Every finding on record at Roberta Trails of Journey LLC

Based on observations, interviews and review of policy titled, Medication Administration, the facility failed to ensure that the narcotics count was documented at the beginning of each shift on three of three medications carts (Hall 1 cart, Hall 2 cart and Hall 3 cart). The deficient practice increased the risk of inaccurate accountability of controlled substances and increased risk of diversion or unauthorized use.Findings include:Review of policy titled, Medication Administration dated 02/01/2024 and revised 02/14/2026 documented under the section, Policy Explanation and Compliance Guidelines number 18 that, If medication is a controlled substance, sign narcotic book. Review of the Narcotic Sheet Count forms, located in the controlled medication count binders on the medication carts for Hall 1, Hall 2 and Hall 3, dated 08/01/2026 - 08/12/2026 documented missing signatures for shift change controlled medication count for the dates of 08/01/2026, 08/02/2026, 08/03/2026, 08/04/2026, 08/05/2026, 08/06/2026, and 08/10/2026. The review revealed there were 20 missing signatures verifying the controlled substances for the cart were counted and that the count was correct.During interview on 08/12/2026 at 4:30 PM, Licensed Practical Nurse (LPN) CC confirmed and verified the missing nurse signatures from the shift narcotic count sheet on her assigned cart binder for Hall 1. During interview conducted on 08/12/2026 at 4:43 PM, with the Director of Nursing (DON) she confirmed and verified that the nurses narcotic shift count sheets for August 2026 had 20 signatures missing across three medication carts. The DON further stated that her expectations were for the nurses to complete the narcotic shift count sheets including the nurse's signature and the card count at the beginning of each shift.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Medication Orders, the facility failed to transcribe a physician order following an approved psychoactive medication gradual dose reduction (GDR) recommendation for one of five residents (R) (R16) reviewed for unnecessary medications. This deficient practice had the potential to contribute unnecessary medication side effects and chemical restraint for R16.Findings include:Review of the facility policy titled, Medication Orders reviewed on February 14, 2024, documented in sections 4: .c: Enter the order on the medication order and receipt record. d: If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and facility policy. E: Call or fax the medication order to the pharmacy provider. F: Transcribe newly prescribed medications on the MAR {medication administration record} or treatment record or ensure the order is in the electronic MAR. G: When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by writing DC' d {discontinued} and the date, or discontinue the order as per the electronic software instructions and retype the new order. H: Enter the new order on the MAR or ensure the new order is in the electronic MAR. I: Notify resident's sponsor/family of new medication order.Review of the electronic medical record (EMR) revealed R16 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, Rheumatoid arthritis (RA), speech disturbances, major depressive disorder, abnormalities of gait, and age-related osteoporosis.Review of the annual Minimum Data Set (MDS) assessment for R16 dated 06/05/2026, revealed that Section C coded R16 was rarely/never understood and therefore a Brief Interview for Mental Status was not indicated. In addition, section D interview was not conducted because R16 was rarely/never understood, section E was not coded for hallucinations or behaviors, and section N was coded for antidepressants. Review of care plan for R16 dated 07/27/2026, documented a problem for, receives psychotropic medication r/t {related to} depression, chronic pain and documented interventions included, but were not limited to, Consult with pharmacy, MD {medical doctor} to consider dosage reduction when clinically appropriate.Interventions- Administer medications as ordered. Observe and document side effects and effectiveness. Consult with pharmacy and MD to consider dosage reduction when clinically appropriate. Observe target behaviors, document as needed. Review of the active Physician's Orders for R16 included, but was not limited to:Order dated for 10/09/2024: mirtazapine 45 mg {milligrams}, one tab at bedtime for depression.Order dated 06/26/2025: bupropion HCL {hydrochloride} 150 mg, one tab daily for depression.Review of a consultation report from the pharmacy for a GDR dated 06/12/2026, documented a recommended reduction for bupropion ER {extended release} to 75mg from 150mg daily and decreasing mirtazapine to 30mg from 45mg daily. The Mental Health Nurse Practitioner (NP) provider approved the reduction for the mirtazapine recommendation on 07/11/2026. Review of the electronic Medication Administration Record (eMAR) for the month of August, as of 08/11/2026, documented that the resident was still receiving mirtazapine 45mg at bedtime.An interview with Licensed Practical Nurse (LPN) CC on 08/12/2026 at 9:40 AM revealed that if the provider wrote a paper order, staff faxed it to the pharmacy, and the provider usually entered the order in the EMR.An interview with Registered Nurse (RN) FF on 08/12/2026 at 9:55 AM revealed that she was a unit manager, and processed GDR recommendations by transcribing approved orders. RN FF stated that usually the provider placed the paper order in a pocket on the wall at the nurse's station that was designated for the unit manager. RN FF stated she entered the order into the EMR and faxed the order to the pharmacy, so they would send the medication to the facility. She stated, I'm not sure how it was missed; it may have been put in the wrong place. RN FF stated the provider was the Mental Health NP, so she may not have known the process.An interview with the Director of Nursing (DON) on 08/13/2026 at 10:10 AM confirmed that she expected the Mental Health providers and the Medical team to address the recommendations for GDRs from the pharmacy within 10 days. The DON stated the Mental Health provider did not address the GDR for a month and did not enter the order into the EMR. She stated that all providers were supposed to enter their own orders in the EMR unless they gave a phone order.

Based on observations, interviews and review of policies titled Medication Storage, Medication Administration, and manufacturers package insert titled, Latanoprost Ophthalmic Solution: Package Insert/Prescribing Information, the facility failed to ensure that medications were stored properly on one of three medication carts (Hall 1 Cart). Specifically, the facility failed to ensure two containers of ophthalmic solutions were labeled when opened and one container of ophthalmic solution was used outside of the use by date. The deficient practice had the potential to affect the efficacy of the medications.Findings include:Review of policy titled, Medication Storage dated [DATE] and revised [DATE] documented the facility's policy was to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers recommendations .A review of the manufacturers package insert for Latanoprost Ophthalmic Solution, last updated [DATE], revealed under number 16, How Supplied/Storage and Handling Latanoprost Ophthalmic solutions once a bottle is opened for use, it may be stored at room temperature up to 25 C (Celsius) (77 F) for six weeks (42 days).Observation of Hall 1 Cart on [DATE] at 3:56 PM, revealed two bottles of ophthalmic solutions that were not labeled when opened and one bottle that was expired.1. Timolol maleate 0.5 percent eye drops that were opened without an open date documented. 2. Timolol maleate 0.5 percent eye drops that were opened without an open date documented. 3. Latanoprost 0.005 percent Eyedrops with an open date of [DATE] documented, which should have been used by [DATE]. During interview on [DATE] at 4:30 PM, Licensed Practical Nurse (LPN) CC verified that no open date was documented on the two bottles of Timolol maleate and the date recorded as opened on the Latanoprost was [DATE]. She confirmed this should have been discarded.During interview on [DATE] at 4:43 PM, with the Director of Nursing (DON), she stated her expectations were that the nurses document the open date on multidose medications and if the multidose medication is found to be opened without an open date documented, the medication should be pulled and reordered

Based on staff interviews, record review, and a review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from abuse for one of 39 sampled residents (R) (R66), by a staff member. The deficient practice had the potential to affect resident psychosocial health and safety. Findings include:Review of the facility's policy titled, Abuse, Neglect, and Exploitation last revised 03/05/2026, documented on page 1: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R66's Brief Interview for Mental Status (BIMS) score was not conducted as R66 was never/rarely understood.Record review of the Electronic Health Record (EHR) revealed R66 was initially admitted to the facility on [DATE] with diagnoses of, but not limited to, schizoaffective disorder, bipolar type and neurocognitive disorder with Lewy bodies.Review of Facility Reported Incident (FRI) dated 08/19/2025 revealed an incident of physical abuse occurred between R66 and a staff member on 08/19/2025. Further review revealed the report was filed within the two-hour regulated time period, the staff member was immediately terminated, and a thorough investigation was completed by the facility.Interview on 08/13/2026 at 2:10 PM with the Director of Nursing (DON), Administrator, and Regional [NAME] President of Clinical Services (RVPCS) JJ, revealed the following: the DON stated she was notified a resident to staff incident occurred on 08/19/2025 and confirmed the incident between the resident and staff member did occur. She stated the staff member was immediately asked to leave the facility, and law enforcement was notified. The DON notified the Responsible Party (RP), Administrator, and Medical Director (MD) and R66 was sent out for further evaluation due to the resident refusing skin assessments and neurological checks. The DON stated R66 returned the same day and there were no injuries or other concerns relayed by the hospital. She stated R66 was placed on one-to-one supervision once he returned to the facility to ensure he was okay. The Administrator stated resident interviews and skin assessments were conducted with other residents, and in-service training was provided to all staff in the facility.Interview on 08/13/2026 at 4:44 PM with the Administrator revealed she expected the facility staff to follow the abuse policy and ensure residents remain free from abuse.

