive and at an appetizing temperature for 5 of 5 residents reviewed (#11, #12, #13, #10 and #14). Findings included: On 05/30/23 at 08:52 a.m., an interview was conducted with Resident #10. The resident stated her eggs were cold. She stated this was a problem. She stated she had been at the facility only 3 days, but during the three days her meals were cold. A review of Resident #10's admission record showed the resident was admitted to the facility on [DATE]. A document titled, Admission/Readmission Data Collection, dated 05/28/23 showed under cognition Resident #10 was alert, oriented to person, place time and her memory was intact. On 05/30/23 at 08:52 a.m., an interview was conducted with Resident #11. The resident stated she did not eat her breakfast. She stated it was cold, especially her eggs. Resident #11's tray was observed on her bedside table with her meal untouched. A review of Resident #11's admission record showed the resident was admitted to the facility on [DATE]. A Minimum Data Set (MDS) dated [DATE], Section C - Cognitive patterns showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. On 05/30/23 at 09:40 a.m., an interview was conducted with Resident #12. The resident stated the meals were served cold all the time. He stated he had notified staff. He stated the staff would not warm up his food and he could not understand why. A review of Resident #12's admission record showed the resident was admitted to the facility on [DATE]. An MDS dated [DATE], Section C - Cognitive patterns showed Resident #12 had a BIMS score of 15, indicating intact cognitive response. On 05/30/23 at 09:20 a.m., an interview was conducted with Resident #13. The resident stated he could not eat his breakfast. He stated his breakfast ws cold. He stated his eggs were sold. The resident opened the plate cover and said, No one can eat that. The resident stated the breakfast was served cold. A review of Resident #13's admission record showed the resident was admitted to the facility on [DATE]. An MDS dated [DATE], Section C - Cognitive patterns showed Resident #13 had a BIMS score of 15, indicating intact cognitive response. On 05/30/23 at 10:06 a.m., an interview was conducted with Resident #14. The resident stated her only complaint was related to food temperatures. She stated the food is always served cold. She stated she had told them numerous times. Resident #14 said, They don't use plate warmers. That could help. A review of Resident #14's admission record showed the resident was admitted to the facility on [DATE]. An MDS dated [DATE], Section C - Cognitive patterns showed Resident #14 had a BIMS score of 15, indicating intact cognitive response. On 05/30/23 at 08:20 a.m., a tour of the kitchen was conducted. An observation was made of breakfast trays set on the tray line already plated, noted covered ready to be transported to the floor. The plates had eggs and biscuits on them. A test of one of the plates revealed eggs held at a temperature of 100 degrees Fahrenheit. A test of a second plate revealed a temperature of 96 degrees Fahrenheit, both below the required food service temperatures. An immediate interview was conducted with Staff E, Cook. She tested the eggs and confirmed they were cold, and not at the appropriate temperatures. She said, These are cold. We will not serve these plates. She stated she would make sure the trays were at the appropriate temperatures before sending them out. She stated hot foods should be held at a minimum of 140 degrees. A review of the food temperature log for breakfast meal on 05/30/23 showed no documentation to indicate the temperatures had been checked prior to meal service. Staff E confirmed they had already delivered the first breakfast cart. She stated they were waiting to deliver a second one. Staff E stated she should have obtained and documented the temperatures prior to meal service. On 05/30/23 at 11:30 a.m., a second tour of the kitchen was conducted with the Kitchen Manager (KM). He stated he heard residents had been complaining about food temperatures. He stated he thought it was because the facility did not use plate warmers. He said, We will be purchasing plate warmers soon. He stated he would expect residents to be served meals at appropriate temperatures at all times. He stated he would in-service the staff. A review of a facility policy titled, Food- Preparation, dated 09/2017, showed all foods are prepared in accordance with the FDA (Food Drug Administration) food code. The dining services director/cook will be responsible for food preparation techniques which minimizes the amount of time the food items are exposed to temperatures greater than 41 degrees Fahrenheit and less than 135 degrees Fahrenheit or per state regulation. Temperature control for safety (TCS) hot foods will be cooked to a minimum internal temperature for 15 seconds as follows: unpasteurized eggs at145 degrees Fahrenheit. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulation requires) for hot holding. Temperature for TCS foods will be recorded at the time of service and monitored periodically during meal service periods.

Based on observation, interview, and medical record review, the facility did not ensure the medication error rate was below 5 % for two (# 5 and #7) of two sampled residents who were administered medications. This resulted in 7 errors from 28 medication administration opportunities for a medication error rate of 25%. Findings Included: 1. On 05/30/22 at 8:00 a.m. a medication administration observation task was conducted alongside Staff member A, Registered Nurse as he prepared and administered the following medications to Resident #5: Aspirin 325 mg (milligrams), Calcium Carbonate 500 mg 2 tablets, Keppra tablet 1000 mg, Klor-Con tablet 10 meq (millequivalents) 2 tablets, Ascorbic acid 500 mg, Venlafaxine HCL 37.5 mg, Ferrous sulfate 325 mg, Folic acid 1 mg, Senna 8.6 mg, Vitamin D 10 mcg (micrograms), Lamictal 50 mg, Oxcarbazepine 300 mg 2 tablets, Topamax 200 mg, Tegretol XR 12-hour 100 mg, and Percocet oral 7.5 mg -325 mg. Staff A stated, the Prilosec capsule is not available; I only have the tablet. Review of Resident #5 Physician orders revealed calcium carbonate antacid oral tablet chewable 750 mg give 2 tablets by mouth two times a day for supplement dated 08/13/2023 that indicated the wrongs dosage was administered. Prilosec capsule delayed release 20 mg give 20 mg by mouth everyday related to gastroesophageal reflux disease dated 07/08/2021 was omitted. 2. On 05/30/2023 at 9:00 a.m. medication observation was conducted alongside Staff Member B, Licensed Practical Nurse as the following medications were prepared and administered to Resident #7: Amlodipine 5 mg, vitamin B12 500 mcg, Eliquis 5 mg, Fish oil 500 mg, Januvia 100 mg, Labetalol 200 mg, Lamotrigine ER 100 mg, Loratadine 10 mg, Lorazepam 0.5 mg, Methenamine 1 gram, Myrbetriq ER 50 mg, Omeprazole 20 mg, Seroquel 50 mg, and Sodium Chloride 1 gram. Staff B confirmed that was all of Resident #7 medications were provided except for her polyvinyl eye drop that was not available on the medication cart. Medical record review of Resident #7 Physician orders revealed Polyvinyl Alcohol Solution 1.4 % instill 2 drops in both eyes twice daily for dry eyes dated 05/11/2023 was omitted. Further review revealed: -Bisacodyl EC oral tablet delayed release give 100 mg by mouth one a day for constipation dated 05/18/2023 was omitted. -Vitamin D3 super strength oral tablet 50 mcg give 1 tablet by mouth once a day for supplement start date 04/17/2023 was omitted. -Ciprofloxacin HCL Ophthalmic solution 0.3% instill 2 drop in both eyes three times a day (TID) for Pink eyes for 5 days start date 05/26/2023 was omitted. -Insulin Glargine Solution Ten-injector 100 Unit/ml inject 15 unit subcutaneously twice a day related to Type 2 Diabetes Mellitus without complications start date 04/13/2023 was omitted. On 05/30/2023 at 10:20 a.m. an interview was conducted with Staff Member A, he was asked about Resident # 5 calcium carbonate he had administered that reflected a different ordered dosage. Staff A stated, Let me look at it and I'll be right back. Staff A did not return before the survey was concluded. On 05/30/2023 at 11:30 a.m. an interview was conducted with the Director of Nursing related to medication error and omissions. She confirmed medications should be given as ordered. Review of facility Polices and Procedure subject: Medication -Oral Administration Of Revision Date: 922/2017 Procedure: Obtain and verify physician's order. Verify Physician's Order Sheet with Medication Administration Record (MAR) if any uncertainties exist. Compare unit/dose medication on Medication Administration Record (MAR). Read label on the container THREE (3) TIMES: BEFORE REMOVING the drug from the container or card, before returning the drug to the med cart or disposing of the container; and BEFORE HANDLING the drug to the resident.

