**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report an allegation violation of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#41) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an allegation of verbal abuse of Resident #41 by a staff member to the facility administrator, local law enforcement or the State Agency. Findings include: I. Facility policy The Abuse Prevention policy, reviewed on 7/18/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 5:47 p.m. It documented in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation. and or misappropriation of resident property is more likely to occur to include trained and qualified. registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms, if any. Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect. II. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physicians orders (CPO), diagnoses included Parkinson's disease, spinal stenosis, history of falling and muscle weakness. The 11/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. The resident required supervision or touching assistance with dressing, transfers and bathing. She was independent with eating and personal hygiene. B. Resident interview Resident #41 was interviewed on 2/27/24 at 9:13 a.m. Resident #41 said licensed practical nurse (LPN) #2 hurt her mouth and teeth when he administered the medications because he broke the capsule of the medication creating a lot of pieces of the capsule in her mouth. She said the capsule was not supposed to be broken because it was an extended-release medication. Resident #41 did not recall water being put in her mouth and said she was upset that LPN #2 broke the capsule because the pieces of the capsule caused pain in her gums and teeth. She said she reported her concern to the provider the following morning. Cross-reference F610 for failure to investigate alleged abuse. C. Record review A 2/13/24 provider visit note documented the following in pertinent part; At the end of my encounter, nursing stepped out to attend to a call bell, during which time the resident reported that the previous shift (night shift) care was 'rough' and 'hurt my lips and my teeth, I'm surprised I could eat breakfast'. It also said that concerns over rough nursing care were reported to the social services director (SSD). -The facility investigation was requested. However, the NHA stated they had not reported or investigated the allegation (see interviews below). The NHA provided a statement from the SSD dated 2/13/24. It read in pertinent part, Resident stated that she is hard to wake when she is sleeping. Nurse was attempting to give her medication and she believes she was in a deep sleep. They put a syringe of water to moisten her mouth. The SSD provided her handwritten note from her initial interview on 2/13/24 with Resident #41. It read in pertinent part, Alleged night nurse woke her up pressing on her shoulder last night. Nurse proceeded to put a pillow over her face and syringe in her mouth telling her to take and swallow. Maybe did not associate it with medicine. Collar was wet. Pushed water into mouth. -Review of the State Agency portal for February 2024 failed to reveal the allegation had been reported. III. Staff interviews The SSD was interviewed on 2/26/24 at 4:23 p.m. The SSD said she did not interview the staff that might have been involved because the director of nursing (DON) or the nursing home administrator (NHA) handled that part of abuse allegations. She said she only talked to the residents about their concerns or allegations. She said Resident #41 was a heavy sleeper and it was probably hard to wake her. The NHA was interviewed on 2/26/24 at 4:39 p.m. The NHA said when she received complaints about resident care she interviewed the resident to see if they felt safe. She reviewed the reporting manual to see if the concern fit the guidelines for reporting. When the complaint fit the guidelines for reporting she made sure the resident was safe and reported the event. She said if the complaint met the requirements for reporting she would interview the staff, however, she did not feel Resident #41's complaint met the requirements so the staff was not interviewed. She said the water was not forced into the resident's mouth in this situation and that it was pushed. The SSD was interviewed a second time on 2/26/24 at 4:45 p.m. The SSD said she believed the complaint should have been reported and thoroughly investigated. She said she was very concerned about the report of water being put in Resident #41's mouth while she was sleeping as that would be an aspiration risk. Licensed practical nurse (LPN) #3 was interviewed on 2/26/24 at 4:55 p.m. LPN #3 said nothing should be administered to a resident unless they were completely awake. He said if a resident was not able to be awakened to receive medication he would not give it at all. He said it was not acceptable to push or place water in a resident's mouth when they were not fully awake as this could cause aspiration. LPN #2 was interviewed on 2/26/24 at 5:25 p.m. LPN #2 said he did not remember the night or the complaint in question. However, he then said Resident #41 was asleep when he initially went in to give her medications so he left the room and came back an hour later. At that time she was awake and he gave the medications and offered a cup of water with a straw. He said he held the cup of water while she took a sip.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to thoroughly investigate an allegation of physical abuse involving two (#41 and #21) of two residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to: -Investigate allegations of physical and/or emotional abuse reported by Resident #41 to a provider; and, -Conduct an investigation of a bump and bruising (injuries of unknown origin) to Resident #21. Cross-reference F609 failure to report an allegation of abuse to the State Agency. Findings include: I. Facility policy The Abuse Prevention policy, reviewed on 7/18/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 5:47 p.m. It documented in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation. and or misappropriation of resident property is more likely to occur to include trained and qualified. registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect. II. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physicians orders (CPO), diagnoses included Parkinson's disease, spinal stenosis, history of falling and muscle weakness. The 11/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. The resident required supervision or touching assistance with dressing, transfers and bathing. She was independent with eating and personal hygiene. B. Resident interview Resident #41 was interviewed on 2/27/24 at 9:13 a.m. Resident #41 said Licensed practical nurse (LPN) #2 hurt her mouth and teeth when he administered the medications because he broke the capsule of the medication creating a lot of pieces of the capsule in her mouth. She said the capsule was not supposed to be broken because it was an extended-release medication. Resident #41 did not recall water being put in her mouth and said she was upset that LPN #2 broke the capsule because the pieces of the capsule caused pain to her gums and teeth. C. Record review A 2/13/24 provider visit note documented the following in pertinent part At the end of my encounter, nursing stepped out to attend to a call bell, during which time the resident reported that the previous shift (night shift) care was 'rough' and 'hurt my lips and my teeth, I'm surprised I could eat breakfast'. It also said that concerns over rough nursing care were reported to the social services director (SSD). -The facility investigation was requested. However, the NHA stated they had not reported or investigated the allegation (see interviews below). The NHA provided a statement from the SSD dated 2/13/24. It read in pertinent part, Resident stated that she is hard to wake when she is sleeping. Nurse was attempting to give her medication and she believes she was in a deep sleep. They put a syringe of water to moisten her mouth. The SSD provided her handwritten note from her initial interview on 2/13/24 with Resident #41. It read in pertinent part, Alleged night nurse woke her up pressing on her shoulder last night. Nurse proceeded to put a pillow over her face and syringe in her mouth telling her to take and swallow. Maybe did not associate it with medicine. Collar was wet. Pushed water into mouth. D. Staff interviews The SSD was interviewed on 2/26/24 at 4:23 p.m. The SSD said she did not interview the staff that might have been involved because the director of nursing (DON) or the NHA handled that part of abuse allegations. She said she only talked to the residents about their concerns or allegations. She said Resident #41 was a heavy sleeper and it was probably hard to wake her. The NHA was interviewed on 2/26/24 at 4:39 p.m. The NHA said when she received complaints about resident care she interviewed the resident to see if they felt safe. She reviewed the reporting manual to see if the concern fit the guidelines for reporting. When the complaint fit the guidelines for reporting she made sure the resident was safe and reported the event. She said if the complaint met the requirements for reporting she would interview the staff, however, she did not feel Resident #41's complaint met the requirements so the staff was not interviewed. The SSD was interviewed a second time on 2/26/24 at 4:45 p.m. The SSD said she believed the complaint should have been reported and thoroughly investigated. She said she was very concerned about the report of water being put in Resident #41's mouth while she was sleeping as that would be an aspiration risk. LPN #3 was interviewed on 2/26/24 at 4:55 p.m. LPN #3 said nothing should be administered to a resident unless they were completely awake. He said if a resident was not able to be awakened to receive medication he would not give it at all. He said it was not acceptable to push or place water in a resident's mouth when they were not fully awake as this could cause aspiration. LPN #2 was interviewed on 2/26/24 at 5:25 p.m. LPN #2 said he did not remember the night or the complaint in question. However, he then said Resident #41 was asleep when he initially went in to give her medications so he left the room and came back an hour later. At that time she was awake and he gave the medications and offered a cup of water with a straw. He said he held the cup of water while she took a sip.III. Resident #21 A. Resident status Resident #21, age greater than 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included dementia, anxiety disorder and major depression disorder. According to the 12/26/23 MDS assessment, the resident was severely cognitively impaired with a BIMS score of one out of 15. She was dependent on staff for toileting, showering and putting on footwear. She needed extensive assistance with dressing, hygiene and eating. The resident used a wheelchair for mobility. The assessment indicated the resident did not exhibit any behaviors during the assessment period. B. Record review An 8/17/23 nursing progress note documented an unknown certified nurse aide (CNA) reported a bump and bruise on Resident #21's left forehead and eye. The unknown CNA noticed the injuries when she transferred the resident out of bed. The CNA reported the injuries to the nurse. The progress note indicated the DON would do the investigation. The Abuse/Adverse Event investigation, dated 8/17/23, documented the resident had a fall with injury. Resident #21 had two prior falls on 11/2/22 and 7/29/23. The incident was not witnessed. Resident #21's daughter was interviewed and agreed the bruise was from the clutter in the resident's room. The daughter was not present at the time of the event. The daughter said there was a small dresser in the room that she may have bumped into. The dresser was removed from the room since it was at eye level. -Several sections of the investigation event were not completed, including the section on what had occurred, the chronological timeline and interviews from staff. The staff interview section documented the resident moved while in her bed and had caused multiple injuries. -The investigation did not indicate who was interviewed. There were no behavioral issues documented in the progress notes before the incident. C. Staff interviews CNA #1 was interviewed on 2/27/24 at 8:50 a.m. CNA #1 said she would report any bruises or injuries to the nurse and document them in the resident's chart. CNA #1 said reporting injuries of unknown origin was important so an investigation could occur. CNA #1 said Resident #21 would squirm in her bed and checking on her regularly to prevent her from falling was essential. CNA #1 said she was not working in the facility during the incident. Registered nurse (RN) #1 was interviewed on 2/27/24 at 9:05 a.m. RN #1 said she would start an incident report and report bruises of unknown origins to the DON once she was made aware of them. RN #1 said the administration would perform investigations of injuries of unknown origin to rule out abuse. RN #1 said Resident #21 did not get restless often. RN #1 said a dresser in the resident's room next to her bed was at eye level and was three inches from the bed. RN #1 said the resident had wedges on her bed to keep her from falling. RN #1 said she could not remember the incident on 8/17/23. The NHA was interviewed on 2/27/24 at 9:56 a.m. The NHA said staff should report bruises of unknown origins to the nurse and she would notify the DON and administration. The NHA said staff should immediately report injuries of unknown origin. The NHA said the administration would investigate to ensure there was no abuse and that the investigation would depend on staff and environmental factors. The NHA said the staff interviews were not documented in the 8/17/23 investigation. The NHA acknowledged the blank spaces in the investigation and said during a huddle held in the resident's room they decided the resident did not fall. The NHA said the resident turned in her bed and bumped her head and no further investigation was done. The NHA said she talked to staff but did not document what they said. The NHA said the resident had anxiety before the incident occurred and that was what led to the bump and bruise on her forehead and eye.