Based on interview, record review, and review of the facility policy titled, Discharge Planning Process, reviewed 3/20/25, the facility failed to document a recapitulation of stay for one of 19 sampled residents (R62). The deficient practice increased the risk of insufficient and/or omitted care requirements with the receiving facility for R62.Findings include:Review of the electronic medical record (EMR) for R62 revealed there was only an incomplete face sheet and a Discharge Minimum Data Set (MDS) assessment, dated 07/16/2026, which was the day he was admitted to the facility and then transferred to another unnamed skilled nursing facility (SNF). There were no progress notes, admission assessments, notifications to the physician and responsible parties, or a recapitulation of stay documented.Review of the Discharge MDS assessment, dated 07/16/2026, revealed the following:Section A: unplanned discharge to another SNF/no return anticipatedSection GG: supervision required for the available ADL (activities of daily living) observations (toileting, dressing); mobility: supervision required for ambulation and transfersSection Q: referral not wantedReview of the facility policy titled, Discharge Planning Process, reviewed 03/20/2025, revealed the following: Procedure #3: If discharge to the community is determined not to be feasible, the facility will document in the clinical record who made the determination and why.In an interview with the Director of Nursing (DON) on 08/13/2026 at 3:35 PM, confirmed that there was no nursing documentation related to R62's brief stay at the facility. She stated R62 was evaluated as an appropriate admission for the facility, but once admitted , he displayed physical and verbal behaviors which the facility staff could not manage. She stated that, in order to keep R62 and other residents and staff safe, R62 was transferred to a sister facility with a locked unit.

Based on observation, staff interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene F880 and Administering Medication F760, the facility failed to ensure infection control processes were followed during medication pass observation for one of three nurses observed. This deficient practice had the potential to place residents at risk for infections due to cross-contamination. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene F880, effective 10/2024, revealed the Policy section stated, The facility considers hand hygiene the primary means to prevent the spread of germs. Review of the facility policy titled Administering Medication F760, effective 10/2024, revealed the Guidelines section included, . 15. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. Observation on 5/7/2025 at 8:42 am of medication pass with Licensed Practical Nurse (LPN) AA revealed she removed a medication tablet from a container into her ungloved hand, and used her fingernail to move medication tablets around in the medication cup to count them. In an interview on 5/7/2025 at 9:00 am, LPN AA stated that she didn't always wear gloves during medication pass. She confirmed that she touched the medication tablets with her bare hands and should have had gloves on before touching the tablets. In an interview on 5/8/2025 at 8:01 am, Registered Nurse/Unit Manager (RN/UM) CC stated nurses should wear gloves when preparing medications and should not touch pills that are administered.

Based on observations, staff interviews, and review of the Quality Assessment and Performance Improvement (QAPI) Plan 2023, the facility failed to have an effective Quality Assurance (QA) program that developed and implemented actions to repair and/or replace the flooring throughout the facility in a timely manner. This failure had the potential to affect 70 residents. Findings include: Observation of Hall Two on 12/20/2023 at 12:21 pm revealed the flooring had soft areas and breaks/missing tiles down the entire hallway. During observations with the Maintenance Director on 12/21/2023 beginning at 10:42 am, he confirmed the soft/spongy flooring and missing tiles on Hall Two and throughout the common areas of the facility. Interview on 12/21/2023 at 10:42 am with the Maintenance Director revealed the flooring project was already in progress for over a year when he was hired in January 2022. He stated he will continue to repair the flooring until they can secure a qualified contractor. Review of the Environmental Performance Improvement Plan (PIP) 2022 revealed the status was in progress and no records were found. The Root Cause Summary, in which audits were conducted, related to floors. The target end date was June 2, 2022, and the PIP status was unsuccessful. Review of the Environmental PIP 2023 QAPI Goal revealed the PIP status was in progress with a target end date of December 31, 2023, with floors in need of repair. Review of the email correspondence between the National Director of Plant Operations and the Regional Maintenance Director, the Administrator, and others, revealed ongoing discussions related to securing contractors. In an interview with the Regional Nurse Consultant (RNC) on 12/21/2023 at 11:29 am, she stated the flooring in the facility was a huge priority for corporate office and they speak about it weekly. She stated they were reviewing current bids for a contractor, and they would like to start in the first quarter of 2024. In an interview with the Administrator on 12/21/2023 at 11:45 am, she stated she started a PIP related to the flooring when she was hired in November 2021, but the flooring replacement project was already underway. She stated it had been a challenge to find a licensed, bonded contractor who was able or willing to take on this massive project in this region.

Based on observations, staff interviews, record review, and review of the facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, the facility failed to ensure timely repair of a wheelchair for one of 33 residents (R) (R54), who utilized a wheelchair. The facility also failed to ensure a homelike environment in R54's room and bathroom, on one of four hallways (Unit Two Hall), and in the facility entrance area. The failures had the potential to place residents at risk for the use of unsafe equipment, unsanitary conditions, and a potential for diminished quality of life. The census was 70 residents. Findings include: Review of the facility policy titled Safe, Clean, Comfortable, Home-like Environment F584, with an effective date of 9/2023, revealed the policy statement of: Residents have the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Observation on 12/20/2023 at 8:13 am of R54's wheelchair revealed the arm tray on the right side was loose and hanging to the side of the wheelchair and was movable back and forth. Further observation revealed the wheelchair frame had an unprotected hole in it. The wheelchair wheels had a buildup of brown substance and there was dust all over the chair. Observation on 12/20/2023 at 12:00 pm of R54's room revealed the top of the wooden nightstand was protruding, had a gap across the front and the right side, and the plastic framing around the top was not in place. Observation of the bathroom for R54's room revealed rust colored areas that were rough to the touch on the grab bar, the sink faucet had white colored areas on it with a rough texture, the toilet flushing button on top of the tank had rust colored areas on it, the over the toilet seat had chipped paint and rust colored areas on it, there was a 1 inch hole in the adjoining bathroom door, and chipped paint on the ceiling over the hand towel dispenser. Observation on 12/20/2023 at 12:21 pm of Unit Two Hall near the boiler room door revealed the ceiling had a darkened area and the ceiling around the light fixture had an opening where the sheetrock met the light fixture on each side. The floor of Unit Two Hall had torn and soft areas in the flooring and missing pieces of the flooring. Observation on 12/20/2023 at 12:30 pm revealed a fluorescent light in the front hallway by the offices and near the front door had a cover that was hanging down from one side. Walking rounds on 12/21/2023 at 8:24 am with the Maintenance Director (MD) confirmed the findings in R54's room, restroom, and the findings of R54's wheelchair. The MD further confirmed the findings on Unit Two Hall. He revealed they were aware of all the problems, and they were trying to get things repaired. An interview on 12/21/2023 at 12:06 pm with Certified Nursing Assistant (CNA) FF revealed if she saw equipment in disrepair, she reported it to the nurse and to maintenance. She stated staff documented maintenance concerns in a reporting system on the computer. An interview on 12/21/2023 at 12:09 pm with CNA GG revealed equipment repair needs were documented by staff in a notebook that maintenance staff checked. She further stated she documented R54's wheelchair disrepair in the notebook three or four weeks ago. An interview on 12/21/2023 at 12:29 pm with Licensed Practical Nurse (LPN) BB revealed she was unable to locate the maintenance book at the nurse's station and that she used the facility's electronic system to report maintenance concerns. An interview on 12/21/2023 at 12:41 pm with LPN AA revealed if she found equipment in need of repair, she would report it to maintenance and report it using the facility's electronic reporting system. An interview on 12/21/2023 at 1:13 pm with the Maintenance Director revealed the Work Order Report, dated 10/01/2023 through 12/20/2023, revealed R54's room had no history for any type of repairs. He revealed he had thrown the maintenance logbook away two years ago. An interview on 12/21/2023 at 1:38 pm with the Administrator revealed if a wheelchair required repairs, the maintenance department should be able to fix it. An interview on 12/21/2023 at 1:49 pm with the MD revealed he had weekly and monthly task lists. He stated he and his assistant took care of issues as they came to them. He further stated wheelchairs were cleaned monthly by housekeeping, and he recently ordered wheelchair armrests. He reported that he did not have anything documented.