Based on observations, interviews and record review, the facility did not ensure an effective pest control program was in place related to insects, gnats, cockroaches, ants, and animal droppings observed in 14 resident rooms (#102, #104,#106, #111, #117,#116, #118, #212, #214, #215, #216, #226, #231, #229) and two (East and West) of two clean linen storage rooms during four of four days of survey for two wings (East and West) of two wings. Findings included: During a facility on 06/27/22 at 10:18 a.m., an observation was made of a large size insect, resembling a cockroach on the floor in Room #106. The winged insect was observed in the closet. On 06/27/22 at 10:41 a.m. an observation was made of a live cockroach on the bathroom floor in Room #111. An interview was conducted with Staff T, Housekeeping Aide. Staff T stated they have a problem with roaches. Staff T did not know when pest control last sprayed. Staff T stated he cleans out dead insects all the time. On 06/27/22 at 10:43 a.m. an observation was made of small gnat like insects flying around in Room 117. An interview was conducted with the resident in bed A. The resident stated the facility has a problem with gnats. The resident stated the gnats get in the food when she is eating. The resident stated she has to shoo away flies during meals. On 06/27/22 at 10:45 a.m. an observation was made of a cockroach in the bathroom in Room #116. In an interview with the resident in bed A, the resident stated she saw three roaches crawling around this morning. On 06/27/22 at 11:43 a.m. an interview was conducted with the resident in Room #118 in bed A. The resident said, The only problem I have is the roaches, or [MEDICATION(S)] bugs. They are always in my bathroom. On 06/28/22 at 12:46 p.m., an observation was made of a group of small two-winged gnat like flying insects in Room #106, an estimated count of 20 insects. The insects were flying on the floor, under the resident's bed and on top of the resident's bed. Resident #40 stated the gnats fly over her food. Resident #40 stated sometimes they drop in the food or drink, and she can't get them out. Resident #40 stated she keeps her drinks covered but her roommate is not able to do so. Resident #40 stated all the staff who come in the room have seen them. During the interview, a dead cockroach was observed on the floor in the closet. On 06/28/22 at 10:14 a.m. two dead insects were observed on the floor in the bathroom in Room #118. On 06/28/22 at 10:17 a.m. an observation was made of live gnat like insects on a commode with feces in the bathroom in Room #118. On 06/29/22 at 12:25 p.m. in Room #106 during lunch, an observation was made of a group of gnat like insects on the floor and flying around Resident #4's bed and lunch tray. An observation was made of the gnat like insects landing on the resident's lunch (a croissant sandwich). An observation was made of a dead roach on the floor in the closet. This was the third observation. The administration was immediately notified of the gnat like insects on the resident's plate. The Regional DON immediately came to the room and made the observation. The Regional DON said, This is not acceptable. The Regional DON stated they would get her another tray right away. On 06/30/22 at 9:45 a.m., an interview was conducted with Staff P, Housekeeping. Staff P stated he cleans the resident's rooms, and the expectation is for all rooms to be cleaned daily. Staff P stated sometimes they do not get around to cleaning all the rooms because there are only two housekeeping staff working. Staff P stated it is too much work for just the two, but they make it work. Staff P stated it is hard on the housekeeping staff and residents when the residents do not get their rooms cleaned per their standards. On 06/30/22 at 1:24 p.m., an observation of live gnat like insects and a dead cockroach was made in Room 106. This was the fourth observation. On 06/30/22 at 1:30 p.m., a live cockroach was observed in Room #116. Staff S, Certified Nursing Assistant (CNA) confirmed the observation. An interview was conducted on 06/30/22 at 1:32 p.m. with Staff S, CNA. Staff S stated she has seen the gnats, roaches, and [MEDICATION(S)] bugs around the facility. Staff S stated pest control comes out. Staff S did not know how often they were treated. On 06/30/22 at 1:50 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA toured Room #106 and observed the gnat like insects flying around the resident's bed, floors, and walls. The NHA stated pest control was out today and they are doing their best to clean. The NHA stated he will address the situation. On 06/30/22 at 3:28 p.m. an interview was conducted with the Director of Maintenance (DOM). The DOM stated he was aware the facility was having challenges with pests. The DOM stated all the rooms that were listed in their pest control book were treated today. The DOM said, As far as the gnats, I put a spray in the vents. That's where they are coming from. The roaches have been treated. They keep coming back. The DOM stated they are making sure housekeeping is cleaning, covering foods and throwing out open food that is old. A maintenance request dated 05/23/22 showed a licensed practical nurse (LPN) put in a work order for the East Wing, indicating the hallways and rooms were noted with cockroaches the size of hummingbirds fruit flies/ gnats throughout. 2. An observation of Room 231, on 6/27/22 at 10:57 a.m., identified dusty animal droppings along the length of the windowsill and in the window track. (Photographic Evidence Obtained) The DOM confirmed the findings and stated he did not think it was a rodent since the droppings were on the window and rodents did not climb glass. (Photographic Evidence Obtained) An observation was conducted on 6/27/22 at 11:25 a.m. of Room 229. The window area had dried pest droppings on the windowsill and in the window track. (Photographic Evidence Obtained) On 6/27/22 at 1:06 p.m. Staff A, Housekeeping Manager and the Housekeeping District Manager (DM) stated that rooms were cleaned daily including weekends. Staff A and the DM viewed photos taken of Room 231's windowsill. The DM asked the staff member, Didn't you identify this on Saturday? The staff member agreed she had seen the droppings on Saturday and she had identified it on the pest control log and the Nursing Home Administrator (NHA) had a pest control binder in his office, as well as the two binders on each unit. A review of the West Wing (200-hall) Pest Control log, obtained on 6/27/22 at 11:14 a.m., did not identify the droppings in Room 231 were reported on Saturday (June 25th). A review of the East Wing (100-hall) Pest Control log, obtained on 6/28/22 at 9:40 a.m., identified Staff A, Housekeeping Manager had logged at 11:30 a.m. an unreadable date, Potential Dropping in Room 232. On 6/28/22 at 9:31 a.m., an observation was made of a live cockroach on a door hinge of the double doors between Rooms 102 and 104. Staff H, Licensed Practical Nurse (LPN), confirmed the sighting and stated, Looks like a roach. Staff H moved away and reported not liking bugs and staff were supposed to put sightings in the pest control book. (Photographic Evidence Obtained) 3. On 06/27/2022 at 10:15 a.m. ants, small live lizards, and lizard droppings, as well as live and dead roaches were observed in the East Wing and West Wing storage rooms for clean linen. The observations were as follows: *East Wing: a dead roach and a live lizard with lizard droppings under the clean linen rack *West Wing: lizard droppings, roaches and ants some alive and some dead on floor next to boxes and filing cabinet. In addition, observations of resident rooms (#212, #214, #215, #216, and #226) revealed the following: *#212 - lizard droppings under air conditioning (a/c) unit, *#214 - dead ants on the windowsill and in the bathroom behind toilet, an under the resident's bed, *#215 - lizard dropping in the corner of the room and under a/c unit, *#216 - dead roaches in the right hand corner of the room behind the resident's