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the facility medication administration observation error rate was 7.14% or two errors out of 28 opportunities. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/28/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Administration of Medications policy, revised 7/14/21, was provided by the nursing home administrator (NHA) on 2/7/24 at 12:37 p.m. It read in the pertinent part, Medication Error - means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1.The prescriber's order; 2.Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or 3.Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. III. Observations On 2/26/24 at 9:49 a.m., licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #183. The resident's physician's order was for: Gabapentin capsule 100 mg (milligrams). Give one capsule by mouth three times a day for pain. Scheduled for 8:00 a.m., 2:00 p.m. and 7:00 p.m. -LPN #1 was unable to locate the medication for the resident and therefore did not administer the medication to Resident #183. On 2/26/24 at 9:57 a.m., LPN #1 was observed preparing and administering medications to Resident #80. The resident's physician's order was for: Pantoprazole Sodium oral tablet delayed release 40 mg. Give 40 mg by mouth one time a day for gastroesophageal reflux disease (GERD). Scheduled for morning administration. -LPN #1 was unable to locate the medication for the resident and therefore did not administer the medication to Resident #80 III. Staff interviews LPN #1 was interviewed on 2/26/24 at 9:59 a.m. LPN #1 said she was unable to locate the ordered medications. She said she did send a request to the pharmacy for the gabapentin for Resident #183 and this was the third request sent to the pharmacy. The NHA was interviewed on 2/26/24 at 11:08 a.m. The NHA said she would look into the medications that were not administered. She said LPN #1 was fairly new to the facility and may not have been aware of the emergency medications that were available to administer in the event a medication was unavailable in the medication cart. IV. Facility follow up On 2/26/24 at 11:28 a.m., the NHA said she was able to find Resident #183's gabapentin in another location in the medication cart and LPN #1 administered the medication to the resident. -However, the gabapentin had been scheduled for 8:00 a.m. Therefore, the late administration of the medication was still a medication error. The NHA said the order for pantoprazole sodium had a standing order (an order authorized by a prescriber) to substitute with omeprazole (another medication used to treat GERD). The NHA said she updated the order in Resident #80's medical record, educated LPN #1 and LPN #1 gave the medication to the resident. -However the pantoprazole sodium had been scheduled for the morning administration. Therefore, the late administration of the medication was still a medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#140) of one resident out of 38 sample residents. Specifically, the facility failed to: -Ensure clinical signs and symptoms of an infection were identified for Resident #140 prior to administering antibiotics; and, -Ensure a urinalysis with a culture (laboratory test to identify bacteria) and sensitivity (a laboratory test used to determine what medication/antibiotic will work best to treat an infection) (C&S) were obtained, according to a physician's order, prior to administering antibiotics for Resident #140. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix B, retrieved online on 3/6/24 from https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdf, Incomplete assessment and documentation of a resident's clinical status, physical exam or laboratory findings at the time a resident is evaluated for infection can lead to uncertainty about the rationale and/or appropriateness of an antibiotic. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing elements have been addressed and recorded. II. Facility policy and procedure The Antibiotic Stewardship policy and procedure, reviewed May 2023, was provided by the nursing home administrator (NHA) on 2/21/24 at 10:00 a.m. It revealed in pertinent part, The antibiotic stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program will be managed and overseen by the infection preventionist. Assessment of residents suspected of having an infection: the facility will utilize the McGeer Criteria when considering initiation of antibiotics. Antibiotic time out: at 72 hours after antibiotic initiation or first dose in the facility, each resident should be reassessed for consideration of antibiotic need. At this time, laboratory testing results, response to therapy and resident condition will be considered. Tracking: process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of SBAR's (situation, background, assessment and review) and other clinical documentation during clinical meetings and ongoing reviews of the completeness of prescribing documentation to include dose, route, duration and indication for use. III. Resident #140 A. Resident status Resident #140, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included hemiplegia (complete paralysis affecting one or more extremities on one side of the body) and hemiparesis (partial weakness affecting one or more extremities on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. B. Record review The February 2024 CPOs documented the following physician order: Keflex (antibiotic) oral capsule 500 mg (milligrams) - give one capsule by mouth two times a day for a UTI (urinary tract infection). Please do not start until urinalysis and urine culture has been collected, ordered 2/21/24. The February 2024 medication administration record (MAR) documented that the resident was administered Keflex starting on 2/21/24 until 2/26/24. -A review of the resident's medical record did not reveal documentation that a urinalysis had been completed with a urine culture per the physician's orders. -It did not include documentation indicating what symptoms Resident #140 exhibited to warrant an antibiotic being ordered. IV. Staff interviews The infection preventionist (IP) and the NHA were interviewed on 2/26/24 at 4:33 p.m. The IP said the facility followed a specific criterion when an infection was suspected. She said, in order for a lab test to be ordered, the resident had to meet all criteria. The IP said she had researched Resident #140's use of Keflex. She said she was only able to find documentation that the resident had experienced dysuria (painful urination), but no other symptoms. She said the dysuria alone did not meet the criteria for the resident to be administered an antibiotic. The IP said she was unable to find documentation that a urinalysis with a culture had been completed as ordered by the physician. She said the medication should not have been administered until the results of the laboratory with the culture had returned. She said she contacted the laboratory and confirmed a urinalysis had not been obtained. She said she called the physician and recommended the antibiotic be discontinued. She said since the resident did not meet the criteria and the facility did not follow the physician's order, the resident was administered the antibiotic unnecessarily. The IP said she was responsible for the antibiotic stewardship program at the facility. She said she had not reviewed Resident #140's use of the antibiotic prior to 2/26/24, during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for two out of three units. Specifically, the facility failed to: -Ensure disinfectant dwell times were followed by the housekeeping staff when cleaning resident's rooms; and, -Ensure staff performed hand hygiene appropriately when passing medications. Findings include: I. Failure to ensure disinfectant dwell times were followed appropriately A. Facility policy The Daily Room Cleaning policy and procedure, revised 2/24/22, was received by the nursing home administrator (NHA) on 2/27/24 at 12:37 p.m. The policy read in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections. All housekeeping personnel must adhere to infection prevention and control guidelines. Using a damp rag (Hospital Grade EPA Registered Disinfectant List N and water) damp dust the room starting with the resident's area (over bed table, bedside table, and phone) and move to the rest of the items in the room. This includes window sills, door frames, shelves, walls, and doors. Clean and disinfect restrooms. Using a Hospital Grade EPA Registered Disinfectant List N solution and clean rag, wipe counters, shelves, shower, horizontal, and vertical surfaces. B. Observations During an observation on 2/22/23 at 11:48 a.m. in room [ROOM NUMBER], housekeeper (HSK) #1 was cleaning the resident's room. HSK #1 sprayed Virex II 256 disinfectant around the sink and inside of the sink and then went into the bathroom and flushed the toilet and sprayed around the toilet with Virex II 256 disinfectant. -At 11:49 a.m. (one minute after spraying the sink with the disinfectant), HSK #1 turned on the water in the sink and wet the clean rag and used the wet rag to clean inside the sink. HSK #1 took another clean rag and wiped around the sink. She grabbed a couple of paper towels and finished cleaning around the sink. HSK #1 disposed of the two rags she had used to clean the sink area. -HSK #1 failed to leave the sprayed disinfectant on the sink surface for the 10 minute dwell time before wiping the sink. At 11:52 a.m. HSK #1 took the Virex II 256 disinfectant spray and two clean rags back into room [ROOM NUMBER]. She sprayed one of the clean rags with the disinfectant spray, turned on the water in the sink and got the rag wet and began wiping down the top of the resident's bedside table. -HSK #1 wiped the top of the resident's bedside table for 10 seconds. -HSK #1 failed to spray the top of the bedside table directly with the disinfectant and wait the dwell time of 10 minutes before wiping down the bedside table. During an observation on 2/26/24 at 9:40 a.m. in room [ROOM NUMBER], HSK #2 was cleaning the resident's room. HSK #2 had the Virex II 256 disinfectant spray and two clean rags sitting on top of the sink. At 9:47 a.m. HSK #2 sprayed the Virex II 256 disinfectant spray around the sink and in the sink. She turned on the sink and placed the clean rag under the water to wet it and began cleaning around the sink and inside the sink. -HSK #2 failed to leave the sprayed disinfectant on the sink surface for the 10 minute dwell time before wiping the sink. At 9:48 a.m., HSK #2 got a clean rag, sprayed, Virex II 256 disinfectant spray directly on the rag and began wiping down the