Based on observations, staff and resident guardian interviews, record review, and review of the facility policy titled F625 Bed Hold, the facility failed to ensure one resident (R) (R225), or their guardian, was provided notification of the facility's bed-hold policy upon transfer to a hospital. The facility census was 70 residents. Findings include: Review of the facility's policy titled F 625 Bed Hold, last revised June 2023, revealed the policy was: The community staff shall inform residents upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed-hold policy. The Guidelines section line numbered 1 stated: Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. Review of the Physician's Orders revealed an order dated 9/22/2023 of: May transfer to (the local psychiatric hospital) for evaluation and treatment. Review of the Progress Notes revealed a nursing progress note dated 9/23/2023 that R225 left with transport emergency medical services (EMS) and the local psychiatric hospital received report. Interview on 12/20/2023 at 12:50 pm with Business Office Manager (BOM) revealed R225 was a private pay resident and was admitted on [DATE]. She stated R225 had a conservator and a guardian handling business affair. She stated she spoke with the conservator about the bed hold policy and the conservator understood R225 did not have to pay anything until 10/01/2023. She stated R225 had already paid for the month of September on the day of admission. She stated that she was not in the office with the Social Services Director (SSD) on 9/19/2023 when the bed hold was issued but remembered being told they gave it to the guardian before R225 was transferred to the hospital. Interview on 12/20/2023 at 1:00 pm with the Administrator revealed when R225 was scheduled to be transferred to the psychiatric hospital, the unit nurse gave the bed hold paperwork to R225's guardian. She confirmed the facility did not make a copy of R225's bed hold documents when they were transferred to the hospital. The Administrator stated education was provided when she realized the staff were not honoring the bed hold policy for the residents. A telephone interview on 12/21/2023 at 11:20 am with R225's guardian confirmed she did not receive a bed hold policy from the facility.

Based on observation, interview, product page review, and policy review, the facility failed to ensure the product used by two of four housekeeping staff to disinfect high touch areas was effective against the COVID-19 virus and was used effectively by staff. This failure had the potential for cross contamination and infection of residents and/or staff that may come in contact with ineffectively cleaned/disinfected surfaces on the halls where the two housekeepers were assigned. Findings include: In an interview on 2/10/21 at 10:55 a.m. regarding what products were used and how high touch areas of the facility were cleaned and disinfected, Housekeeper (Hskpr) DD responded by stating they used an orange cleaner. Hskpr DD was then observed on 2/10/21 at 10:55 a.m. to pull a spray bottle of Keystone Orange Multi-Surface Cleanser from the cleaning cart. Hskpr DD stated I spray it, leave it on for five seconds, then wipe it with a dry cloth. When asked about any other products in use, Hskpr DD pulled a second spray bottle from the cart. This bottle was unlabeled, and Hskpr DD stated it was a bleach solution that was already mixed to refill the bottles in the laundry room. Hskpr DD stated, It is used on blood and urine and needs to stay wet for ten seconds. In an interview on 2/10/21 at 3:52 p.m. responding to the question of what product was used on high touch areas, Hskpr JJ pulled out a bottle of Orange Multi-Surface Cleaner and stated she sprayed it, left it wet for four to five seconds and then dried it. When asked what was used in the bathrooms, Hskpr JJ stated a bleach solution that she left on toilets and sinks for about 10 seconds. Review of the Keystone Orange Multi-Surface Orange Cleaner product page at https://www.cleanwithkeystone.com/products/keystone-orange-multi-surface-cleaner showed the product did not have an EPA (Environmental Protection Agency) registration number included on the EPA list N as virucidal against the COVID-19 virus. In an interview on 2/10/21 at 7:24 p.m. regarding an expectation of cleaning products used in the facility, the Director of Nursing (DON) stated the product .needs to be safe for residents and kill bacteria [MEDICAL CONDITION]. I was not aware they were using orange products - there are certain products we are supposed to use that is (sic) safe for residents and kills bacteria. I know the Healthcare Clorox products are - I've looked them up. In an interview on 2/10/21 at 7:28 p.m., the Administrator stated the Housekeeping Supervisor was responsible for looking at and obtaining EPA-registered products. The Housekeeping Supervisor was not available for an interview. Review of the facility policy titled Cleaning and Disinfection of Environmental Surfaces, last approved 01/2020, showed: .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. -1. Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture, and floors. -2. Most non-critical items can be decontaminated where they are used (as opposed to being transported to a central processing location.) 2. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. a. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. b. By law, all applicable label instructions on EPA-registered products must be followed 6. A one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes will be used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or b. uncertainty exists about the presence of [MEDICAL CONDITION] on such surfaces.

Based on observation, review of facility policy titled(NAME)Health and Rehab Cleaning Protocol and Self-Care Policy - COVID-19, and resident/staff interviews, the facility failed to practice social distancing among residents during smoke breaks and failed to disinfectant resident smoking aprons between use to prevent the spread of COVID-19 for nine of ten residents (R) (R#13, R#14, R#15, R#16, R#17, R#18, R#19, R#20, and R#22) assessed to smoke. Findings include: Review of the undated facility policy titled(NAME)Health and Rehab Cleaning Protocol and Self-Care Policy-COVID-19 revealed that team members working in a support center are required to wipe down common equipment before and after each use. Social distance six feet have been placed to help aid in social distancing/disinfectant wipes/sprays and hand sanitizers are available throughout facility locations for staff use. In addition, the facility team will continue to perform regular cleaning, focusing on high touch point surface areas, such as: smoke area - 2 times per day. An observation on 11/18/2020 at 2:08 p.m. revealed R#13, R#14, R#15, R#16, R#17, R#18, R#19, R#20, and R#22 smoking on the outside screen porch. The residents were within arm length of each other and less that six feet apart. CNA AA and CNA BB were observed supervising and assisting residents with the smoke break at this time. An observation on 11/18/2020 at 4:00 p.m. revealed R#13, R#14, R#15, R#16, R#17, R#18, R#20, and R#22 smoking on the outside screen porch. The residents were within arm length of each other and less that six feet apart. In addition, observations on 11/18/2020 at 2:08 p.m. and 11/18/2020 at 4:00 p.m. revealed that the facility staff failed to sanitize the smoke apron before and after the resident use. Twelve smoking aprons were observed and only three of 12 aprons were labeled with current smokers (residents) names. Interview on 11/19/2020 at 9:13 a.m., R#19 revealed that staff never disinfectant the apron prior to and between each smoke break. Staff have always positioned everyone close together and she was not educated on being six feet apart for social distancing during smoking. Interview on 11/19/2020 at 9:15 a.m., R#13 revealed that staff never applied disinfectant on the apron prior to and between each smoke break. She could always sit wherever she chooses. She further stated that she was not educated on social distancing during smoke breaks. Interview with Certified Nursing Assistant (CNA) AA on 11/19/2020 at 11:00 a.m. revealed that housekeeping staff are responsible for disinfecting the smoking aprons between each smoke break. Interview with CNA BB on 11/23/2020 at 10:00 a.m. revealed that they usually wipe the smoking aprons with Sani wipes provided by the Housekeeping Supervisor. Interview on 11/23/2020 at 2:55 p.m. with the Housekeeping Supervisor revealed that she has been on leave and stated that her staff clean the aprons weekly and the CNA cleans the aprons daily. During an interview on 11/19/2020 at 2:00 p.m., the Director of Nursing (DON) revealed she was unaware that staff were not [MEDICATION NAME] social distancing.