bed, *#226 - live ants on the windowsill an under the a/c unit. On 06/27/2022 starting at 10:30 a.m. interviews with residents who resided in Rooms #214 and #216 stated their rooms are not kept clean or cleaned on a routine basis. The garbage is not emptied, and bathrooms are dirty and they have seen ants, little lizards, and roaches in their rooms and reported the pests to the nursing staff. On 06/27/2022 at 4:05 p.m. an interview was conducted with the DOM. He stated the facility should be pest free. Unfortunately, there are times that pests do fine their way in. We have pest control logs at each nursing station for the staff to write in when they observe any type of pest in the facility. I check the log every morning and see if anything was recorded. I would then go to the area and observe for myself. If there is any evidence of pests, I would call in the pest company to treat the affected areas. He stated the pest control company comes out once a month to treat unless there is activity, and then they are called to come and treat the building. He also stated he will speak to the Housekeeping department to make sure the housekeeping staff clean the rooms more accurately and remove all garbage and food from the rooms. A review of the Pest Control Log for the East Wing nursing station showed entries on: 06/25/2022 at 3:00 a.m. of roaches at the nursing station and resident rooms by staff; 06/27/2022 at 11:30 a.m. of potential droppings in room #232 by the Housekeeping Manager. There was no documented evidence that action had been taken. On 06/28/2022 at 10:59 a.m. a phone interview was conducted with a family member of Resident #302 who stated the facility was dirty and unsanitary. The family member stated (Resident 302's) room had an oversized hole in the wall, there was trash on the floor and live roaches were observed in the room. The family member stated the bathroom was disgusting, smelled like urine and it was all over the floor. The family member stated there was feces on the wall. The family member stated the bathroom had no soap in the dispenser or paper towels in the holder; the dresser was very dirty and broken. The family member spoke with the nurse (could not remember his name) regarding the condition of the room and told him that she was signing (Resident #302) out and taking her home. On 06/28/2022 at 2:45 p.m. an interview with Staff C, LPN was conducted related to the policy and procedure for reporting pests in the facility. Staff C stated if they see any kind of pest they are to record it in the pest log at the nurses' station. This is where the Maintenance Director (DOM) would look to see if there is any type of pest activity and take the corrective action. Staff C stated that over the past month there were gnats, and fruit flies on the unit (East Wing). He recorded it in the pest log and notified the Maintenance Director the same day he observed the pests. He also stated he heard about roaches and ants but did not observe them. A review of the Pest Control Log for the East Wing showed an entry on 03/02/2022 at 3:30 p.m. documenting gnats and fruit flies throughout each Wing and treated on 03/7/2022. A copy of the Pest Control Log for the East Wing was reviewed on 6/28/22 at 4:15 p.m. and revealed the listed pest sightings on the following dates with no action being recorded: 06/25/22 at 3:00 a.m., roaches Nurses Station and resident room (could not identify room number) 06/27/22 at 11:30 a.m., potential droppings room 232 06/28/22 at 07:41 (a.m.), roaches room 116 06/28/22 at 14:22 (2:22 p.m.), roaches room 131 06/28/22 at 14:22 (2:22 p.m.), roaches room 130 06/28/2022 at 14:22 (2:22 p.m.), roaches room 126. A copy of the Pest Control Log for the West Wing was reviewed on 6/28/22 at 4:15 p.m. and revealed the listed pest sightings on the following dates: 06/05/2022 at 12:00 p.m. ants, location 216 - on the patient!! Nursing + family; treated on 6/13/22, 06/10/2022 at 10:18 a.m. roaches in room 218 A; treated on 6/13/22 06/17/2022, no time, mosquitos in room 211; treated on 6/24/22 06/23/22 at 11:00 a.m., ants in rooms 225, 226 and back hall; treated on 6/24/22 06/24/2022 at 8:15 a.m., ants in room 226 by a/c unit; treated on 6/24/22. On 06/28/2022 at 4:50 p.m. an interview with the NHA was conducted. The NHA stated they try and do everything possible to keep them (pests) out. The facility has pest control logs at each nurses' station for employees to fill out when pests are sited. The Maintenance Director is responsible for checking those logs daily as well as calling the pest control company for additional treatments besides the facility's monthly treatment. He stated he has not seen any (pests) or been told that there is an issue. He also stated the pest company was here a couple of weeks ago. On 06/29/2022 at 4:00 p.m. an additional tour was conducted of resident rooms and Rooms #214 and #216 still had evidence, in the same location, of dead roaches, ants and lizard droppings on the floors and windowsills. In addition, an observation revealed the East Wing clean linen storage room still had dead roaches in the same location. On 06/30/2022 at 2:30 p.m. an interview with the Staff A, Housekeeping Manager was conducted. Staff A stated if they (housekeeping staff) see any type of pest they should notify the nurse on the unit and have it recorded. The staff will also let me know or tell the maintenance department directly. She confirmed she was informed, on a few occasions, of dead pests found in rooms but not anything recently. She confirmed she has noticed pests or evidence pests. She stated, I have and I spoke with the Maintenance Director with my concerns. Review of the policy and procedure titled, Pest Control, dated with an effective date of 11/30/2014, revealed the policy to read as: The facility will maintain a pest control program, which includes inspections, reporting and prevention. Procedure: 1. A pest control contract will be maintained with a licensed exterminator 2. The contract will include routine quarterly inspections 3. Treatment will be rendered as required to control insects and vermin 4. Any unusual occurrence of sightings should be report immediately to the Supervisor (see policy-Maintenance Repair Request Form) Proper action will be taken. (Photographic Evidence Obtained)

Based on observations, record reviews, and interviews, the facility failed to implement an effective Infection Control Program in response to COVID-19 as evidenced by: 1. two staff members (O, K) not doffing Personal Protective Equipment (PPE) and not wearing PPE appropriately in two of two COVID positive rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 2. not providing clean and sanitary water cups on a daily basis for three residents (#33, #35 and #407) and in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 3. one staff member (U) not performing hand hygiene during the passing of food trays on one unit (West) of two units; and 4. not maintaining a clean environment in the laundry area used to process facility linen and the residents' personal items with the potential to affect a census of 97 residents. Findings included: 1. On 6/27/22 at 12:15 p.m., an observation was made of Staff O, Restorative Aide, standing in the hallway outside of room [ROOM NUMBER], where a COVID-19 positive resident (#405) was residing. Staff O was observed doffing a blue isolation gown, placed it in an opaque trash bag and then began to walk toward the end of the hallway to the nursing station without performing hand hygiene. Staff O stated the gown should have been removed prior to exiting the room and hand hygiene was going to be done in the dirty utility room. A review of the Centers for Disease Control and Prevention (CDC) infection control guidelines for isolation titled, 2007 Guideline for Isolation Precautions Preventing Transmission of Infectious Agents in Healthcare Settings, last updated May 2022 instructed: Remove gown and perform hand hygiene before leaving the patient's environment. (accessed at