top of the resident's bedside table. -HSK #2 failed to spray the top of the bedside table directly with the disinfectant and wait the dwell time of 10 minutes before wiping down the bedside table. C. Record review The material safety data sheet (MSDS) was provided by the housekeeping director (HSKD) on 2/26/24 at 2:00 p.m. The disinfectant in the facility was identified as VIREX II 256. It was a one-step disinfectant cleaner. The directions for the VIREX II 256 disinfectant spray read in pertinent part, Apply solution to hard, non-porous environmental surfaces. Contact time: allow surface to remain wet for 1 (one) minute to kill human immunodeficiency virus (HIV)-1, 5 (five) minutes to kill hepatitis b virus (HBV) and hepatitis c virus (HCV), and for 10 minutes to kill all other organisms cited on the label. D. Staff interviews HSK #1 was interviewed on 2/22/24 at 11:55 a.m. She said when she used the Virex II 256 disinfectant spray she used a little bit of water because the smell was strong for the residents. HSK #2 was interviewed on 2/26/24 at 9:50 a.m. She said when the residents were not in the room she could do a better job deep cleaning but when the residents were in the room she could only clean what she was able to get to. She said she would deep clean three to four rooms a week. She said she did not know if the disinfectant spray she used was safe to clean the bedside table tops so she said she used soap and water and a little bit of the Virex II 256 disinfectant spray to clean them. HSK #2 was interviewed again on 2/26/24 at 1:10 p.m. HSK #2 said she had been trained to leave the disinfectant spray on for three to four minutes and then wipe it off the surfaces. She said she thought that was the right way to do it. HSK #1 was interviewed again on 2/26/24 at 1:20 p.m. HSK #1 said she left the disinfectant spray on surfaces for five minutes before wiping it off. She said she was trained to leave the disinfectant spray on for five minutes. The HSKD was interviewed on 2/26/24 at 1:47 p.m. She said the dwell time for the disinfectant spray was 10 minutes. She said she trained housekeeping staff on the appropriate dwell times. She said she reminded her staff at least once a month about dwell times. She said housekeeping staff used water and the disinfectant spray because the residents did not like the smell of the disinfectant spray. The HSKD said it was not okay to dilute the disinfectant spray. She said diluting the disinfectant spray with water was concerning because it would not kill all the viruses or bacteria if it was diluted.II. Failure to ensure hand hygiene was performed effectively during medication administration A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 2/29/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Observations On 2/26/24 at 9:02 a.m., licensed practical nurse (LPN) #1 prepared medications for a resident. She walked to the resident's room with her blood pressure cuff and stethoscope and administered medications to the resident after obtaining the resident's blood pressure and pulse. LPN #1 returned to the medication cart, put on gloves and cleaned her equipment. She discarded her gloves and went to the sink behind the nurses station and began washing her hands at 9:11 a.m. -She washed her hands with soap and water for six seconds. At 9:16 a.m., LPN #1 went to a resident's room and obtained vital signs from the resident. She returned to the medication cart and cleaned her equipment. At 9:20 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for six seconds. At 9:26 a.m., LPN #1 administered medications to a resident. At 9:28 a.m., she went to the sink in the resident's room and washed her hands. -She washed her hands with soap and water for eight seconds. At 9:30 a.m., LPN #1 went to a resident's room and obtained his vital signs. At 9:33 a.m., she returned to the medication cart and cleaned her equipment. At 9:35 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for six seconds. At 9:36 a.m., LPN #1 went back to the resident's room and administered his medications. At 9:38 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for two seconds. At 9:45 a.m., LPN #1 went to a resident's room and obtained his vital signs. At 9:47 a.m., she returned to the medication cart and cleaned her equipment. At 9:49 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for six seconds. At 9:57 a.m., LPN #1 administered medications and applied a medication patch to a resident. At 10:00 a.m., she went to the sink behind the nurses station and washed her hands. -She washed her hands with soap and water for seven seconds. At 10:14 a.m., LPN #1 was notified of a small yellow pill on the floor in the medication room. She picked it up and destroyed it. At 10:19 a.m., she went to the sink behind the nurses station and washed her hands. -She washed her hands with soap and water for six seconds. At 10:22 a.m., LPN #1 applied a medication patch to a resident. At 10:23 a.m., she went to the sink in the resident's room and washed her hands. -She washed her hands with soap and water for three seconds. C. Interviews The director of nursing (DON) was not available for an interview during the survey. The regional nursing consultant (RNC) was interviewed on 2/27/24 at 9:50 a.m. She said that staff should wash their hands or use hand sanitizer before and in between each resident during the medication pass. She said when staff washed their hands they should wash them for a total of 20 seconds or the amount of time it took to sing the happy birthday song twice. She said failure to perform hand hygiene properly could lead to the spread of viruses or infections in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to establish and maintain infection control designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically, the facility failed to: -Ensure residents were offered hand hygiene prior to eating for room trays; and, -Ensure staff perform hand hygiene between residents during room tray delivery. I. Professional reference The Hand Hygiene guidance, updated 1/30/2020, retrieved on 12/28/22, from: https://www.cdc.gov/handhygiene/providers/guideline.html, documented in part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: after touching a patient or patients immediate environment and immediately after glove removal. II. Facility policy and procedure The Hand Hygiene for Residents, Families, and Visitors policy, dated 6/7/22, received from the Nursing home administrator (NHA) on 12/29/22 at 12:52 p.m. revealed in pertinent part, to decrease the risk of transmission of infection by enabling residents to perform appropriate hand hygiene. Staff should encourage and assist the resident as needed to ensure proper hand hygiene through hand washing or use of alcohol based hand rub. Hand hygiene should be offered/performed: prior to handling and/or consumption of food or beverage. The Hand Hygiene policy, dated 7/15/22, received from the NHA on 12/29/22 at 12:52 p.m. revealed in pertinent part, hand washing and hand hygiene is generally considered the most important procedure in preventing nosocomial infections. The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. Facility to provide education to associates on hand hygiene, associates are to perform hand hygiene before and after contact with a resident, after contact with objects in resident's rooms. III. Observations Certified nurse aide (CNA) #1 observed on 12/28/22 at 12:05 p.m. passing trays on the North unit. She passed a meal tray to room [ROOM NUMBER]-1 there was no resident present in the room, she left the tray on the bedside table. No hand sanitizing wipe was on the meal tray. She completed hand hygiene on exit with alcohol based rub. She then proceeded to pass the meal tray to room [ROOM NUMBER]-1, there was not a hand sanitizing wipe on the tray. She failed to offer hand hygiene to the resident and complete hand hygiene on exit of the resident's room. She then collected the tray for room [ROOM NUMBER]-1. The meal tray contained a hand sanitizing wipe which, was placed on the meal tray by CNA #7. She delivered the meal tray to the resident but failed to offer assistance with hand hygiene. She exited the residents room without performing hand hygiene. She then delivered a meal tray to room [ROOM NUMBER]-2. There was no hand sanitation wipe on the meal tray. She failed to offer hand hygiene to the resident and the CNA failed to perform hand hygiene on exit. CNA #5 was observed at 12:22 p.m. passing room meal trays on the North unit. She passed a meal tray to room [ROOM NUMBER]-1. There was no hand sanitizing wipe on the meal tray. The CNA failed to offer hand hygiene to the resident. The CNA touched resident personal items on the bedside table in order to place the meal tray down. She then exited the room without performing hand hygiene. She proceeded to pass a meal tray to room [ROOM NUMBER]-1. There was no sanitizing wipe on the meal tray, and no hand hygiene was offered to the resident. She failed to perform hand hygiene on exit of the residents room. She then delivered a meal tray to room [ROOM NUMBER]-2. The CNA applied gloves without performing hand hygiene prior, collected the meal tray, a hand sanitizing wipe was not on the meal tray. She failed to offer hand hygiene to the resident. The CNA removed her gloves and exited the resident room, she failed to perform hand hygiene and returned to the meal cart. The resident was in isolation for extended spectrum beta-lactamase (ESBL, a type of infection) in urine. At 12:30 p.m. the dietary aide (DA) transported the meal tray cart to the South wing. She then placed sanitizing hand wipe on top of every tray for the South wing. CNA #4 was observed to be passing the meal trays on the South wing at 12:31 p.m. He passed to room [ROOM NUMBER], where he failed to perform hand hygiene before and after entering the room. He did not offer hand hygiene to the resident. He then passed a meal tray to room [ROOM NUMBER]. He removed the hand sanitizing wipes off of the meal tray. He failed to perform hand hygiene before and after passing the tray. He failed to offer hand hygiene to the resident. He passed a meal tray to room [ROOM NUMBER]. He failed to perform hand hygiene prior to entering the resident room. He placed a clothing protector for the resident, removed the cover from the dish, cut up the food and checked for condiments. He failed to offer hand hygiene to the resident and there was not a sanitizing wipe on the tray. He failed to perform hand hygiene on exit of the residents room. He went to the meal cart and touched the cart to check for additional meal trays. CNA #3 was observed to be delivering meal trays on the South wing at 12:36 p.m. She delivered to room [ROOM NUMBER] where she failed to perform hand hygiene prior to entering the room and failed to offer hand hygiene to the resident. She delivered a meal tray to 209. She failed to perform hand hygiene prior to entering the room. III. Staff interviews CNA #1 was interviewed on 12/28/22 at 12:37 p.m. She said this was her second shift at this facility and she had not seen hand sanitizing wipes being offered for any meals. She said there were none yesterday or this morning with breakfast. Staff should wash their hands between residents if they touch any personal items in their rooms or the residents. CNA #5 was interviewed on 12/28/22 at 12:37 p.m. She said sanitizing wipes were to be provided to residents with every meal and staff should perform hand hygiene between tray delivery especially if we touch the residents personal items. CNA #6 was interviewed on 12/28/22 at 1:40 p.m. She said the process for meal delivery was when trays arrive on the floor, read the ticket for drinks, then deliver to residents and assist with tray set up. Hand hygiene was offered to each resident with each meal, after restroom breaks and when their hands appeared to be dirty. Staff were to perform hand hygiene between residents, during meals if staff touch personal items in resident rooms or the residents themselves. The NHA and the infection preventionist (IP) #1 and #2 were interviewed on 12/29/22 at 11:15 a.m. The NHA said residents were to be offered hand hygiene either with soap and water or be provided with a hand sanitizing wipe before meals. The NHA said staff were to perform hand hygiene before and after resident cares and after touching resident personal items either soap and water or alcohol based hand rub may.