Based on observation, review of facility policies titled Pest Control and Other Environmental Conditions, and staff interviews, the facility failed to maintain effective pest control services to ensure the kitchen area was free from roaches. Findings include: Review of policy titled Pest Control approved February 2020 documented The community shall maintain an effective pest control program. (1). This community maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. (5). Maintenance services assist, when appropriate and necessary in providing pest control services. Review of policy titled Other Environmental Conditions dated September 2020 documented Maintain an effective pest control program so that the facility is free of pests and rodents. Observation on 11/18/2020 at 1:27 p.m. revealed a dead roach in the handwashing sink in the kitchen. Interview and observation on 11/18/2020 at 1:29 p.m. with the Cook revealed a roach crawling on the steam table. The dietary staff were no longer serving lunch. The Cook stated that the kitchen has roaches. There have been roaches observed crawling in the kitchen area. The Cook stated that the Dietary Manager (DM) has requested for the kitchen to be sprayed but has not seen anyone come into the kitchen to spray the kitchen. An observation on 11/24/2020 at 7:24 a.m. revealed dietary staff plating breakfast food and a cart containing a rack of utensils (uncovered). Further observation of the cart revealed a dead roach on the floor next to cart. During an interview on 11/18/2020 at 3:07 p.m., the DM confirmed that there is a pest problem of roaches in the kitchen. He has been employed with the facility for five months in the position as DM and was not sure when the kitchen was last sprayed. He has observed quite a few roaches when moving the refrigerator once. He had spoken with the Maintenance Supervisor about three weeks ago about having someone spray the kitchen area. DM stated that he has in-serviced his staff on sanitizing the kitchen due to past observation of roach residue. Interview on 11/23/2020 at 4:31 p.m., the Maintenance Supervisor stated that the Pest Control Serviceman only sprayed outside (exterior side) of the building. He was given a pesticide product to use in the kitchen and other areas of the facility. The last time he put the pesticide products in the kitchen was back in July 2020.The Maintenance Supervisor stated that he was not aware that the kitchen had a problem with roaches. The dietary staff had not informed him to spray the kitchen area. Further interview on 11/24/2020 at 1:01 p.m. with the DM revealed that the Register Dietician, on her last visit (last month), had submitted a memo to the Administrator about an identified roach problem in the kitchen during her visit. He stated that the Maintenance Supervisor had not been in the kitchen to treat the kitchen for roaches. Interview with the Administrator on 11/24/2020 at 12:24 p.m. revealed that she was unaware that the kitchen had a pest control problem. The DM and dietary staff had not reported a problem to her. The Administrator revealed that her expectation is for the kitchen area and the facility to be free of pests. She would had expected the dietary staff to inform her if there were roaches in the kitchen area. The Administrator further stated that the facility had identified an infestation of roaches when the basement flooded a few months ago due to bad pipes. The facility in the past few months was having the pest control services to treat the outside of the facility for all pests. The Pest Control company had given the Maintenance Supervisor a roach repellant to use in the interior building to treat for roaches. The Administrator stated that she was unaware that the Maintenance Supervisor had not treated the kitchen area for roaches within the last few months.

Based on observation, interviews and review of the facility policies titled Cleaning and Disinfection of Resident -Care Items and Equipment and Work Orders, Maintenance, the facility failed to provide an environment free from peeling paint with jagged edges on a doorframe of one resident's room (room [ROOM NUMBER]), dirty walls/ baseboards and nails protruding out of a wall on Hall 4, and peeling paint with jagged edges and missing sheetrock on Hall 3. In addition, the facility failed to ensure sanitary conditions related to the cleanliness and upkeep of one sit/stand lift and one activity supply cart (buildup and/or rust); and failed to ensure five wheelchairs were clean and in good repair on Hall 4. The census was 70 residents. Findings include: Record review of policy titled Cleaning and Disinfection of Resident -Care Items and Equipment documented Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendation for disinfection and the OSHA bloodborne Pathogens Standards. (5). Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Record review of policy titled Work Orders, Maintenance dated 1/2020 documented Maintenance work orders shall be completed in order to establish a priority of maintenance service. (1). In order to establish a priority of maintenance service work orders must be filled out and forwarded to the Maintenance Director. An observation of Hall 4 which is the facility secure unit on 11/19/2020 at 11:31 a.m., 11/23/2020 at 12:44 p.m. and 11/24/2020 at 8:42 a.m. revealed stained dirty wall and baseboards in the resident dining area near resident tables. Further observations of the hallway in the secure unit revealed nails protruding out of the wall that was within arm reach of the residents. Positioned against the wall on the secure unit was three resident wheelchairs stored for resident use covered with dark sticky grey and brown substances on the seats, bars near the armrest, spokes, and undercarriage. Two of the wheelchairs observed contained heavily rust substances either on the bars and handles. An observation of on 11/18/2020 at 1:00 p.m.,11/19/2020 at 10:12 a.m., 11/23/2020 at 12:23 p.m. and 11/24/2020 at 8:05 a.m., revealed dirty dark brown and white splattered substances on the footrest and bar of the stand leg of the stand/sit lift. An observation of a wheelchair located on Hall 2 revealed heavily rusted substance on the tipper. room [ROOM NUMBER] doorsill frame had peeling paint and jagged rough edges and peeling paint on the doorway. An observation on 11/19/2020 at 2:24 p.m., 11/23/2020 at 12:16 p.m. and 11/24/2020 at 8:02 a.m. revealed missing paint and sheet rock along the edge of the corner of a wall located directly adjacent to the nurse station on Hall 3. A closer observation of the same wall revealed rugged jagged splinters lining the edges. An observation on 11/24/2020 at 8:10 a.m. revealed dark brown sticky substances coating the interior of the activity cart that contained resident activity supplies and cigarettes. An observation and interview of the activity cart was conducted with the Director of Nursing (DON) on 11/23/2020 at 8:21 a.m. The DON confirmed that the dark brown sticky substances was dirt and debris. She stated that cart should be maintained in a clean and sanitary manner because resident activity items and cigarettes are stored on the cart. She stated that Housekeeping staff are responsible for cleaning the cart. The Activity Director is responsible for submitting the request to housekeeping staff. During an interview on 11/23/2020 at 8:23 a.m., the Activity Director confirmed that the cart had not been cleaned. She stated that she uses the cart to store resident's activity supplies and items including cigarettes cartons. An observation and interview on 11/23/2020 at 8:55 p.m. was conducted with the Director of Nursing (DON) and Maintenance Supervisor(MS) of the five wheelchairs, peeling paint on the wall, scraped rugged edges on the wall and doorways, and sit/stand lift, nails protruding from the walls, and stained dirty walls. DON stated it is facility policy to wipe the wheelchairs down if a wheelchair is being used for a resident. She and the MS identified the brown substances as dirt and debris and confirmed that all the equipment was partially covered with rust. The DON and the MS stated that they were both unaware of the condition of the wheelchairs and the sit/stand lift. The DON stated that housekeeping and nursing staff are responsible for cleaning resident equipment. The MS is responsible for changing out the resident equipment that contains rust and hazardous materials. The MS revealed that he was unaware of the rust on resident medical equipment (wheelchairs and sit/stand lifts), missing paint on the wall and rugged jagged edges on the walls and doorsill of room [ROOM NUMBER]. The MS and the DON both confirmed that a work order should had been submitted by the nursing staff for any needed repairs. The DON revealed that routine angel rounds surveillance of environment is conducted weekly and should include reporting any environmental issues or needed repairs. During an interview on 11/23/2020 at 4:00 p.m., the Administrator stated that her expectation is for the environment and resident's equipment to be maintained in a clean and sanitary manner. She further stated that any resident equipment that contains rust should be replaced and removed from the building. She stated that a work order should be submitted to the MS for any repairs. The nursing staff is responsible for completing all work orders.