https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html) On 6/28/22 at 10:02 a.m., an observation was made of Staff K, Housekeeper, standing near the first bed in room [ROOM NUMBER] sweeping. Posted on the door of room [ROOM NUMBER] was a sign that identified visitors, including staff, were to observe Droplet Precautions. Both residents in room [ROOM NUMBER] were COVID-19 positive. Staff K was observed in the room without wearing a gown, eye protection, or gloves. When leaving the room, the staff member placed the cleaning equipment on the housekeeping cart parked outside of the room and reported being educated on the use of PPE. Staff K acknowledged PPE should have been worn in room [ROOM NUMBER]. An interview was conducted at 10:08 a.m. on 6/28/22, with the Housekeeping District Manager who stated yes, the contracted staff had been educated on the use of PPE and should be wearing appropriate PPE while in a COVID positive room. Staff K, Housekeeper was observed, on 6/28/22 at 10:10 a.m., in a different hallway (Rooms 219 - 232). Staff K reported being re-educated on the use of PPE from the manager. The staff member stated he received no other advisements in response to contamination from being exposed to COVID positive residents. The Nursing Home Administrator reported on 6/28/22 at 10:18 a.m., the housekeeper (Staff K) who was observed in the COVID positive room was being sent home. A sign posted on the doors of room [ROOM NUMBER] and 218 instructed everyone to clean their hands before entering and when leaving the room, make sure their eyes, nose, and mouth are fully covered before room entry, or remove face protection before room exit. (Photographic Evidence Obtained.) The policy titled, Isolation - Categories of Transmission-Based Precautions, revised October 2018, indicated: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The Droplet Precautions section of the policy indicated masks would be worn, gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. 2. On 6/27/22 at 10:05 a.m., an observation indicated a foam cup sitting on the over-bed table of the second bed in room [ROOM NUMBER], the cup was dated 6/24. On Monday, 6/27/22 at 10:37 a.m., an observation identified a foam cup sitting on the over-bed table for the first bed of room [ROOM NUMBER], written on the cup was Friday. During the observation of room [ROOM NUMBER], the second bed was observed with a foam cup on the over-bed table with Jun 24, written on it. (Photographic Evidence Obtained). An observation was conducted on 6/27/22 at 3:29 p.m. of Resident #35's two drinking cups. One of the foam cups was dated 6/24. Staff V, Certified Nursing Assistant (CNA), confirmed the cups were from three days ago. On 6/28/22 at 2:17p.m., Resident #33 stated the night shift was supposed to change the water cups every night and they did last night but prior to that it was a couple of days, and before that the Resident's cup was dated 6/3, 21 days, it was disgusting. The resident reported the cup had backwash in it, the straws were dirty, and knew stuff was growing in it. A review of the Admission Record revealed, Resident #33 was admitted on [DATE] and a review of the Quarterly Comprehensive Assessment completed on 4/21/22, the Resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating the intact cognition. 3. An observation was conducted on 6/27/22 at 12:37 p.m., of one staff member passing lunch trays to the residents. The observation identified Staff U, CNA turn off the light in room [ROOM NUMBER], deliver a lunch tray to room [ROOM NUMBER] B-bed, and returned to the lunch cart and took another tray out and delivered it to the A-bed of room [ROOM NUMBER]. Staff U served coffee to the resident in room [ROOM NUMBER] B-bed, removed a tray from the lunch cart and delivered it to room [ROOM NUMBER] B-bed, took another tray to A-bed in room [ROOM NUMBER], removed a mechanical lift from room [ROOM NUMBER] then removed a tray from the lunch cart and placed it in room [ROOM NUMBER]. During this observation, that began at 12:37 p.m. on 6/27/22, Staff U, CNA did not perform hand hygiene. Staff U stated, on 6/27/22 at 12:55 p.m., yes, sanitizing and/or washing hands between residents while passing meal trays was supposed to be done and confirmed hand hygiene was not done. Staff U said, I forgot. 4. An observation on 6/28/22 at 2:50 p.m. was conducted with Staff M, Laundry Aide, of the laundry processing area. The staff member stated the shift worked was normally 2:30 p.m. - 9:30 p.m. but she often worked a double. Staff M stated two of the seven days a week that she didn't work the Housekeeping Manager did the laundry. The staff member stated she hadn't gotten a chance to clean the laundry room. The observation identified the outer casing of two of two washing machines were dusty, a matted substance was hanging from the air vent above and in front of the second washing machine, the air exchange filters on both washing machines were dusty, the blinds behind the washing machines had dust attached to them, and the water drain behind the washing machines had a tan-colored substance attached to the floor and walls and contained trash, which was also covered with the tan-colored substance. The laundry area processed both facility linens and resident personal items. On 6/30/22 at 3:35 p.m., the Maintenance Director reported he fixes and repairs the laundry equipment and was not given a policy for cleaning the equipment. He stated in all his other buildings housekeeping was supposed to clean the areas. If the water trap behind the washing machine becomes clogged, then they put in a work order for him to unclog it. During an interview on 6/30/22 starting at 1:55 p.m., the Infection Preventionist (IP) reported staff are trained in PPE use during the town hall meeting and return demonstration was not done. The facility just asks staff to tell them how it's done. If a break in infection control is observed the IP reported education was done at that time. She stated housekeeping was expected to adhere to transmission-based precautions. The IP stated the PPE requirement in COVID positive rooms were gowns, gloves, goggles/face shields, and a N95 mask and that staff were to doff PPE prior to leaving a COVID positive room. During this interview an observation was conducted with the IP of the laundry area. Staff M, Laundry Aide was folding clean laundry during the observation. The previous findings of the laundry room remain unchanged (dusty washers, dusty blinds, and dirty water drain) and the IP stated dust could fall into the clean laundry and the water drain/trap in the laundry room should be cleaned. The observation of the foam water cups were described to the IP, and she stated the cups should be changed daily. The policy titled, COVID-19 - Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified COVID-19 as a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). The plan indicated the following: - The facility should initiate transmission-based precautions per CDC including PPE - N95 or higher respirator, eye protection, gown, and gloves for a resident with suspected COVID-19. - Staff will be trained on the facility Pandemic COVID-19 plan and related policies and procedures - Staff will be re-trained in Hand Hygiene and proper use of PPE including competency . - Cleaning and disinfection for pandemic COVID-19 follows the general principles used daily in health care settings, per CDC guidance. On 06/27/2022 at 10:15 a.m. an observation of two resident rooms (room [ROOM NUMBER] Bed A, and room [ROOM NUMBER] Bed A) revealed white foam cups with water dated June 24th on the residents' bedside tables. In addition, a white foam cup with water dated June 24th was observed in Resident #407's room and she stated the water cups are never filled or outdated. (Photographic Evidence Obtained) The policy titled, COVID-19 - Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified COVID-19 as a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). The plan indicated the following: - The facility should initiate transmission based precautions per CDC including PPE - N95 or higher respirator, eye protection, gown, and gloves for a resident with suspected COVID-19. - Staff will be trained on the facility Pandemic COVID-19 plan and related policies and procedures - Staff will be re-trained in Hand Hygiene and proper use of PPE including competency . - Cleaning and disinfection for pandemic COVID-19 follows the general principles used daily in health care settings, per CDC guidance.