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure oxygen was administered at the physician-ordered flow rate to prevent potential complications for 1 (Resident #80) of 3 sampled residents reviewed for oxygen therapy. Findings included: Review of a facility policy titled, Oxygen Administration/Safety/Storage/Maintenance, dated as reviewed 10/07/2022, revealed Oxygen will be administered in accordance with physician orders and current standards of practice. Review of an admission Record revealed Resident #80 had diagnoses including chronic diastolic (congestive) heart failure and obstructive sleep apnea. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #80 scored 14 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more people with bed mobility and transfers. According to the MDS, the resident had not received oxygen therapy in the 14 days prior to the assessment. Review of a care plan, dated as initiated 07/08/2021, revealed Resident #80 needed oxygen therapy due to shortness of breath from congestive heart failure. A planned intervention was to administer oxygen at 1.5 liters per minute (LPM) continuously. Review of an Order Listing in Resident #80's electronic medical record revealed the resident had a physician's order dated 06/08/2021 for oxygen to be administered continuously at 1.5 LPM via nasal cannula. Observation on 11/07/2022 at 10:30 AM revealed Resident #80 sitting in a wheelchair in their room with a portable oxygen cannister behind the wheelchair. The resident was receiving oxygen via nasal cannula, with the flow rate set at 2.5 LPM, instead of 1.5 LPM as ordered by the physician. Review of a November 2022 Treatment Administration Record indicated Resident #80 was to receive oxygen at 1.5 LPM via nasal cannula and that the nurses were to document the oxygen administration every shift. Further review revealed Registered Nurse (RN) #3 had initialed the oxygen to have been administered as ordered during the day shift on 11/07/2022. Observation on 11/08/2022 at 2:20 PM revealed Resident #80 was receiving oxygen via nasal cannula, with the flow rate on the resident's oxygen concentrator set on 3 LPM, instead of 1.5 LPM as ordered by the physician. During an interview at this time, Resident #80 denied ever having adjusted the oxygen flow and stated the nurses took care of that. The resident indicated they were unsure what the oxygen flow rate should be. Review of the November 2022 Treatment Administration Record revealed RN #3 had initialed the oxygen order to indicate the oxygen was administered as ordered during the day shift on 11/08/2022. Observation on 11/09/2022 at 2:55 PM revealed Resident #80 was sitting in a wheelchair receiving oxygen at 2.5 LPM via nasal cannula connected to a portable oxygen tank. Review of the November 2022 Treatment Administration Record revealed RN #3 had initialed the oxygen order to indicate the oxygen was administered as ordered during the day shift on 11/09/2022. During an interview on 11/09/2022 at 2:55 PM, Licensed Practical Nurse (LPN) #1 revealed RN #3, who was assigned to care for Resident #80, was on lunch break. LPN #1 checked Resident #80's oxygen flow rate and verified it was set at 2.5 LPM. The LPN stated he was not sure what the rate should be. During an interview on 11/10/2022 at 9:10 AM, RN #3 stated nursing staff should check on residents who received oxygen therapy at the beginning of their shift and ensure the resident was wearing the nasal cannula correctly, ensure oxygen tanks were full, and check the flow rate on the oxygen concentrator/tank. RN #3 stated that most of the time, he looked at the physician's orders, but he did not always verify the order when documenting on a resident's TAR. RN #3 stated he thought Resident #80's physician's order for oxygen was 2.5 LPM. He indicated he did not know why he documented the flow rate as 1.5 LPM on 11/07/2022, 11/08/2022, and 11/09/2022. RN #3 stated he kept Resident #80's oxygen at 2.5 LPM and had not informed the physician about the change in flow rate. He stated he did not request an order to change the flow rate but should have. Observation on 11/10/2022 at 8:00 AM revealed Resident #80 lying in bed receiving oxygen at 3 LPM via nasal cannula. Review of the November 2022 Treatment Administration Record at this time revealed staff had not yet initialed the resident's oxygen for day shift on 11/10/2022. During an interview on 11/10/2022 at 8:03 AM, LPN #2 verified Resident #80's oxygen flow rate was set to deliver oxygen at 3 LPM. LPN #2 stated she checked on Resident #80 that morning and that a certified nursing assistant (CNA) obtained the resident's vital signs. She indicated the resident had since been sleeping, and she had not checked the resident's oxygen setting nor physician orders. LPN #2 stated nursing staff should always check residents' physician orders; however, she stated she could not remember the last time she looked at Resident #80's physician orders and could not remember Resident #80's physician-ordered oxygen flow rate. During an interview on 11/10/2022 at 9:23 AM, the Director of Nursing (DON) revealed that if staff needed to increase a resident's oxygen rate, staff should document the need and contact the physician. The DON indicated nursing staff should review the current physician orders when documenting oxygen administration on a resident's Treatment Administration Record. She stated there were probably times when staff knew the correct oxygen flow rate and did not look at the orders. The DON stated she expected staff to ensure residents were receiving oxygen at the flow rate ordered by the physician and to accurately document. The DON confirmed that RN #3 had Resident #80's oxygen set on 2.5 LPM when the order was for 1.5 LPM, and stated RN #3 should have contacted the physician. During an interview on 11/10/2022 at 10:13 AM, the Administrator stated she expected nursing staff to have an order for oxygen administration and for nurses to follow the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews he facility failed to ensure the right to self-administer medications was appropriately assessed by the interdisciplinary team for one (#13) of four out of 40 sample residents. Specifically, the facility failed to complete an assessment to keep Benadryl medications at bedside for Resident #13. Finding include: I. Facility policy The Self-Medication policy, reviewed on 4/15/19, was provided by the nursing home administrator (NHA) on 7/12/21 at 1:00 p.m., it read in pertinent part; Each resident who desires to self-administer medication was permitted to do so if the facilities interdisciplinary team had determined the practice would be safe fo the resident and other residents in the facility. The procedure: 1.If the resident desires to self-administer medication, an order for self-administration will be obtained from the physician, and an assessment was conducted by the interdisciplinary team of the residents cognitive, physical, and visual ability to carry out the responsibility. 2.The interdisciplinary team determines the residents ability to self-administer medications by means of a skills assessment. II. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), diagnoses included hypertension, depression, osteoarthritis and chronic kidney disease. The 4/12/2021 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required extensive assistance with two people for transfers. Extensive assistance with one person assist for bed mobility, toilet use, dressing and personal hygiene. She was totally dependent on bathing and required a hoyer lift for transfers with two people. No rejection of care was documented. III. Resident observations and interviews Resident #13 was observed on 7/7/21 at 10:30 a.m. laying in her bed. She had a bottle of medication unlabeled on her bedside table. She also had a spray bottle of Benadryl on the table. She said the pills were Benadryl tablets she took when her allergies flared up to help stop her from itching. She said the spray bottle of Benadryl she used on her skin to stop the itch. She said she kept the bottle out of sight but she used it regularly since she moved to the facility a few years ago. She said her family brought the medication to her and she thought the facility was aware she took the medication in her room. She did not tell the facility when she needed the medication and when she took the medication. She said she had not been assessed to take the medication but she was going to take it anyway. IV. Record review Review of the July 2021 CPO for Resident #13 on 7/7/21 at 3:30 p.m., revealed no orders to self administer medications and no order for Benadryl tablets or Benadryl spray. Further review of records showed no self administration of medications assessment for Resident #13 and no care plan to self administer medications. V. Staff interviews Unit manager (UM) #1 was interviewed on 7/12/21 at 9:30 a.m. She said when a resident had medications at the bedside an assessment was completed to check the resident's cognition. The assessment was completed to make sure the resident knew when and how to take the medication correctly. She said the families of the residents often brought in medications without the facility being aware. She did not know if Resident #13 took her own medication or not. Registered nurse (RN) #2 was interviewed on 7/12/21 at 10:30 a.m. She said when a resident had to self administered medications a physician's order was completed and an assessment prior to the medication being at bedside. She said an assessment to make sure the resident was safe to administer their own medications. She was not aware that Resident #13 took medication on her own at bedside. Licensed practical nurse (LPN) #1 was interviewed on 7/12/21 at 11:16 a.m. He said some residents had medications at their bedside. He said an assessment was completed for the resident who took the medication on their own to make sure they were safe to take the medication and to store the medication safely so no other residents had access to the medication in the residents room. The director of nurses (DON) was interviewed on 7/13/21 at 11:30 a.m. She said self medication administration for residents required a physician order and a full assessment with the resident to make sure they were safe to take the medication on their own. She said Resident #13 was not assessed for self medication administration until 7/12/21 (during the survey). VI. Facility follow-up: A physician's orders was completed on 7/12/21 at 12:56 p.m. for Resident #13 that read; Resident #13 was ok to have over the counter medications at bedside as needed. The order did not specify which medication and/or how to monitor the medication. An assessment to self administer medications for Resident #13 was completed on 7/12/21 at 11:52 a.m. and was provided by the unit manager (UM) #1 on 7/12/21 at 1:15 p.m.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#6) of two residents reviewed for abuse out of 40 sample residents. Specifically, the facility failed to report an incident of verbal aggression by Resident #6 toward Resident #86 to the State Agency timely. Findings include: I. Facility policy and procedure The Reporting Alleged Abuse policy and procedure, revised February 2017, was provided by the nursing home administrator (NHA) on 7/7/21 at 10:00 a.m. It revealed, in pertinent part, All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. All personnel are mandated to promptly report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin will be promptly reported to the administrator and/or director of nursing. Federal requirements mandate that facilities must ensure all allegations of abuse, neglect, exploitation, or mistreatment are reported immediately to their state survey agency. Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials, including the state survey agency. II. Record review An incident of verbal aggression by Resident #6 toward Resident #86 occurred on 5/9/21. The facility was unable to provide documentation an investigation had been completed following the 5/9/21 incident of verbal aggression from Resident #6 toward Resident #86 and was reported to the State Survey Agency during the survey process (7/7/21-7/13/21). Cross reference F610: the facility failed to ensure an allegation of verbal aggression was thoroughly investigated. III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 7/12/21 at 12:42 p.m. She said any incidents of verbal abuse should be reported to the nurse, DON and NHA. She said the NHA and DON were responsible for conducting the investigation. The social services director (SSD) and the NHA were interviewed on 7/12/21 at 2:47 p.m. The NHA said the facility was unable to find documentation that the incident of verbal aggression was reported to the State Survey Agency. She said she was responsible for reporting all allegations of abuse to the State Survey Agency. The NHA said she was not made aware of the incident of verbal aggression from Resident #6 toward Resident #86. The SSD said he did not think the incident of verbal aggression rose to the level of abuse and did not feel it was a reportable incident. The NHA acknowledged the federal requirement that indicates any allegation of abuse must be reported to the State Survey Agency and the investigation would yield results to determine if the incident substantiated abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to investigate an allegation of verbal aggression involving one (#6) of two residents reviewed for abuse out of 40 sample residents. Specifically, the facility failed to conduct an investigation of an incident of verbal aggression by Resident #6 toward Resident #86. Findings include: I. Facility policy and procedure The Abuse Investigation Protocol policy and procedure, revised November 2017, was provided by the nursing home administrator (NHA) on 7/7/21 at 10:00 a.m. It revealed, in pertinent part, If a resident, family, visitor or staff member observes or alleges that .has been yelled at or been rude to .then a concern/comment blue cart is initiated documenting the allegation of abuse. The card is to be entered on the 'investigation log' by the executive director (ED). When there is an allegation, an investigation is required and the executive director will lead the investigation. The executive director will assign interviews to be completed by the social services department: resident, family and staff; interviewing 10% of the population. Be sure to interview all departments that have interacted with the resident alleging the abuse. Once the investigation data collection has been completed, the interdisciplinary team comprised of the executive director, director of nursing, and social services at a minimum, will review the data and together attempt to determine if the allegation of abuse can be substantiated. II. Resident status A. Resident #6 Resident #6, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood and manic episodes. The 4/9/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was independent with all activities of daily living. The resident did not exhibit behaviors during the assessment period. B. Resident #86 Resident #86, age [AGE], was admitted on [DATE]. According to the July 2021 CPOs, the diagnoses included lack of expected normal physiological development in childhood and insomnia. The 6/28/21 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing and toileting. She required limited assistance of one person with personal hygiene. The resident did not exhibit behaviors during the assessment period. III. Record review The behavior care plan for Resident #6, initiated 1/20/21, documented the resident exhibited verbally aggressive and vulgar behavior related to her anxiety. The interventions included: two person staff with all care provide to the resident; analyze key times, places, circumstances, triggers and what de-escalates the resident's behavior; assess and anticipate the resident's needs; assess the resident's coping skills and support system; give the resident as many choices as possible about care and activities; and provide positive feedback for good behavior. The 5/9/21 behavioral progress note documented Resident #6 exhibited verbal aggression towards her roommate, Resident #86. It indicated Resident #6 called her roommate lazy because she would not get up out of bed and was showered while she was in bed. It did not indicate the episode of verbal aggression was reported to a supervisor or was investigated to determine if verbal abuse occurred. Resident #86's medical record was reviewed on 7/12/21 at 3:56 p.m. It did not reveal documentation of the incident with the roommate on 5/9/21. The facility was unable to provide documentation an investigation had been completed following the 5/9//21 incident of verbal aggression from Resident #6 toward Resident #86 and had been reported to the State Agency during the survey process (7/7/21-7/13/21). Cross reference F609: the facility failed to report the incident to the State Agency timely. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 7/12/21 at 12:42 p.m. She said Resident #6 was very verbally abusive, aggressive and vulgar in her language. She said she would get verbally aggressive toward her roommate. She said they would argue, but Resident #6 would become aggressive. She said Resident #6 would yell explicit language at Resident #86. She said Resident #6 was easily triggered by the littlest things, such as not wanting the air conditioning on. She said the resident's roommate, Resident #86, was more easy going and would let Resident #6's behavior roll off her back. She said Resident #86 did not want to move because she knew what to expect from Resident #6 and did not want a worse situation with a new roommate. She said any incidents of verbal abuse should be reported to the nurse, director of nursing (DON) and NHA. She said the NHA and DON were responsible for conducting the investigation. The social services director (SSD) and the NHA were interviewed on 7/12/21 at 2:47 p.m. The NHA said the facility was unable to find documentation of an investigation into the incident of verbal aggression by Resident #6 toward Resident #86. The SSD said the facility did not have any documentation Resident #6 or Resident #86 were interviewed following the incident of verbal aggression. He said the facility did not have documentation that the staff were interviewed following the incident. The NHA acknowledged the federal requirement that indicates any allegation of abuse must be thoroughly investigated to determine if abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to inform residents of the facility's bed hold policy for two (#65 and #76) of two residents reviewed for discharge/transfer out of 40 sample residents. Specifically, the facility failed to ensure the resident's or their responsibility party were informed in writing of the facility's bed hold policy prior to being discharged or transferred from the facility. Findings include: I. Facility policy and procedure The Acknowledgement of Bed Hold policy, not dated, was provided by the business office manager (BOM) on 7/13/21 at 12:00 p.m., it read in pertinent part: Bed hold facility protocol revealed in the case of emergency medical transport; the bed hold agreement was included with other paperwork, which accompanied the resident to the hospital. The health information manager mailed a copy of the agreement to the resident within 24 hours unless the resident had been readmitted back to the facility. In the event of a non-emergent medical transfer the bed hold agreement was given to the resident or legal representative prior to the transfer. II. Resident #65 A. Resident status Resident #65, age [AGE], was admitted on [DATE], and discharged from the facility 7/12/21. According to the July 2021 computerized physician orders (CPO), diagnoses included Parkinson, depression, dementia and chronic kidney disease. The 6/9/2021 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of nine out of 15. B. Record review Nurse note on 7/12/21 at 1:44 p.m. read Resident #65 continued to have difficulty with pocketing medications and water. She required cues and reminders to swallow and to stay awake when given evening medications. She was not speaking to the staff and her spouse and her blood pressure was high at 220/100. The physician was notified and ordered the resident to go to the emergency room for an evaluation. On 7/13/21 at 11:30 a.m., Resident #65's medical record was reviewed and showed no written bed hold notice. III. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE], and discharged from the facility 7/12/21. According to the July 2021 computerized physician orders (CPO), diagnoses included end stage renal disease, diabetes, and chronic obstructive pulmonary disease. The 5/6/2021 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a (BIMS) of 10 out of 15. B. Record review Nurse note on 7/12/21 at 5:00 p.m. read Resident #76 went to the hospital in the morning for a blood transfusion. She did not return on 7/12/21 to the facility since she was admitted to the hospital. On 7/13/21 at 11:33 a.m., Resident #76's medical record was reviewed and showed no written bed hold notice. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/13/21 at 11:45 a.m. He said the facility did not provide a bed hold to the residents when they went to the hospital. He said he had worked there a long time and had not seen any. Registered nurse (RN) #2 was interviewed on 7/13/21 at 11:50 a.m. She said Resident #65 and #76 did not have a bed hold in their electronic records because the facility did not provide those to the residents or the families. The business office manager (BOM) was interviewed on 7/13/21 at 11:55 a.m. She said the facility did not provide written notice of bed holds to the residents or families unless the resident was private pay or the facility had 90 percent (%) capacity. She said the residents were able to come back to the facility and have their same room. The nursing home administrator (NHA) was interviewed on 7/13/21 at 1:00 p.m. She said the residents were allowed to come back from the hospital into the same room so the bed hold was not given to them. She said a private pay resident was given the bed hold policy if they left the facility to go to the hospital. She acknowledged the bed hold policy to provide written notice was to be provided to any resident that was sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#68) of two residents out of 40 sample residents. Specifically, the facility failed to ensure Resident #68 was provided activities and developed a comprehensive care plan which addressed the resident's socialization and activity needs. Findings include: I. Resident #68 status Resident #68, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included fracture of the left acetabulum, fracture of the femur, fracture of parts of the lumbosacral spine and pelvis and adjustment disorder with mixed anxiety and depressed mood. The 6/11/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required extensive assistance of two people with bed mobility, transfers, and toileting. She required extensive assistance of one person with dressing and personal hygiene. It indicated it was somewhat important to the resident to have books, newspapers and magazines to read, and doing things with groups of people. It was very important to the resident to listen to music she liked, be around animals, go outside to get fresh air, and participate in religious services. It documented the assessment was conducted with a family member, not the resident. A. Resident interview Resident #68 was interviewed on 7/7/21 at 4:55 p.m. She said she lived at an assisted living facility and was admitted for rehabilitation from a fall. She said she was used to attending group activities where she lived. She said she had not been invited to any group activities since she was admitted to the facility (June 2021). She said she sits in her room, when not doing therapy, and watches television. She said she had not been provided any visitation from the activity staff. She said she would like to attend activities but she needed help to get to them and did not know where to go to attend activities. She said they don't visit you here unless they are giving you medication. Resident #68 was interviewed again on 7/12/21 at 5:45 p.m. She said she had not been invited to any group activities this week thus far or the previous week. B. Observations During a continuous observation conducted on 7/7/21 beginning at 11:15 a.m. and ended at 5:00 p.m. the following was observed: -At 11:15 a.m. Resident #68 was observed lying in bed with the television on. The resident did not have any meaningful activities within reach. -At 11:26 a.m. the resident activated the call light. At 11:29 a.m. a certified nurse aide (CNA) entered the room to assist the resident. -At 12:34 p.m. a CNA entered the resident's room to deliver the lunch meal tray. -At 1:15 p.m. a staff member entered the resident's room and took the meal tray. -At 2:00 p.m. Resident #68 was observed