Based on observations, facility reports and staff interviews, the facility failed to provide an effective pest control program for multiple areas within the facility including the kitchen and residents areas. This failure affected all residents who reside in the facilty. The current census was 87. Findings include: 1. Initial Observations on 7/15/19 at 11:20 a.m. with the Dietary Manager (DM) and Registered Dietician (RD) present - and verifying observations in the dry storage area of one live roach on floor, two live roaches on the wall and one unidentifiable bug crawling into the ceiling. One roach was observed up on the ceiling area in the DM office. The back-door area was observed with webs up in the corner. The DM stated that she would notify the Pest Control company who would come out and treat. Last treatment was noted on 6/17/19 and monthly prior. On 7/16/19 at 3:10 p.m. One live roach was observed on the wall in the dry storage room. On 7/17/19 at 11:15 a.m. one live roach was observed in the dry storage top doorway area and at 12:40 p.m. additional observations was seen: of a live roach crawling on the wall in the dishwasher area, on the floor at the stove/oven area and one dead roach back under the kitchen prep table. On 7/18/19 at 2:30 p.m. an observation was made of one live roach on the wall behind the dry storage door. An interview with dietary staff 'AA' and 'BB' who both stated every morning that roaches are 'dropping all over.' 2. An observation tour was conducted on 7/15/19 from 11:15 a.m. to 12:00 p.m. in the rooms and the hallway on Hall-2 as follows: room [ROOM NUMBER] two live roaches were noted on the hall floor outside the room; many dead insects were observed along the length of the floor baseboards on both sides of the hall; room [ROOM NUMBER]A multiple live ants were observed crawling on the wall located just inside the door-jam; room [ROOM NUMBER]A a live spider was observed crawling across the drywall above the entrance door, visible from inside the room; and in room [ROOM NUMBER] a live spider was observed crawling in his web behind the door in the corner on the drywall. After the Hall-2 and room tour, a further observation was conducted of the main dining room on 7/15/19 at 12:00 p.m. where an electric insect catcher was observed to be mounted on the central wall in the dining room, however multiple live flies were observed flying around residents seated for lunch. Four residents were observed with hand held fly swatters. An observation and interview was conducted on 7/17/19 at 12:27 p.m. with the Maintenance Supervisor (MS) who confirmed he had worked at the facility for some time, but became MS in 12/2018. During the observation, the MS confirmed pest issues currently present as follows: 1) in room [ROOM NUMBER] a live spider was observed crawling in his web behind the door in the corner on the drywall, the MS confirmed he would spray for the live spider and the large web still present, he also revealed that their pest control had sprayed the facility on Monday, 7/15/19; 2) in room [ROOM NUMBER]A multiple live ants were observed crawling on the wall just inside the door-jam to the room, the MS assured that he would spray for the live ants still present. The MS explained that flies were probably coming in from open doors near the dining room. A review was conducted of the Maintenance Request Book located and mounted on the wall near the nurse's station, it documented one (1) maintenance request, no requests were found for pest issues. A review was conducted of provided pest control work orders. Evidence of service for the following dates was found: 7/15/19, 6/17/19, 5/21/19, 4/16/19, 4/3/19, 2/27/19, 1/18/19 and 12/14/18. The kitchen was treated for [REDACTED]. An interview was conducted on 7/17/19 at 12:45 p.m. with the MS where he explained that requests for maintenance items and pest concerns come to him from the nurses just letting him know verbally, or they will use the maintenance log. The MS confirmed he is the only person that does maintenance and he has been busy. Copies were requested of the Hall-2 maintenance request logs, the Pest Control Contract and copies of recent pest control service orders and/or invoices. Copies of the maintenance request logs for Hall-2 were not provided. A review was conducted of the pest control contract dated 9/26/18. The contract shall be effective for an original period of one year. Thereafter, the contract shall renew itself from year to year. The section titled Intent documents they will provide services as needed to effectively control cockroaches, ants, rodents, silverfish, or other insect infestations (except for flies, fleas, bedbugs and wood destroying organisms) by periodic treatment using products according to approved label procedures. treatment for [REDACTED]. The section titled Treatment Areas documents the entire interior with special attention to all cockroach nesting and feeding areas which include plumbing voices; cracks and crevices created by fixtures, moldings and cabinets; ceiling attics and crawl space areas; and surfaces under and behind appliances and cabinets.

Based on observation, review of records, and resident and staff interview, the facility failed to provide staff in sufficient numbers to care for the needs of its residents as determined through resident assessment instruments and the Facility Assessment of (MONTH) (YEAR). This failure affected five of five residents (R), R#65, R#84 and Residents A, B, C who required extensive to total assistance for themselves in some or all Activities of Daily Living or who expressed concern for roommates who required this level of care. The facility assessment documented that the facility's average daily census is 83. Findings include: A review of the Facility Assessment of (MONTH) (YEAR) revealed that the facility had an average daily census of 83. The assessment also documented that, when compared to the national average, the facility cared for a high to very high percentage of residents that needed the assistance of 2+ persons with Activities of Daily Living (ADLs). The assessment concluded that the facility had a high percentage of residents with the need for increased assistance with ADLs including: eating, daily care, bed mobility, transfers, toilet use, bathing, dressing, and hygiene/grooming assistance. The assessment also concluded that the assistance of 2 staff were required for daily care, bed mobility, transfers, toilet use, bathing, dressing, hygiene/grooming assistance of these residents. During an interview on 7/17/19 at 3:26 p.m., Resident A said that the facility was short-staffed. The resident said, there was usually only one CNA on her hallway (Hallway Two) during the 3:00 p.m. to 11:00 p.m. (evening) or the 11:00 p.m. to 7:00 a.m. (night) shifts. When this happens, Resident A said, the residents on that hall often wait for 2-3 hours after they press their call buttons before they receive assistance from staff. A review of the most recent Minimum Data Set (MDS) assessment for Resident A completed in (MONTH) 2019 revealed a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates that an individual is cognitively intact. This assessment also documented the resident needed extensive assistance from staff to transfer from bed to chair and vice versa, and that she needed total assistance with dressing and toileting. The assessment also said that the resident needed the assistance of two-plus staff for transfers and dressing. During a group interview with active members of the resident council on 7/18/19 at 11:40 a.m., several residents said they believed, based on observation and staff response to their requests, that the facility did not have enough staff to care for their needs: Resident B said there was usually only one Certified Nursing Assistant (CNA) on her hall on the evening and