Based on observations, interviews, record review, and review of policies and procedures the facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring: 1. cleanliness of 10 resident rooms, (104, 116, 126, 130, 131, 201, 214, 216, 226, 231) were free from dried food, spilled liquids on the floors, buildup of dust, dirt, and debris found under resident beds, broken furniture, 2. air conditioning units were free from bio-growth, dust and debris or leaking water for seven resident rooms (#106, #108 #110 #114, #231, #221, #220), 3. five ceiling vents in the kitchen were free from bio growth dust and debris, 4. two residents (#58 and #33) and in addition one resident room (#227) had sufficient clean bedding or linen. The failed to provide a safe, clean, comfortable, and homelike environment affected two wings (East and West) of two wings for four of four days of survey. Findings included: 1. On 06/27/2022 at 10:30 a.m. the following observations of resident rooms #104, #116, #126, #130, #131, #201, #214, #216, and #226 revealed: * #104 - dust and debris under the resident's bed (B), * #116 - the floor had dark brown in color stains and debris under the resident's bed (A), * #126 - dust and food particles were under the resident's bed and at side of the bed (A), * #130 - dust and debris under the resident's bed (B) and behind bedside table, * #131 - white tissues and debris alongside of the resident's bed (A) next to the wall, * #201 - dust and debris under the resident's bed (B), yellow in color stain on the floor in front of bed, * #214 (A & B)- dirt and dust under the resident's bed, brown substance on the floor next too and under the bed appeared dried and smeared, also a pale orange in color puddle of liquid dried, but also appeared to have a wet look, * #216 - empty cup and dirt under the resident's bed (A ), * #226, food particles on the floor next to and under the resident's bed. On 06/27/2022 starting at 10:30 a.m. interviews with residents who resided in rooms 214 and 216 stated their rooms are not kept clean or cleaned on a routine basis. The garbage is not emptied, and bathrooms are dirty and they have seen ants, little lizards, and roaches in their rooms and reported the pests to the nursing staff. On 06/27/2022 at 4:05 p.m. an interview was conducted with the Director of Maintenance (DOM). He stated that he will speak to and follow-up with the housekeeping department to make sure the housekeeping staff are cleaning the rooms more accurately and remove all garbage and food from the rooms. On 06/28/2022 at 9:45 a.m. an additional tour of resident rooms #104, #116, #126, #130, #131, #201, #214, #216, and #226 revealed: * #104 - dust still under the resident's bed, * #116 - stain still under the bed, * #126 - dust still under the bed, * #130 - dust still under the bed, * #131 - debris still under the bed, * #201 - stain still in front of the bed, * #214 (A & B)- dirt and dust under the resident's bed, brown substance on the floor next too and under the bed appeared dried and smeared, also a pale orange in color puddle of liquid dried, but also appeared to have a wet look, * #216 - room was not cleaned, observed empty cup and dirt still there, * #226 - floor was still dirty and not mopped. On 06/28/2022 at 10:59 a.m. a phone interview was conducted with a family member of Resident #302 who stated the facility was dirty and unsanitary. The family member stated (Resident 302's) room had an oversized hole in the wall, there was trash on the floor and live roaches were observed in the room. The family member stated the bathroom was disgusting, smelled like urine and it was all over the floor. The family member stated there was feces on the wall. The family member stated the bathroom had no soap in the dispenser or paper towels in the holder; the dresser was very dirty and broken. The family member spoke with the nurse (could not remember his name) regarding the condition of the room and told him that she was signing (Resident #302) out and taking her home. On 06/28/2022 at 4:50 p.m. an interview with the Nursing Home Administrator (NHA) was conducted related to the NHA's expectation of cleaning the residents' rooms. The NHA stated, yes, it is obvious that we have issues with accomplishing those tasks, and we could do a lot better; but the company that is contracted for housekeeping cannot find sufficient help to staff the building. The NHA stated the housekeeping policies and procedures are those of the management company not of the facility company. The NHA stated he has addressed the concern with their management. On 06/30/2022 at 8:04 a.m. an interview was conducted with Staff A, Housekeeping Manager and Staff B, Housekeeping Area Manager. Staff A and B both stated they are short staffed and are doing the best job they can. Staff A stated she is well aware of how the building is looking and they are trying to keep on top of things. The employees are working hard and extra days to get it completed but just can't get to all of it at once. She stated the staff, as far as she knows is properly trained but has not been able to do a proper training with the current staff, since arriving at the facility. Staff A confirmed they are to clean every room during a shift and stated, we do try, but I know that we do miss rooms and then they fall behind. On 06/30/2022 at 10:00 a.m. a follow-up interview with the NHA was conducted. He stated that yes, the building needs a lot more attention, although it is cleaner than it has been, and the staff are trying and working to get it completed. He also stated he has come in at night and on weekends to assist the staff with routine cleaning, washing, and waxing of floors and has done resident room deep cleans. 06/30/2022 at 2:45 p.m. an interview with the District Manager for the housekeeping contract management company apologized for the way the building was presented during survey. He stated they are short staffed and doing the best with what they have. A review of the housekeeping contract management company document agreement with the facility revealed under Article II Responsibilities and Duties of Housekeeping Company: (2.1) Laundry and Housekeeping Responsibilities (a) Housekeeping Company will establish laundry and housekeeping policies, philosophies and objectives to provide the Client with laundry and housekeeping services that meet all of the Clients legal, regulatory and professional obligations with respect to the services being performed by Housekeeping Company hereunder for Housekeeping Company 's scope of work. (b) Housekeeping Company will, during the term of this agreement, provide laundry and housekeeping services in a manner reasonably consistent with the policies and procedures established pursuant to section 2.1(a) and all legal, regulatory and professional requirements governing their scope of work. Such laundry services shall also include customary services for personal clothing for resident of client. (c) All laundry and housekeeping services shall be provided by employees of Housekeeping Company and will provide on site at Clients facility. Housekeeping Company will also provide local supervisor as well as a district manager to oversee operations and ensure quality control and compliance with the obligations under this Agreement. (d) If client's agents identify any violation of this agreement, including performance that may subject Client to citations or tags by the regulatory agencies, Housekeeping Company shall correct the issue to the reasonable satisfaction of