lying in bed watching television. -At 5:00 p.m. the resident continued lying in bed watching television. During the observations, Resident #68 was not provided with any meaningful activities nor did facility staff enter the resident's room to invite the resident to participate in the Catholic services, Young at Heart activity or Glamour Nails activity (see activity calendar of events below). During a continuous observation conducted on 7/12/21 beginning at 9:15 a.m. and ended at 2:00 p.m., the following was observed: -At 9:15 a.m. Resident #68 was observed sitting on the side of her bed, eating her breakfast. The television was turned off. -At 9:38 a.m. the resident was observed lying down in bed with the television turned on. -At 9:53 a.m. a nursing student entered the resident's room and asked her if she was finished with her breakfast. The nursing student removed the breakfast tray from the resident's room. -At 10:55 a.m. Resident #68 pushed the call light. At 11:00 a.m. the nurse entered the room to assist the resident. -At 12:30 a.m. a CNA delivered the lunch tray. -At 1:30 p.m. a CNA entered the resident's room to remove the lunch tray. The resident laid back in bed and watched television. During the observations, Resident #68 was not provided with any meaningful activities nor did facility staff enter the resident's room to invite the resident to participate in the exercise class and refresher social (see activity calendar of events below). C. Scheduled activity events The July 2021 activity calendar documented the following activities: On 7/7/21: -8:30 a.m. Daily Chronicle -10:00 a.m. Catholic Services -10:00 a.m. Young at Heart -1:30 p.m. Movie Matinee -5:15 p.m. Glamour Nails On 7/8/21: -8:30 a.m. Daily Chronicle -10:00 a.m. Music with [NAME] Group -1:30 p.m. Blueberry Slushie Social -3:00 p.m. Glamour Nails On 7/12/21: -8:30 a.m. Daily Chronicle -10:00 a.m. Exercise Class -1:30 p.m. Refresher Social -3:00 p.m. Bingo -5:15 p.m. Yahtzee D. Record review The 6/15/21 activity evaluation revealed the resident enjoyed pet visits, current events and news, family and friend visits, gardening, movies, music, reading, religious services and television. It documented the resident preferred daily activities in her room, the activity room and/or out of the facility. It indicated the resident was able to structure and make her own choices in daily activity pursuits. The resident enjoyed watching television, movies and keeping up with the news. The resident was focused on getting well enough to return home. It documented the resident was very interested in life and activities, cooperative and needed encouragement and was willing to try. A review of the resident's medical record on 7/8/21 at 4:08 p.m. did not reveal documentation a comprehensive care plan was developed to identify and address the socialization and activity needs of the resident. The July 2021 individual resident daily participation record documented the resident attended current events/news and movies, and refused the sing-a-long and socials on 7/7/21, 7/8/21 and 7/12/21. -However, observations showed the resident remained in her room and did not attend any group activities. Observations also showed activity staff did not enter the resident's room to invite her to any group activities (see interview with the activity assistant). II. Staff interviews Activity director (AD) #1 and AD #2 were interviewed on 7/12/21 at 5:00 p.m. AD #1 said an activity assessment was conducted when the resident was first admitted to the facility. He said, from the activity assessment, the comprehensive care plan was created to address the resident's socialization needs. He said the comprehensive care plan should be developed within 14 days of the resident's admission to the facility. AD #2 said the activity directors always introduced themselves when the resident was first admitted to the facility, provided the activity calendar and a daily chronicle. She said the daily chronicle was delivered every morning to every resident. She said the daily chronicle was not considered an activity. AD #1 said short-term residents were usually admitted for rehabilitation services and were more focused on getting better and discharging home, than attending any facility activities. He said he was not aware of Resident #68's interests. He said he did not recall seeing Resident #68 attending any group activities. AD #2 said all residents should be invited to the group activities. She said the daily chronicle details the group activities scheduled for the day. She said the activity assistants were responsible to remind residents prior to the activity and to assist the residents with attending. AD #1 said all participation was documented on the participation log. The activities assistant (AA) was interviewed on 7/12/21 at 5:23 p.m. She said a lot of residents admitted for rehabilitation would refuse activities. She said she tried to invite all of them, but she was busy. She said in her experience, a lot of residents could be hostile, so when she interacted with residents she tried to maintain her distance. She said Resident #68 seemed very passive and it was hard to understand her. She said she completed the resident's initial activity assessment. She said Resident #68 would not always answer all of the questions. The AA confirmed Resident #68 was significantly hard of hearing. She said the resident probably did not answer her questions because she could not hear her. She said she had not thought of that before right then. The AA confirmed she documented the Resident #68 had refused the sing-a-longs and socials on the daily participation record. She said the resident had not actually refused to attend the group activities. She said on some occasions she was unable to find a CNA to assist the resident in getting out of bed and attending the activity. She said she was told to write an R for refusal on the participation record instead of a U for unavailable if she could not get someone to assist the resident in getting up out of bed. She confirmed she had not entered Resident #68's room last week or this week to invite her to the group activities prior to the activities. She said she gave her the daily chronicle in the morning and reminded Resident #68 the group activity schedule was on the paper. The NHA was interviewed on 7/13/21 at 1:50 p.m. She said the residents at the facility were very active and vocal. She said that freed up the activity staff to go and ensure residents who were not as active were invited and assisted to attend group activities. She said the ADs were responsible for conducting the initial activity assessment and the activity care plan. She said the care plan should be developed within 14 days of the resident's admission to the facility. She said each resident should be invited to attend group activities, whether they were a short-term or long-term stay resident. She said R for refusal should not be documented on the participation record if the resident did not actually refuse to attend. She said she had not been informed by the activities department that they were having a hard time finding staff to assist in getting residents down to group activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#65) of one resident received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable, out of 40 sample residents. Specifically the facility failed to provide Resident #65 with a restorative range of motion program to promote independence according to the care plan. Finding include: I. Facility policy The Restorative Nursing policy reviewed on 5/14/2020, was provided by the nursing home administrator (NHA) on 7/12/21 at 1:00 p.m., it read in pertinent part; The purpose was the facility was responsible for providing maintenance and restorative programs as indicated by the residents comprehensive assessment to achieve and maintain the highest practicable outcome. The policy was to promote the residents optimum function, a restorative program may be developed by proactively identifying care planning, and monitoring of a resident's assessments and indicators. Nursing assistance must be trained in the techniques that promote resident involvement in restorative activities. Restorative programs may be initiated by nursing and / or therapy. The procedure for restorative nursing list read: 1.Accurate and thorough assessment of the resident was fundamental in determining the residents' need for restorative services. 2.Restorative indicators are resident specific information that when alone or combined with other indicators establish the level of residents restorative potential. 3.Restorative nursing functions can be within one of the following categories: Range of motion 4.Communicate the restorative care plan and care directives to other members of the interdisciplinary team. 5.Provide resident / caregiver teaching regarding the restorative care plan. 6.The trained CNA documented techniques per the restorative care plan in the medical record. 7.The licensed nurse conducted a monthly evaluation to include progress toward goal and response to the program. Any changes will be documented in the medical record. 8.The restorative care plan and care directive will be reviewed / revised as indicated. 9.Restorative nursing does not require a physician order. II. Resident #65 status Resident #65, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPOs), diagnoses included parkinson, depression, dementia and chronic kidney disease. The 6/9/2021 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of nine out of 15. She required extensive assistance with two people for transfers. Extensive assistance with one person for bed mobility, dressing, hygiene and toileting. Bathing required the total assistance of one person. No rejection of care was documented. Functional limited range of motion showed no impairment. III. Observations and interviews Resident #65 was observed on 7/7/21 at 10:00 a.m. to sit in her recliner chair in her room. Her legs were fully reclined in the up position. She leaned to the right side in the chair. She said she needed help with many things and asked if she could have some water. Her mouth and lips were dry. She said she could not reach the adaptive cup of fluids on her bedside table. A caregiver was informed to assist her with some fluids. -On 7/7/21 at 3:30 p.m. she was interviewed again. She said she used to get up and walk when she was admitted to the facility but not now. She said she did not get the help with things she wanted to do like call her family. There was a cell phone mounted to the bedside table next to her but it was out of reach. -On 7/8/21 at 10:37 a.m. Residents #65's family member was interviewed and he said Resident #65 used to have physical therapy at the facility and he wondered why she no longer had that assistance. He said he was going to check with the therapist to see what the resident's program was about. He talked to the nurse and was told the therapist was out of town until Saturday. He said he tried to talk to Resident #65 daily via phone but she had a hard time holding the phone. He said he tried new things for the resident to adapt to, to help her be more independent. IV.Record review The restorative care plan for Resident #65 was revised on 5/27/21, read in pertinent part; The intervention for Resident #65 ways to use the transfer pole from the wheelchair to the mat with a two person assist to pivot. Sitting on the edge of the mat the resident was to balance a midline posture and reach to the left of her body. Restorative nursing to be completed five times a week for 15 minutes. The activities of daily living (ADL) care plan for Resident #65 was revised on 6/17/21, it read in pertinent part; Resident #65 has an ADL self-care performance deficit. The goal was to have her maintain her current level of function with ADL tasks through the next review date. Interventions said she needed maximum assistance with one person for transfers and toileting. She was one assist for hygiene, dressing and meal set with frequent cueing to eat on her own. Discuss with the resident and family any concerns related to loss of independence. Observe and report as needed any changes, any potential for improvement, and reasons for self-care deficit, expected course, and declines in function. The functional care plan for Resident #65 revised on 6/23/21 was provided by the restorative director (RD) on 7/12/21 at 11:30 a.m. it read in pertinent part; Resident #65 had a restorative program for poor