night shifts. Thus, when she presses her call button for staff assistance for herself or her roommate during those hours, each must wait at least on hour for assistance. Resident B said after waiting more than an hour for staff to arrive after she pressed her call button a few nights before, she was forced to take matters into her own hands and assist her roommate with changing the roommate's brief. It was better than her lying there naked, she said. Resident B also said when a CNA on one of the other halls does not come in to work on one of these shifts, then the CNA on her hall must pitch in with the CNAs on the remaining halls to provide coverage on the hall with that missing CNA. A review of the most recent Minimum Data Set (MDS) assessment for Resident B completed in (MONTH) 2019 revealed a Brief Interview for Mental Status (BIMS) score of 14. A score of 13-15 indicates that an individual is cognitively intact. The most recent quarterly MDS assessment for the roommate of R#23 dated (MONTH) 2019 revealed a BIMS score of 3. A score of 3 indicates an individual is severely cognitively impaired. The roommate's most recent MDS assessment also documented a need for extensive assistance in all activities of daily living such as toilet use and personal hygiene. During the same group interview, Resident C said there are a lot more CNAs on the 7:00 a.m. to 3:00 p.m. (day) shift than there are on the evening or night shifts. Resident C said there are sometimes only three CNAs - one for each of three of four halls - hall one, hall two, and hall three - on the evening shift. A review of the most recent Minimum Data Set (MDS) assessment for Resident C completed in (MONTH) 2019 revealed a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates that an individual is cognitively intact. Resident A said, during the interview, that on the evening shift a few nights before, she turned her light on some time after 10:00 p.m. because it was past her usual bedtime, she was tired, and wanted to be assisted into bed. Some considerable time after she had pressed her call button, Resident A said the CNA on duty passed her room on her way down the hall, asking, why you turn that light on? You know I'm here by myself. Resident A said, It's not my fault they are short-staffed. A review of the resident council minutes for (MONTH) 28, 2019 revealed one resident, R#65 complained that her roommate was sitting in their room, soiled for up to 2 hours at a time and that staff on the evening shift was unavailable all the time. During the same meeting, another resident, R#84, complained that staff never checked on her during the entire night shift. The minutes documented that grievances related to these complaints were filed on 3/28/19. A review of the grievances revealed R#65 was told that rounds are made every two hours and she was asked to use her call button. The Registered Nurse supervisor was documented as having educated CNAs about checking residents more frequently during the shift, being more visible to residents, and letting the nurse know where they are at any given time. The grievance response for R#84 was that the CNA was asked to wake resident when checking on her. A review of the staffing schedules for the previous 90 to 120 days revealed the residents' observations of the staffing numbers provided to care for them on each shift were accurate. The average number of CNAs scheduled for four hallways each day during the months of (MONTH) through July, 2019 was 7-9 on the day shift, 4-5 on the evening shift, and an average of 3 - 4 on the night shift. These numbers suggested that, on average, one CNA was expected to provide care on each of the four halls on the evening shift, and fewer that one on the night shift. The facility census was greater than 80 during that period. A further review of the staffing schedules for the same period revealed that an average of 2-3 nurses were scheduled on the day and evening shifts, and an average of 2 on the night shift. However, there were several days during this period when only one nurse was documented to be scheduled on the day and evening shifts. During an interview on 7/18/19 at 3:44 p.m. with the Director of Nursing (DON), it was revealed that she was responsible for scheduling the number of nursing staff - CNAs and nurses - needed for each shift and her calculation of the number of each required for each shift is based on the facility's census. The DON said her aim is to provide a Per Patient Day (PPD) of 2.5. Thus, she regularly scheduled 8-9 CNAs on the day shifts. She schedules one CNA each for Hall One and Hall Three, plus a third to float between both. She schedules two CNAs for Hall Two because that hall has the highest acuity, plus it is the longest hall with the most residents. She schedules two CNAs for Hall Four, the secure unit. She also schedules two restorative CNAs to work during that shift. On the evening shift, she schedules 5-6 CNAs; one on each of halls One through Three and two on Hall Four, the secure unit. If there are five CNAs scheduled for that shift, then Hall Two (the largest hall) gets a second CNA. She normally schedules 4-5 CNAs on the night shift. If there are four CNAs scheduled on that shift, two CNAs are scheduled on the secure unit and one on each of halls One and Two, and these are expected to work together on Hall Three. If 5 CNAs are scheduled on the night shift, then 2 work on the secure unit and one each on halls One, Two, And Three. Sometimes only three CNAs work on these shifts. When that happens, the nurses are expected to help. At least three nurses are scheduled on each of the three shifts. However, only two are sometimes scheduled on the night shift. A review of the staffing schedules for the days of the survey - 7/15/19 to 7/18/19 revealed 6-7 CNAs were scheduled on the evening shift and 3-5 on the night shift on the schedules provided by the facility for the period. However, a close perusal of these schedules revealed that these numbers consisted of staff who were scheduled to work more than one shift each day. For example, of the 7 CNAs scheduled on the evening shift for 7/15/19, three were also scheduled on the previous shift, and of the four scheduled on the night shift, two were scheduled to work on earlier shifts. During an observation on 7/18/19 at 5:15 p.m. one CNA was observed to be providing care on hall one and one CNA on hall two. During an interview on 7/18/19 at 5:23 p.m., CNA JJ confirmed she was the only CNA assigned to her hall. CNA JJ said two CNAs are sometimes assigned to that hallway, but most often only one. When only one CNA is assigned to that, then a CNA from one of the other halls is called on to help if more than one staff member is needed to provide care for a resident on the hall. During an interview on 7/18/19 at 5:34 p.m., CNA KK confirmed that only one CNA was assigned to Hall Two. CNA KK said he/she usually worked on the evening shift - 3:00 p.m. to 11:00 a.m. and was familiar with the staffing patterns on that shift. CNA KK said two CNAs were typically assigned to that hall during the evening shift, in the past. However, only one was assigned on a regular basis and, if one CNA on another hall calls out, then that CNA is expected to assist the remaining CNAs to cover the needs of the residents on the missing CNA's hall. CNA KK said there were 27 residents on Hall Two at the time of this interview. The CNA on that hall is expected to call on CNAs from the other halls for assistance for residents that need the assistance of at least two members of staff. However, this CNA said it worked better when were at least two CNAs working exclusively on that hall for the safety of each resident and so the CNAs can better meet their (the residents') needs a little bit quicker. CNA KK said the CNAs have worked short on all the halls for at least 6 months.