Client. (Photographic Evidence Obtained) 2. During a tour of the East Wing on 06/27/22 at 10:20 a.m., Room #106 was observed with towels on the floor collecting water that was dripping from the air conditioning (A/C) unit. An interview was conducted with both residents residing in that room. The residents stated the issue has been on-going and the unit has not functioned properly for a period of three months. An interview was conducted on 06/27/22 at11:30 a.m. with Staff K, Housekeeping Aide. Staff K was observed cleaning Room #106. Staff K confirmed the A/C has been leaking for quite some time and the Director of Maintenance is aware. Staff K stated he does not change the wet towels on the floor. Staff K said he thought it had been a month or so. An interview was conducted on 06/27/22 at 12:40 p.m. with Staff Q, Certified Nursing Assistant (CNA). Staff Q stated the A/C has not been working for three months. Staff Q stated, It has been leaking, they put towels on the floor all the time. Staff Q stated she had not heard anything about its repairs or why it is leaking. Staff Q stated she works often with the residents in Room #106 and they had not asked her to turn it down. On 06/27/22 at 2:55 p.m., an interview was conducted with Staff R, CNA. Staff R confirmed the A/C has been leaking for quite some time. Staff R said, I have seen the towels on the floor. They are there because the A/C is leaking. Staff R did not know exactly how long this had been going. An interview was conducted on 06/27/22 at 3:07 p.m. with Staff L, Registered Nurse (RN)/Unit Manager. Staff L stated the A/C has had a problem for a while, about 2- 3 months. Staff R does not know what they are doing to fix it. Staff R stated he had reported it to the DOM. A follow -up interview was conducted on 06/27/22 at 3:22 p.m. with the NHA. The NHA stated the unit has had problems since April or May. The NHA stated a replacement unit was ordered and that it was on back order. The NHA stated they are waiting on a replacement. The NHA stated he offered the residents to move to a different room, but they have refused to move. On 06/27/22 at 3:26 p.m. an interview was conducted with Resident #40, Resident #40 stated to the NHA, You never offered us to move out of the room. We could have moved. Resident #40 stated the only request they made was to be moved together. Resident #40 stated they have been roommates for a while and did not want to be separated. On 06/27/22 at 4:15 p.m., an interview was conducted with the DOM. The DOM stated he had installed a new A/C unit in March. The DOM stated the unit was working fine but early May he was notified it was leaking. The DOM stated he thought it was leaking because the residents were setting the unit below 64 degrees causing it to freeze and, hence leaking. The DOM stated he had educated the residents. When asked how residents who cannot get out of bed without staff assistance would have adjusted the unit, the DOM stated maybe staff do it for them. In a follow- up interview with the NHA on 06/27/22 at 4:25 p.m., the NHA stated the problem was the residents were asking staff to turn the A/C below what is required and the staff were honoring the residents' request. The NHA stated they had educated the residents and the staff not to lower the A/C below 64 degrees. The NHA stated the residents were okay. An immediate tour of Room #106 was conducted with the NHA. Observation was made of dirty, wet towels on the floor and water under the resident's bed. The NHA agreed it was not an acceptable standard of living. During subsequent tours on 06/28/22 at 12:46 p.m., and 06/29/22 at 12:36 p.m. observations revealed Room #106 was noted with a water on the floor by window bed and under the resident's bed and the A/C units in Rooms #108, #110 and #114 were observed with bio growth, debris and dust build up. On 06/30/22 at 1:24 p.m., observations were made of Room #106 with water all over the floor and A/C leaking under the resident's bed. The A/C units with bio growth were observed in Rooms #108, #110, and #114. On 06/30/22 at 9:45 a.m., an interview was conducted with Staff P, Housekeeping. Staff P stated he cleans the resident rooms, and the expectation is for all rooms to be cleaned daily. Staff P stated sometimes they do not get around to cleaning all the rooms because there are only two housekeeping staff working. Staff P stated it is too much work for just the two, but they make it work. Staff P stated it is hard on the housekeeping staff and residents when the residents do not get their rooms cleaned per their standards. On 06/30/22 at 1:50 p.m., a follow -up tour of Room #106 was conducted with the NHA. The NHA stated they are trying to fix the A/C problem. Resident #40 stated the unit was still leaking and no one had adjusted it all week. During the tour, a water puddle was noted on the floor. The NHA stated he will address the situation. 3. On 06/29/22 at 11:34 a.m., a tour of the kitchen was conducted. The ceiling vents in the kitchen service areas were noted with bio growth, dust, and debris. A total of five vents were noted. An immediate interview was conducted with the Certified Dietary Manager (CDM). The CDM stated the maintenance department is responsible for cleaning the vents. The CDM said, They should have done it. The Dietary District Manager stated she had notified them. The Dietary Manager stated they should have cleaned them. The CDM stated, Can see how debris could fall on the food. On 06/30/22 at 3:28 p.m. an interview was conducted with the DOM. The DOM stated he was the only maintenance personnel in his department. The DOM stated this was why it is hard to keep up with everything. The DOM reviewed the A/C units that were identified with dirt, dust, and bio-growth during four of four days of survey. The DOM stated, they are not supposed to look like that. The DOM said, That does not look good. It is not good for the residents. The DOM stated about a month ago they hired an outside company to come and clean the A/C units. The DOM stated he was told they were coming, but they had not been there yet. The DOM stated he reviews work orders in the morning. The DOM said, I review them. I clean one unit here and there as I go. I am supposed to fix everything. I am one person. The DOM stated he was responsible for maintaining the vents in the kitchen. The DOM stated he was responsible for all repairs and cleaning in the entire facility. The DOM stated he was notified of dirty vents in the kitchen and laundry, and he has not gotten to them. The DOM stated the A/C in Room #106 was still frozen and he had used a shop vac and sucked water out. The DOM stated he had asked housekeeping to keep mopping the water up. Review of a maintenance request dated 03/08/22 showed the DOM was notified the A/C was not working in Room #106 and that a replacement was made. Maintenance requests dated 05/03/22 and 06/13/22 showed documented concerns with the A/C leaking. Completed work notes showed residents were educated. There was no documented evidence of training provided to staff related to adjusting the temperature in the room. 4. An observation was made of room 231,on 6/27/22 at 10:57 a.m., where two residents were residing. The observation identified there was dusty pest droppings along the entire length with dust in the window tracks and along the window frame. On the floor of Room 231, in the corner behind the second bed was dirt/sand from the baseboard. The Packaged Terminal Air Conditioner (PTAC) unit under the window of Room 231 had a black bio-growth substance and other substances on the outside vent. The bathroom of Room 231, the toilet was running continuously, a plunger was observed in the corner under the sink, a water basin was on the floor between the toilet and wall, and dust was hanging from the vent on the room's ceiling. (Photographic Evidence Obtained) An observation was conducted on 6/27/22 at 11:25 a.m. of Room #229. The windowsill in the room had crumbs of some substance along the edge and the window had a dried