sitting posture and muscle rigidity. The goal was to maintain the current level of upper extremity and lower extremity range of motion. The intervention was to invite the resident to activity programs that encourage physical activity, such as exercise group, walking activities to promote mobility. Observe and report as needed any signs or symptoms of immobility, contractures forming or worsening. Provide supportive care and assistance with mobility as needed. The restorative note dated 6/11/21 was provided by the RD on 7/12/21 at 11:30 a.m. it read in pertinent part; Resident #65 had a decline in cognition and physical abilities with noted muscle and posture increased stiffness and rigidity. Residents symptoms were reported to the medical director and the resident was started on anti Parkinson medication with a trial time. She had a max assist of two people for transfers and stability. Residents' cognition created challenges as residents was unable to follow simple directions and when assisted to complete the tasks. The restorative program will continue at that time and reevaluation was in session with time for the medications to be effective. The restorative note dated 6/23/21 was provided by the RD on 7/12/21 at 11:30 a.m. it read in pertinent part; Resident #65 restorative programs change secondary to residents' disease process of her medical diagnosis with poor sitting posture, muscle rigidity and cognitive changes. Program modified to be passive range of motion for upper extremities and lower extremities with active extension when resident was able to follow directions as residents cognition status can vary. Program to be five times a week for 15 minutes a day. The documentation for restorative tasks for Resident #65 was provided by the RD on 7/12/21 at 11:30 a.m., it revealed in the month of May 2021, the restorative program was completed 12 of the 31 days. For June 2021, 16 of the 30 days and four of the 12 days were completed in July 2021. The facility failed to provide consistent restorative range of motion program for Resident #65 as recommended to prevent the possible decline in function. V. Interviews Certified nurse aide (CNA) #3 was interviewed on 7/13/21 at 10:00 a.m. She said Resident #65 had a decline since she had been here. She said the resident used to stand and assist with her own meals but now needed maximum assistance for care. She said the restorative aide was pulled to the floor to work because of short staffing (cross-reference F725). She said they tried to do the range of motion on residents but had no time for everything. She was not trained specifically to do any restorative care. She said they wanted to hire her to be the other restorative aide but it had not happened yet. Licensed practical nurse (LPN) #1 was interviewed on 7/13/21 at 10:15 a.m. He said Resident #65 had a decline with stiffness and a new medication was started recently to help. She said the family declined to have the medication before. The resident was on a restorative program and was seen by the therapist at times. The restorative aide (RA) was interviewed on 7/13/21 at 12:30 p.m. She said she was supposed to be the restorative aide five times a week to assist the residents with their programs but she got pulled to work the floor because of short staffing. She said Resident #65 had a decline with her transfers and her range of motion. She said the restorative program was not consistent and the restorative director assisted residents when she could not. She said she did not have enough time to complete charting but said she did see the resident more often than what was recorded. The restorative director (RD) was interviewed on 7/12/21 at 10:30 a.m. She said she oversaw the restorative program for residents. She said she documented the progress for each resident from the communication she had with the RA and the documentation recorded. Resident #65 was in a standing program but recently went to just range of motion due to a decline in her disease process. She said the resident had a lot of stiffness so a new medication was ordered to assist her with mobility. She said the restorative program was not consistent due to the RA getting pulled to work on the floor due to short staffing. She filled in on the days the RA was pulled to the floor. She said she was pulled more often than not and ideally the restorative program should have two restorative aides to cover the residents care needs. (cross-F725) She said the RA documented in the computer when she did see Resident #65 and agreed the resident was not being seen on a regular basis per her care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure for three (#1, #27 and #81) of four residents reviewed for respiratory care were provided such care in accordance with professional standards of practice out of 40 sample residents. Specifically the facility failed to: -Have physician's orders and care plans for oxygen therapy for Resident #1 and Resident #27; -Ensure Resident #81 received oxygen as ordered; and, -Ensure that Resident #81's oxygen concentrator filter was clean and free of dust and debris. Findings include: I. Facility policy The Oxygen Administration/Safety/Storage/ Maintenance Policy, revised 5/15/2020, was provided by the director of nursing (DON) on 7/12/21 at 2:00 p.m. It read in pertinent part, Assure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area.Change oxygen supplies weekly and when visibly soiled. Clean exterior of concentrators weekly with an EPA registered hospital disinfectant. External filters should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and reinsert. Discard and replace when damaged. The Nursing Documentation Policy was provided by the DON on 7/13/21 at 2:19 p.m. It read in pertinent part, The medical record must contain an accurate representation of the of the actual experience of the resident and include enough information to provide a picture of the of the resident's progress, including his/her response to treatment and/or services, and changes in her/his condition, plan of care goals, objectives and /or interventions. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 computerized physician order (CPO) , diagnosis included congestive heart failure, Parkinson's Disease, hypertension and facial weakness. According to the 6/27/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision assistance from staff to perform activities of daily living. The resident assessment indicated that the resident did not receive oxygen therapy. B. Observations On 7/7/21 Resident #1 was in her room at 9:12 a.m. There was an oxygen concentrator next to her bed and tubing and a nasal cannula lying on her bed. C. Resident interview Resident #1 was interviewed on 7/8/21 at 9:40 a.m. She said that she had been on oxygen at night for many years. She said that she would have sleep apnea but did not need to wear it during the day. She said that her doctor felt it was best to keep her routine for wearing oxygen. D. Record review Review of the resident's electronic medical record (EMR) revealed the resident did not have a physician's order to receive oxygen therapy and it was not included in her plan of care either. III. Resident #27 A. Resident status Resident #27, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 CPO diagnosis included respiratory failure, dysphagia, insomnia and traumatic subdural hemorrhage. According to the 4/27/21 MDS assessment, the resident had a moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required extensive assistance from staff to perform activities of daily living. The resident assessment indicated that the resident did not receive oxygen therapy. B. Resident observation and interview Resident #27 was observed on 7/7/21 at 4:42 p.m. lying in her bed receiving oxygen therapy via nasal cannula. Her oxygen therapy concentrator was set to 1.5 liters per minute flow. She said that she had been on oxygen therapy for a few months; she said she did not know how much oxygen was prescribed for her. On 7/12/21 at 9:37 a.m., the resident was observed lying in her bed with a nasal cannula in place and oxygen concentrator tubing. She said the nursing staff had replaced her tubing the previous evening. C. Record review Review of the resident's medical record revealed that the resident did not have a physician order to receive oxygen therapy and it was not included on her plan of care. The medical record revealed that the resident's oxygen saturation was monitored and recorded daily. The record revealed: -On 7/7/21 the resident's oxygen saturation was 94.0 percent via nasal cannula. -On 7/8/21 the resident's oxygen saturation was 95.0 percent via nasal cannula. -On 7/9/21 the resident's oxygen saturation was 93.0 percent via nasal cannula -On 7/10/21 the residents oxygen saturation was 96.0 percent via nasal cannula -On 7/11/21 the resident's oxygen saturation was 96.0 percent via nasal cannula -On 7/12/21 the resident's oxygen saturation was 95 percent on room air. The above documentation, of via nasal cannula, the nursing staff failed to indicate the oxygen liter flow the resident was currently administered at the time the oxygen levels were checked. IV. Resident #81 A. Resident status Resident #81, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 CPO diagnosis type 2 diabetes congestive heart failure, atherosclerotic heart disease, muscle wasting and atrophy, dependence on supplemental oxygen, presence of cardiac pacemaker, hypertension, infectious gastroenteritis and hyperkalemia According to the 6/21/21 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required extensive assistance from staff to perform activities of daily living. B. Resident interview and observation Resident #81 was interviewed on 7/12/21 at 9:36 a.m. He said that he had been on oxygen for a while but said he would still get short of breath sometimes when dressing himself. His oxygen concentrator was set to 2.5 liters of oxygen flow per minute. (cross reference F676: activities of daily living) On 7/12/21 at 12:45 p.m. it was observed that the resident's concentrator had been adjusted to correct physician ordered three liters per minute oxygen flow, however, the resident reported that the oxygen tubing connected to his concentrator felt warm and he took his nasal cannula off because the air coming through felt hot. The concentrator filter located on the back of the concentrator was observed to have dust and a thick, black wool-like build up on it. He said that staff had not cleaned or replaced the filter to his concentrator since he had been admitted to the facility. C. Record review A physician order dated 6/14/21 prescribed three liters per minute of oxygen flow continuously via nasal cannula. The resident's respiratory care plan, dated 6/29/21, instructed that the resident should receive three liters per minute of oxygen flow. Interventions included to administer medication as ordered by the physician, encourage or assist with ambulations as needed. The facility had no record of Resident #81's oxygen concentrator having been cleaned since the resident had admitted to the facility on [DATE]. The resident's oxygen care plan, revised 7/9/21, included that the oxygen tubing connected to the concentrator should be changed every Sunday. The care plan did not include that the oxygen concentrator filter should be checked or cleaned. V. Staff interviews Registered nurse (RN) #3 was interviewed on 7/12/21 at 9:41 a.m. Said said that oxygen therapy should be administered as ordered by the physician. She said that Resident #1 and Resident #27 both received two liters of oxygen therapy. She reviewed the physician orders and care plans for both residents and said that neither of the residents had physician orders for oxygen therapy and she verified that neither resident had use of oxygen therapy on their care plans. She said that nurses could administer oxygen as needed if a resident's oxygen saturation suddenly dropped and then call the physician. Licenced practical nurse (LPN) #2 was interviewed on 7/12/21 at 9:50 a.m. She said that nurses should be the staff to adjust liter flow on oxygen therapy concentrators and ensure that it was the correct liter flow per minute as ordered by the physician. She said that Resident #81 had a physician order to receive three liters per minute of oxygen therapy. She went to Resident #81's room and observed that his concentrator was set to 2.5 liters per minute and said that she would adjust the concentrator to the prescribed liter flow. RN #2 was