Based on staff interview, and review of records, the facility failed to provide nursing staff in sufficient numbers to ensure that the Director of Nursing (DON) did not function as the charge nurse when the facility's census was greater than 60. Findings include: A review of the staffing schedules for the period (MONTH) 2019 through (MONTH) 2019 revealed that an average of 2-3 nurses were scheduled on the day and evening shifts, and an average of 2 on the night shift. However, there were several days during this period when only one nurse was documented to be scheduled on the day and evening shifts. During an interview on 7/18/19 at 3:44 p.m.with the DON, it was revealed that she schedules at least three nurses on each of the first (7:00 a.m. to 3:00 p.m.) and second (3:00 p.m. to 11:00 p.m.) shifts, and 2-3 on the third (11:00 p.m. to 7:00 a.m.) shift. However, if there are less than three nurses available to work during the day or evening shifts, then the Registered Nurse (RN) supervisor or a part-time nurse gets on the cart and function as the third charge nurse. The DON said she also gets on the cart when needed. She does so at at least twice a week. She worked as the charge nurse twice the week before - once on Hallway One and once on Hallway Two. A review of the facility daily census numbers for the month of July, 2019 revealed that the census for each day during that period was greater than 80. Refer to F725

Based on observation, interview and review of facility documentation, the facility failed to ensure that it was maintained in a safe, clean and comfortable environment on two (2) of four (4) halls. The facility census was 87 residents. Findings include: 1. An initial observation was conducted on 7/15/19 from 11:15 a.m. to 12:00 p.m. the observation conducted was in resident rooms and the hall-way on Hall-2 as follows: Two (2) of seven (7) ceiling light panels were not working on Hall-2. The hall-way appeared much darker than the other halls. room [ROOM NUMBER]A- over bed lights not working after two attempts room [ROOM NUMBER]B -over bed lights not working after two attempts room [ROOM NUMBER] -ceiling light for room working intermittently on then goes off room [ROOM NUMBER]A- over bed light not working short cord, multiple live ants crawling on wall just inside the door-jam to room [ROOM NUMBER] room [ROOM NUMBER]B- room air conditioner near 228B bed with an approximate 1 inch gap between air conditioner and will, outside is visible from the gap on right side and top of air conditioner, broken blinds room [ROOM NUMBER]B over bed light with short cord (4 inches) room [ROOM NUMBER]B over bed light with short cord (4 inches) room [ROOM NUMBER]A- live spider crawling across drywall above the door visible from inside the room, over bed light with short cord (4 inches) room [ROOM NUMBER]- live spider crawling in his web behind the door in the corner on the drywall, a whole approximately 2 inches, found in the corner between baseboard and door-jam to the bathroom room [ROOM NUMBER]A- over bed light with short cord (4 inches) room [ROOM NUMBER]A call light not working, bathroom shared (4 residents share) between rooms [ROOM NUMBERS]- an old appearing white toothbrush observed on sink behind hat and cold water knobs room [ROOM NUMBER]A- soiled privacy curtain, over bed light with short cord (4 inches) room [ROOM NUMBER]A- over bed light short cord (4 inches); privacy curtain very soiled room [ROOM NUMBER]B- over bed light with short cord (4 inches); privacy curtain very soiled room [ROOM NUMBER]A- over bed light not working with short cord (4 inches) room [ROOM NUMBER]B- over bed light not working A follow-up observation and interview was conducted on 7/17/19 at 12:27 p.m. with the Maintenance Supervisor (MS) on Hall-2 who confirmed he had worked at the facility for some time, but became MS in 12/18. The MS then rechecked rooms and confirmed issues identified by the surveyor on 7/15/19 in rooms as follows: The MS confirmed the hall ceiling lights had just been replaced. room [ROOM NUMBER]A- the over bed light now working- confirmed with testing it was working intermittently, confirmed he will keep an eye on it. room [ROOM NUMBER]B- the over bed light not working- confirmed will fix the light. room [ROOM NUMBER]A- the over bed light not working, confirmed it has a short cord, confirmed he would fix the light and spray for live ants still present. room [ROOM NUMBER]B- the room air conditioner near 228B bed with an approximate one (1) inch gap between air conditioner and wall, the outside is visible from the gap on the right side and top of the air conditioner, broken blinds- MS confirmed he was not aware of the air conditioner gap and would fix it, that it needed screws to the mounting and the gap caulked. room [ROOM NUMBER]B- the over bed light with a short cord (approximately 4 inches long)- the MS confirmed it would be fixed. room [ROOM NUMBER]B- the over bed light with short cord (approximately 4 inches long)- the MS confirmed it would need to be fixed. room [ROOM NUMBER]- a live spider crawling in his web behind the door in the corner on the drywall, and a hole approximately two (2) inches in diameter, confirmed to be found in the corner between the baseboard and door-jam to the shared bathroom- the MS confirmed both issues that he would fix, and would spray for the live spider and large web still present, stated the pest control came out and sprayed the facility on Monday, 7/15/19. room [ROOM NUMBER]A- the over bed light with a short cord (approximately 4 inches long) the MS confirmed it needs a longer cord, the MS confirmed the call light was not working and he would replace it immediately. room [ROOM NUMBER]A- a soiled privacy curtain and over bed light with short cord (approximately 4 inches long)- the MS confirmed he would have housekeeping replace the curtain and get a new cord. room [ROOM NUMBER]A- the over bed light noted with a short cord (approximately 4 inches long); privacy curtain very soiled- the MS confirmed he would fix the cord and tell housekeeping about the curtain. room [ROOM NUMBER]B- the over bed light with a short cord (approximately 4 inches long); privacy curtain very soiled-MS stated he would tell housekeeping and he would fix the cord. room [ROOM NUMBER]A- the over bed light not working; has a short cord (approximately 4 inches long)- the MS confirmed the issue and stated he would fix it. room [ROOM NUMBER]B- the over bed light not working- the MS confirmed, and stated he would fix it. In addition, during the interview and observation conducted on 7/17/19 with the MS, Pest Control invoices were requested. A review of was also conducted of the maintenance request book located on the wall near nurse's station, it reflected one request. When asked how requests come to him, he confirmed that staff just let him know, and use the maintenance request book located at the nurse's station. He confirmed he is the only person that does maintenance, that he has been busy, that he tries to make routine rounds. He confirmed that housekeeping is responsible for privacy curtains. A request was also made to review copies of the maintenance log; however, they were not provided. A review was conducted of the facility form provided by the MS titled, Housekeeping Daily Checklist. This form is a daily checklist, that housekeeping staff uses, to list areas of cleaning and observations needed. In the section Resident Room many areas are listed for a check mark for example: window blinds in good condition, privacy curtains clean, chip paint (if so, log in maintenance book) and broken or chipped tile (note in maintenance book). The form also has an area for notes, name, date, hall assigned, and supervisor rounds conducted and findings. Cross refer to F925 2. During an interview with Resident (R)#41 on 7/15/19 at 11:44 a.m., she stated she had to plug holes in her bathroom walls with paper towels to keep pests from entering her room. Observation of the bathroom revealed a hole plugged with paper towel in the lower wall close to the baseboard to the left of the doorway, approximately three inches in length. A second plugged hole, behind the toilet where the pipe extends from the toilet into the wall, measured approximately two inches around the pipe. Continued observation of the room [ROOM NUMBER] bathroom revealed the hot and cold-water knobs were not labeled, and the stem used to plug and unplug the sink was also missing. R#41 stated she was aware the left faucet knob was the hot water and the one on the right was cold. Observation of the room [ROOM NUMBER] on 7/15/19 at 2:39 p.m. revealed the call light for bed two was missing the depress button and the reset button was missing from the wall panel. Observation of the room [ROOM NUMBER] bathroom on 7/15/19 at 2:45 p.m. revealed large amounts of dark brown substance on the floor along the baseboards behind the toilet. In addition, the was a dark substance visible beneath the raised toilet seat. Observation of the room [ROOM NUMBER] on 7/15/19 at 2:51 p.m. revealed call light not working for bed two. In addition, the emergency call light in the bathroom was missing the indicator bulb for the reset button. Observation of room [ROOM NUMBER] on 7/15/19 at 2:59 p.m. revealed the call light wall panel for beds one and two was missing the reset button. During an interview with the Maintenance Supervisor on 7/15/19 at 3:15 p.m., he stated he was not aware of the call light issues in rooms 39, 41 and 47 but would replace the malfunctioning call lights immediately, however, he needed to order parts and bulbs for the call light wall panels. He stated he would place these orders as soon as possible. Observation of the Unit four hallway on 7/16/19 at 11:45 a.m. revealed a live roach crawling across the floor near room [ROOM NUMBER]. During an observational tour and interview with the Maintenance Director on 7/18/19 at 2:10 p.m., he stated he has worked at this facility for [AGE] years but became the Maintenance Supervisor in (MONTH) (YEAR). He confirmed he had already replaced the broken call lights in rooms 39, 41 and 47. He confirmed the holes plugged with paper towels in the room [ROOM NUMBER] bathroom. When paper towels were removed from the holes, there was a hole in the corner of the wall to the left of the doorway which measured approximately 3 inches in length. Removal of the paper towels from around the toilet pipe into the wall revealed a circular hole around the pipe with approximately 1 to 1-1/2 inches in circumference. He stated he would plug the holes with an appropriate substance as soon as possible. During an observational tour with the Housekeeping Supervisor on 7/18/19 at 2:37 p.m. she confirmed the brown substance on the floor in the room [ROOM NUMBER] bathroom and believed the substance to be coffee grounds which some people use for odor control. She confirmed her staff's responsibility to clean the floors, including the floor behind the toilet and corners of the flooring. In addition, she stated housekeeping staff is supposed to clean the portable, raised toilet seat which, when turned over, was soiled with a light brown substance on the under-side of the seat. She also noted the legs of the raised toilet seat were rusty and stated she would replace it. During an interview with the Maintenance Supervisor on 7/18/19 at 3:06 p.m. he stated he repaired the holes in the room [ROOM NUMBER] bathroom and would replace the entire faucet due to unlabeled water knobs and the missing plug stem as soon as the faucet arrived.

Based on observation, interview and review of facility data and a policy titled, Labeling of Medication Containers, last revised (MONTH) 2007, the facility failed to ensure that expired medications and biological's, were not available for resident use in one (1) medication storage room and one (1) medication refrigerator, and failed to label one (1) opened multi-use vial of [MEDICATION NAME] Purified Protein Derivative (PPD) with the open date, ensuring disposal by the appropriate expiration date. Findings include: An observation was conducted on 7/16/19 at 3:11 p.m. in the medication storage room with Licensed Practical Nurse (LPN) CC where she confirmed the facility had one central storage room and one medication refrigerator. The room was locked, the refrigerator was locked. During this observation, 50 expired medications and 19 expired vaccines were found as follows: Located on a shelf with other stock medications were: [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 25 expired 2/28/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 16 expired 5/31/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 3 expired 4/30/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 1 expired 3/31/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 5 expired 1/19/19 Located in the refrigerator, Influenza Flu vaccines 0.5 ml Lot 7 prefilled syringes were found in an open box containing nine (9) syringes, expiration date of 5/31/19. Influenza Flu vaccines 0.5 ml Lot 0 prefilled syringes were found in an unopened box containing ten (10) syringes, expiration date of 5/31/19. Located in the refrigerator, a [MEDICATION NAME] Purified Protein Derivative (PPD) 10 ml vial 5Tu/0.1ml was found opened, no open date on the vial was found, unable to determine when it was opened for use. An interview was also conducted with LPN CC during the storage room observation. The LPN confirmed that all the nurses are responsible for checking for expired medications, stating that the expired vaccines for influenza shouldn't matter since the flu season is now over and there is no resident with an intravenous (IV) medication on her unit currently. The LPN confirmed she did not know about IV medication use on the other units. An observation check for expired or unlabeled medications was also conducted on two medication carts with LPN CC and LPN GG, no expired medications or inappropriately labeled medications were noted. Narcotics were double locked, reconciliation of narcotics was conducted, no missing or undocumented medications noted. A copy of the facility's medication storage policy was requested from LPN CC and from the Director of Nurses, a medication labeling policy was provided, no policy was provided for medication storage. A review was conducted of the facility's policy titled, Labeling of Medication Containers, last revised (MONTH) 2007. Policy Statement: all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Policy Interpretation Sections No. 3, 4 and 5 documented that labels for individual drug containers, floor stock medications and labels for single unit dose package shall include all necessary information such as: the date the medication was dispensed; appropriate accessory and cautionary statements; and the expiration date when applicable.