substance on it. (Photographic Evidence Obtained) On 6/27/22 at 1:06 p.m., Staff A, Housekeeping Manager and the Housekeeping District Manager stated resident rooms are cleaned daily including weekends. The District Manager stated that during a tour it was noted the floors on the West Wing were dirty. He observed the toilet was leaking and continued to run in Room #231 and stated that housekeeping staff should have reported it. Both the District Manager and Staff A observed the outside of the PTAC unit and Staff A stated maintenance took off the front and cleans the inside and confirmed that housekeepers should be cleaning the outside of the unit, and that it was apparent it had not been done. The Housekeeping Manager stated that staff have one form (at the nursing station) to complete for maintenance. On 6/27/22 at 11:31 a.m., an observation was conducted of resident room #226. The observation indicated an unpackaged 60 milliliter syringe lying on the floor under and behind the bed next to the window. An observation of the windowsill area identified dusty cobwebs on the window, in the window track, and in the corner of the windowsill. An observation was made on 6/27/22 at 11:32 a.m. of resident room #221. The observation identified a black substance attached to the outside of the PTAC units vent and a brown wet-looking substance on and inside the bathrooms trash bin. On 6/27/22 at 11:35 a.m., an observation was conducted in resident room #220. The observation identified the PTAC unit was dirty and dusty. The corner of the room, behind bed that was near the window, indicated pest droppings attached to the wall. (Photographic Evidence Obtained) Resident #58, after lunch on 6/27/22, was observed lying on top of a blue mattress and under a knitted blanket with no sheets or pillowcases on the bed. On 6/28/22 at 2:10 p.m., an observation was made with Staff N, CNA of the first bed inside Room #227. The bed had no linen on the bed including pillowcases. The staff member stated the resident in room #227 probably got up and there was not enough (linen) to make the bed. The staff member reported they (facility) do run out of linens sometimes. On 6/28/22 at 2:17 p.m. Resident #33 stated, It's crazy. Resident #33 reported a couple of weeks ago at 10:40 a.m. (I'm good with time) the facility did not have any linen on the floor and another time her CNA came into the room to provide incontinence care at 7:20 a.m. and was not able to since there was no linen on the wing. The resident reported the facility lacks linen very frequent. A review of the medical record revealed Resident #33 was admitted on [DATE]. Review of the Quarterly Comprehensive Assessment completed on 4/21/22, showed the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating intact cognition. On 6/28/22 at 2:50 p.m., Staff M, Laundry Aide stated that normally she worked 2:30 - 9:30 p.m., but often worked doubles. She stated the facility called her in at 9:30 a.m. because the Housekeeping Manager (Staff A) had to go the floor. The staff member reported the linen (situation) could be better. Staff M reported that floor staff throw away linens as the laundry aide has received bags of dirty briefs and trash in the laundry bins. So she knows that staff get confused and threw away the linens. Staff M stated that each wing received a max of 40 towels per shift and the 3:00 p.m. -11:00 p.m. shift today was only going to get 30 towels because the 7:00 a.m. - 3:00 p.m. shift kept coming in and taking them.

Based on observations, record reviews, and interviews the facility failed to implement interventions identified in the comprehensive person-centered care plan for two residents (#35 and #296) related to falls and the refusal of care of a total sample of forty-seven residents. Findings included: 1. A review of the Admission Record revealed Resident #35 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. During an interview with Resident #35, on 6/27/22 at 3:34 p.m., the resident's bed was hip-high. The resident reported going to the hospital due to sliding out of bed. The resident has the bed controller in reach and can move the bed up and down. Resident #35 reported not knowing how high the bed was and did not want the bed that high, and thought the bed was in a low position. On 6/28/22 at 8:43 a.m., an observation was conducted with Staff C, Licensed Practical Nurse (LPN) of Resident #35. The resident's bed was in a hip-high position, near the height of the room's windowsill. Staff C did not advise the resident in lowering the position of the bed. An observation on 6/29/22 at 12:00 p.m., identified Resident #35's bed was in a hip-high position. The resident reported not having a bed height preference. A review of Resident #35's Order Summary Report as of 6/30/22 indicated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident #35 identified a focus as the resident had an actual fall 5/17/22 and the intervention initiated on 5/18/22 indicated the resident should have the Bed in low position. During an interview and observation on 6/29/22 at 3:25 p.m. with Staff G, Unit Manager/Registered Nurse (UM/RN), Resident #35's bed was observed as being in a higher than hip height. The UM stated the resident was able to adjust the height of the bed and the resident was not a fall risk but did have a fall in May (2022). Staff G stated if a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G indicated Resident #35 fell out of bed due to reaching for items on her over-bed table. 2. A review of the Admission Record showed Resident #296 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS), dated [DATE], identified a BIMS score of 6 out of 15, indicating a severe cognitive impairment. The medical record of the resident contained a Physician's Evaluations of Resident's Capacity To Make Health Care Decisions Or Provide Informed Consent, signed by an Attending and Consulting Physician on 5/9/16 an indicated the resident was incapacitated. A care plan for Resident #296, initiated on 8/20/20 and cancelled on 1/3/22, indicated the resident was resistive to care: refusing meds (medications), labs, care, turning and repositioning, shower, is verbally and physically abusive with staff providing care, and confabulation of stories. The intervention, dated 12/2/20, identified if resident was refusing care/shower staff should contact family member, who was also designated as the resident's Health Care Proxy (HCP). A progress note, dated 12/22/21 at 3:45 p.m., read Resident #296 had mobility issues when out of bed and stated, hip hurts. The note identified a mobile x-ray was ordered for mobility issues. A progress note, dated 12/23/21 at 11:53 a.m., indicated Resident #296 refused xray and a stat x-ray was reordered due to complaints of pain and the resident reported a fall. The progress notes between 12/22/21 at 3:45 p.m. and 12/23/21 at 11:53 a.m., did not identify the family member was notified of either x-ray, the reported fall, or that staff had attempted to contact the family member after Resident #296 had refused the first attempted x-ray as the care plan instructed staff. A Change in Condition (SBAR [Situation-Background-Assessment-Recommendation]), effective 12/23/21 at 3:45 p.m., indicated X-ray results were positive for acute fracture of right femur and complaints of pain which started on 12/22/21. The SBAR indicated the HCP was notified of the situation at 3:45 p.m. on 12/23/21. The policy titled, Plans of Care, effective 11/30/14 and revised 9/25/17, indicated an individualized person-centered plan of care will be established by the interdisciplinary (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The policy identified the following: - Review, update and/or revise the comprehensive plan of care based on changing goals, preferences, and needs of the resident. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. - The Individualized Person Centered plan of care may include but is not limited to the following: - Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals.

Based on observations, record reviews, and interviews the facility failed to assess three residents (#408, #19, and #12) out of 97 admitted residents for self-administration of medications related to the medications left at the bedside. Findings included: 1. An observation was made on 6/27/22 at 10:23 a.m. of a medication cup on the over-bed table of Resident #408. The cup contained a white round tablet imprinted with 12, one oval pill imprinted with 125, and a white capsule printed with IP 101. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed the medication was left at bedside for Resident #408. The ADON/IP stated she did not know when they had been administered and the resident had not received any medications from her and she had yet to be in the resident's room that day. The Admission Record revealed Resident #408 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #408's medical record indicated that it did not include a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission/Readmission Data Collection, effective 6/19/22 at 4:00 p.m., identified the resident's primary language was sign language, the resident had been alert to person and place, and did not self-administer medications. The medical record did not indicate Resident #408 had been assessed for the self-administration of medications. 2. An observation was made on 6/27/22 at 10:56 a.m., of a medication cup on the over-bed table of Resident #19. The medication cup contained a small peach-colored tablet (Photographic Evidence Obtained). Staff H, Licensed Practical Nurse (LPN) confirmed the findings and stated she had not given the resident any medications yet. The Admission Record revealed Resident #19 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) for the resident, dated 4/4/22, identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition. A review of Resident #19's Order Summary Report, active as of 6/29/22, identified Resident #19 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission/Readmission Data Collection, effective 9/28/20, indicated Resident #19 was alert and oriented to person, place, and time. The data collection identified the resident did not self-administer medications. 3. An observation was made on 6/27/22 at 4:32 p.m. of a [MEDICATION(S)] inhaler lying on top of Resident #12's over-bed table. The table had water marks, remnants of food, and other personal and food items. Resident #12 stated it was her emergency inhaler. The resident stated staff put liquid in the machine (nebulizer) and she takes it off (when finished). (Photographic Evidence Obtained) An observation was made on 6/28/22 at 2:25 p.m. of two [MEDICATION(S)] inhalers lying on top of Resident #12's over-bed table. The table remained to have water marks, remnants of food, and other personal items. Resident #12 was not in the room however the roommate was. (Photographic Evidence Obtained) An observation was made on 6/29/22 at 3:22 p.m. with Staff G, Unit Manager/Registered Nurse (UM/RN) of Resident #12's room. The staff member confirmed the presence of one [MEDICATION(S)] inhaler on the over-bed table. The UM removed the inhaler from the room and confirmed Resident #12 had not been assessed for self-administration of medication. (Photographic Evidence Obtained) A review of Resident #12's Order Summary Report, active as of 6/29/22 at 4:18 p.m., did not include a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission/Readmission Data Collection, effective 4/12/22, indicated the resident was alert and oriented to person, place, and time. The data collection identified the resident did not self-administer medications. A review of Resident #12's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Aerosol 160-4.5 microgram (mcg)/actuation (act) - 2 puff inhale orally twice daily for respiratory therapy. This order started on 4/12/22 and was discontinued on 6/29/22 at 4:31 p.m., one hour after the observation was made with Staff G of a [MEDICATION(S)] inhaler lying on the resident's over-bed table. - Pending Confirmation [MEDICATION(S)] Aerosol 160-4.5 mcg/act - 2 puff inhale orally twice daily for respiratory therapy. May self-administer. This order was to start on 6/30/22 at 7:00 a.m. The facility provided an Evaluation for Self-Administration of Medications, effective 6/29/22 at 3:58 p.m., (thirty-six minutes after the observation with Staff G) for Resident #12. The evaluation identified the medication to be self-administered was inhaler, and did not identify the actual medication that was to be self-administered. The instructions for the evaluation indicated Medications will be administered by nursing staff until this decision is made by the Care Plan Team. Section II of the evaluation identified the routes of medication to be self-administered was oral, in which inhalant was an available route option and not chosen. On 6/29/22 at 3:25 p.m., Staff G, UM/RN reported residents are assessed for self-administration of medications, then the medications allowed to be administered are put in a locked box with an as needed medication log. Staff G, UM/RN identified one resident was allowed to self-administer medications on the West Wing (where Residents #408, #19, and #12 resided) and the identified resident was not one of the residents (#408, #19, and #12)observed with medications left at the bedside. An interview was conducted, on 6/29/22 at 4:00 p.m., with the Director of Nursing (DON) and a Regional Director of Nursing (RDON). The DON identified neither Resident #408, #19, and/or #12 had been assessed for self-administration of medications. The DON identified the same resident Staff G, UM/RN had earlier identified as the only resident in the facility that had been assessed for the self-administration of medications. The DON stated residents were assessed for self-administering of medications, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy titled, Residents Self-Administrated Medication Procedure, effective 11/30/14, indicated: To offer every resident a life full of independence and freedom, residents who have the cognitive and physical ability to take their own medications are encouraged to do so. A resident who takes his or her own medications must be evaluated by his or her physician to be certain it is acceptable and safe arrangement.