Based on staff interview, record review, and review of policy, Advanced Directive, the facility failed to ensure that the health records, which included the physician's orders [REDACTED].#56) from a sample of 55 residents. Findings include: A review of the policy, Advance Directive last revised 2008 revealed that prior to or upon admission, staff will provide written information to each resident concerning his/her right to formulate advance directives such as Do Not Resuscitate (DNR). A DNR was defined as, in the case of respiratory or cardiac failure, no cardio-pulmonary (CPR) or other life-saving methods are to be used. The Director of Nursing (DON) or designee will notify the attending physician of advance directives selected by the resident/family so that appropriate orders can be documented in that resident's medical record and plan of care. A review of the policy, DNR last revised ,[DATE] revealed that a DNR order is to remain in effect until the resident or legal surrogate provides signed and dated request to end it. Review of the clinical records for resident (R)#56 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the resident's responsible party (RP) signed a physician's orders [REDACTED]. This POLST was signed by the resident's physician on [DATE] and by a concurring physician on [DATE]. A review of a social services progress noted dated [DATE] confirmed that the resident was to have a status DNR. A review of the current physician's orders [REDACTED].#56 had an order dated [DATE] for her to be Full code, all measures. During an interview on [DATE] at 4:15 p.m. with Licensed Practical Nurse (LPN) CC, it was revealed that the charge nurses had been educated on how to locate each resident's code status in the electronic health records (EHR) or in the hard charts located at the nurses' station. In the EHR, each resident's allergies and code status are immediately visible at the top of the screen when that resident's records are accessed via the nurses' computer. In the hard chart, the resident's code status is documented on the inside cover using a color-coded sticker; a green sticker with the words full code or a red sticker with DNR written on it. LPN CC demonstrated that R#56 was listed in the EHR as having a full code status and had a green sticker in the hard chart which also documented that she was full code. During an interview on [DATE] at 5:05 p.m. with the Director of Nursing (DON), she explained that all residents are documented as being a full code on admission, and this code status remains in effect until appropriate paperwork designating otherwise is received. The appropriate paperwork necessary to have a resident's code status changed to that of DNR must be signed by the resident/RP and two physicians, even if the resident is cognitively intact. Once the DNR is signed by both physicians, it is given to the social worker who, in turn, notifies the nursing staff of the change so that the resident's status is updated in the EHR. At the same time, the social worker also notifies medical records. The medical records staff places a red DNR sticker in the chart. If a resident experiences a situation wherein a decision must be made by staff whether to initiate CPR, nursing staff can check either the hard chart or the electronic records to see if CPR needs to be initiated. The DON verified that R#56 was listed as a full code in the EHR, but had a signed POLST documenting that this resident should be a DNR. The DON agreed that, had the circumstances arose, the resident could have had CPR initiated despite having a DNR order. She immediately changed the resident's status in the system and promised to also have hard chart updated. Review of documents provide by the DON on [DATE] at 8:30 a.m., revealed that the facility had completed an audit of the code status of all residents currently in the facility indicating that the code status of each had been verified in all forms of the medical records to be correct.

Based on observation, interviews, and review of facility policy, it was determined the facility failed to provide a safe clean and home like environment for residents on two of four units. Findings include: 1. Observation of the Special Care Unit (SCU) on 5/1/18 from 9:03 a.m. to 9:36 a.m. revealed the following: - room [ROOM NUMBER] had paint peeling along the top of the wall to the ceiling; the resident's room and the bathroom had unpainted areas (white patches); the privacy curtain had brown/black stains, and the toilet paper holder was broken. Further observation revealed the room lacked any of the resident's personal items or decorations. - room [ROOM NUMBER] had three holes in the ceiling; unpainted areas on the walls (white patches), sheet rock cracking and bubbling, top of the wall to the ceiling was peeling; rusted hand rail in the bathroom; closet doors scraped; air conditioner unit loose from the wall and the facing on the top was cracked; and the room lacked any of the resident's personal items or decorations. - room [ROOM NUMBER] had peeling ceiling paint and unpainted areas (white patches) on the walls; molding around the floor scraped with peeling paint, built in cupboards and closets scraped and missing varnish, and the air conditioner unit facing cracked on the top. Further observation of the room lacked any resident personal items or decorations. - room [ROOM NUMBER] had unpainted areas (white patches) on the walls; top of wall to the ceiling was peeling; missing varnish on the built-in cupboards; privacy curtain with stains (missing color like it was bleached); sheet rock cracking, and rusted hand rail in the bathroom. Continued observation revealed no resident personal items or decorations. - room [ROOM NUMBER] had missing paint on the ceiling; peeling paint on the walls; unpainted areas on the walls (white patches); railing behind the bed scraped and missing paint, molding around the floor scraped with peeling paint; varnish missing from the built-in cupboards, and the privacy curtain dragging on the floor. The room lacked personal belongings or decorations. - room [ROOM NUMBER] had missing paint and scrapes on the walls and the built-in closets and cupboards were scraped. The room lacked personal belongings or decorations. Observation of the halls and the Day Room of the SCU lacked any decorations and the Day Room's walls had scrapes present. Interview with the Director of Nursing (DON) on 5/3/18 at 10:44 a.m., in her office, revealed the facility had removed the pictures from the walls last year after the survey, when they started to paint the walls. The DON stated a lot of the families do not bring in personal items for the residents. Interview with the Maintenance Director on 5/3/18 at 11:33 a.m. while touring the SCU, revealed all the rooms on the SCU were painted by a contract company and he believed it was completed in (MONTH) of (YEAR). The facility then added new room doors and now they were doing touch up painting. He stated the holes in the ceiling were important to take care of, but the facility is working on other things. Review of the facility provided Invoices revealed the painting on the SCU was completed on 8/20/17 and the doors were completed on 12/30/17. Interview with the Administrator on 5/3/18 at 3:25 p.m. while touring the SCU revealed he agreed the SCU was not homelike and they would add items to the walls and develop a plan for fixing the SCU. Review of the policy titled, Quality of Life - Homelike Environment dated 10/2009 indicated, the facility staff and management would maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The facility failed to provide clean and homelike environment for the residents residing on the SCU. 2. During a tour of Unit One on 5/2/18 at 10:37 a.m., room [ROOM NUMBER] was noted to have multiple areas of chipped and peeling paint on the walls and the built-in chest of drawers. The walls were painted a deep avocado green. A board had been mounted behind the beds and the white paint was chipped in multiple places. The blinds were damaged, and a light bulb was missing out of the light fixture over the chest of drawers. The flooring was loose and peeling behind the second bed and the plywood was exposed. A subsequent inspection was conducted on 5/3/18 at 4:40 p.m. in room [ROOM NUMBER] with the Administrator and Maintenance Director. The Administrator agreed that the walls, flooring and window coverings needed painting and repairs. Both residents in room [ROOM NUMBER] stated that the room was dreary. An inspection of room [ROOM NUMBER] was conducted on 5/3/18 at 4:43 p.m. in with the Administrator and Maintenance Director revealed that the dark green paint on the walls and built-in chest of drawers was chipped, the white wall board behind the bed was chipped in several places, the door was scuffed in several places, and the resident's end table had a chipped corner. An interview conducted with the Administrator during the inspection revealed that the facility was being repaired in several phases. The Administrator provided a document titled Capital Purchases that documented F tag # 253, Resident rooms were cited for peeling paint. The document was signed by the Administrator on 6/29/17. Dates and descriptions noted the following: - 2/17/17: PTACS - 3/9/18: Hi-Lo Beds - 4/7/17: Interior paint - 3/30/17: Beds/mattresses - 6/14/17: Floor repair/drainage The document did not specify a time frame for completion of the work. An additional document included a contractor's name and phone number and included a description of the work to be performed. The document outlined four phases of the plan. The document did not include painting in the facility or a date for the work to be completed.