interviewed on 7/12/21 at 10:34 a.m. She said that every resident in the facility that received oxygen therapy should have a physician order to prescribe the amount of oxygen the resident should receive. She said that oxygen concentrators should be checked regularly to verify the resident is receiving the correct amount of oxygen. Unit manager (UM)#1 was interviewed on 7/12/21 at 3:24 p.m. She said that oxygen should be administered as ordered by the physician. She said that Resident #27's oxygen saturation levels had been monitored at above 90 percent on room air the past seven days. She said that the resident did not appear to need oxygen. She said when she checked in with the resident she did not see oxygen tubing or a nasal cannula. She said Resident #27 did not have a physician order to receive oxygen therapy in the medical record. She said that Resident #1's physician's orders had been updated to include that she received two liters per minute oxygen flow at night time. The director of nursing (DON) was interviewed on 7/12/21 at 1:18 p.m. She said that physician orders and the resident care plan should be followed when administering oxygen therapy. She said that Resident #1 received oxygen therapy at night. She said that Resident #27 had been receiving oxygen but as of earlier that day, the facility had started a three day titration for her oxygen therapy. She said both residents had been receiving oxygen therapy since the time of admission. She said that nurse unit managers were responsible for ensuring that all physician orders for oxygen therapy were entered into the EMR and resident care plans. She said that she believed that previously, the medical device rental vendor had been coming in to clean the filters, however they had not been coming in. She said she reviewed the facility policy and would educate CNAs to clean the concentrator filters and would update the daily CNA assignment sheets as well as the treatment administration records. She said that the facility utilized two different kinds of oxygen therapy concentrators; she said that blue concentrators did not have an external filter and that the tan concentrators did have an external filter which should be checked and cleared of debris daily and cleaned with soap and water once a week by nursing staff. VI. Facility follow up On 7/12/21 Resident #81's oxygen concentrator was adjusted to be the prescribed three liters per minute oxygen flow by LPN #3. Physician's orders were updated for Resident #1 on 7/12/21 to include that the resident receive two liters per minute of oxygen flow every night shift. Oxygen tubing to be changed every Sunday and oxygen saturation to be monitored every shift. Resident #1's care plan was updated on 7/12/21 to include that the resident received oxygen therapy via nasal cannula at two liters per minute oxygen flow. Staff should observe for signs and symptoms of respiratory distress and report to physician as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Oxygen tubing to be changed every Sunday. A physician order was entered for Resident #27 on 7/12/21 which prescribed to monitor oxygen saturation every shift for three days. The order did not specify that the resident's oxygen saturation should be monitored on room air or via nasal cannula. No order was entered for oxygen therapy. Per the DON, a facility-wide audit of oxygen concentrators was performed on 7/12/21 to ensure that concentrator filters were cleaned and replaced as needed. The facility also provided education to nursing staff on 7/12/21 which read Cleaning of external filters need to be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and reinsert. Discard and replace when damaged. [NAME] concentrators only, blue concentrators need to follow manufacturers guidelines. Maintenance and central supply will complete this, however, nursing to observe for dirt filters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#36) out of two residents out of 40 sample residents who required dialysis services received such services consistent with professional standards of practice, including a comprehensive person-centered care plan. Specifically, the facility failed to: -Obtain an accurate physician's order to receive dialysis services for Resident #36; -Obtain a physician's order to monitor the bruit and thrill and shunt site; and, -Complete dialysis communication forms for the resident between the facility and the dialysis center Findings include: I. Facility policy and procedure The Dialysis policy, effective 4/24/19, was provided by the nursing home administrator (NHA) on 7/14/21 at 9:15 a.m. It was read and revealed in pertinent part: Policy This facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility: and -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Procedure The resident receiving dialysis shall receive consistent care pre and post-dialysis. The shunt site shall be checked on a daily basis with physician notification for any known or suspected problem. General Guidelines: -Monitor intake and output. Observe fluid restriction as ordered by the physician. -Assess for any signs/symptoms of infection, such as redness or edema at the shunt site. -Assess the shunt for signs of clotting every 8 hours. Notify physician if dark blood in tubing or a separation of blood and plasma is observed. -Notify physician of any change in mental or physical status. -Document in the clinical nursing record: dialysis treatment completed, order changes, condition of shunt site, complaints from resident (if applicable), and whether physician was notified. Pre-Dialysis: Physicians shall have established an order for the amount of time required for the resident to be on dialysis. -Lab work, as ordered by the physician, shall be monitored. Day of Dialysis: -Check medications the resident is taking, especially the blood pressure and cardiac medications. -Follow physician orders regarding medication administration pre and post dialysis. -Initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident. Post-Dialysis: -Obtain vital signs of resident upon return from dialysis and complete the Pre/Post Dialysis Communication form. -Follow routine dialysis instructions on dialysis transfer form. -Transcribe any diet, medication, and/or orders received with resident from the dialysis facility. -Monitor shunt site on a routine basis. Notify physician if any unusual problems are noted with the shunt site (tenderness, bleeding). -Monitor dialysis transfer form in the resident's medical record - do not destroy. II. Resident #36 Resident #36, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included type 2 diabetes mellitus, osteomyelitis (inflammation or swelling in the bone), peripheral vascular disease (PVD), end stage renal disease, dependence on renal dialysis, history of falling, and anemia. The 5/13/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance with bed mobility, transfers, locomotion in his room, off the unit, dressing and personal hygiene. The resident required limited assistance with toilet use. The resident was recorded as only walking once or twice in his room and corridor. The resident was coded for dialysis. III. Resident interview Resident #36 was interviewed on 7/12/21 at 12:38 p.m. He said he had just returned from dialysis an hour ago at 11:30 a.m. He said he went to dialysis on Monday, Wednesday and Friday. He said he did not go to dialysis on Tuesday, Thursday and Saturday (as indicated in the record below). IV. Failure to have physician orders The resident's electronic medical records (EMR) were reviewed on 7/8/21 at 10:00 a.m. There were no physician orders for the resident to receive dialysis services. There were no physician orders to monitor the shunt and assess the site for the bruit and thrill (to indicate good blood flow in the dialysis access site). The July 2021 CPO revealed special instructions: Tuesday, Thursday and Saturday (resident) to go to the dialysis center. -However, the resident went to dialysis on Monday, Wednesday and Friday (see interview above). The progress note dated 3/10/21 was read and revealed the resident was on dialysis Tuesday, Thursday and Saturday for renal failure. -However, the resident went to dialysis Monday, Wednesday and Friday (see interview above). The June and July 2021 medication administration record (MAR) revealed there were no physician's orders revealing monitoring of the shunt site or checking the bruit and thrill. V. Dialysis communication forms The pre/post dialysis communication logs were given by the unit manager (UM) #1 on 7/12/21 at 4:20 p.m. Each log had three sections which were read and revealed: The pre-dialysis section was to be filled in by the facility with the date, and the resident's vital signs including: temperature, pulse, respirations, blood pressure and weight in pounds. The section also included: lung sounds, condition of access/site, any antibiotic use, were bruit and thrill present, were any meds (medications) given to the resident to take to the dialysis center, was a meal given to the resident to take to the dialysis center? And a section for additional notes. A signature/title/date and time were to be added by the facility staff. The middle section of the log was to be filled out by the dialysis center staff. The same information was included as above in the pre-dialysis section. The dialysis center staff filled in the middle section with the current vitals the resident had while at the center and then the form was signed and dated by the staff at the dialysis center. The post dialysis section was to be completed by the facility when the resident returned from receiving dialysis. The post section repeated all the vitals to be recorded again as done in the pre section. The facility was to fill in the current vitals and sign again with signature, title, date, and time. The pre/post dialysis communication logs from May to July 2021 revealed the following incomplete communication forms: -5/3/21 the dialysis center did not fill in their section. The post dialysis section was not signed by facility staff and only partial information was documented, temperature, pulse, respirations and blood pressure. -5/5/21 there was no communication log from the facility or the dialysis center. -5/10/21 the facility did not complete the post dialysis section. -5/12/21 the dialysis center did not complete their section of the resident's visit on the communication log. -5/21/21 the dialysis center did not fully complete or sign their section on the communication log. -5/31/21 the facility did not fill in their post section with any documentation on the communication log. -6/2/21 the dialysis center did not sign and date their portion on the communication log. -6/11/21 the dialysis center did not fill in their section on the communication log. -6/21/21 the facility did not fill in their post section on the communication log. -7/5/21 did not have any communication logs in the communication book. -7/7/21 the facility did not fill in their pre section on the communication log. -7/9/21 the facility did not fill in the post section on the communication log. III. Interviews Licensed practical nurse (LPN) #2 was interviewed on 7/12/21 at 1:15 p.m. She said the resident just got back from dialysis and she did not have time yet to fill in the post dialysis section on his communication form. She said when a resident left for dialysis the nursing staff filled in the pre dialysis section of the communication sheet. She said the facility was to send the dialysis book with the resident to his appointment. She said the dialysis center would send back their section filled in with information about the resident during his dialysis visit. She said the nurses fill in the post dialysis section after he returns from his appointment. She said she did not know why some sheets were missing and some were not filled in on all three sections for the month of July 2021. She said she did not know where the missing sheets would be. She said she did not know if the resident was sent with the communication book every time he went to dialysis but it was supposed to happen. Unit manager (UM) #1 was interviewed on 7/12/21 at 4:45 p.m. She said the resident should have three sheets per week in the medical chart for his pre visit, dialysis visit and post visit from dialysis. She said the communication log was important to monitor his vitals. She said she was going to call the dialysis center and see if they forgot to send some of the missing days that should be in the chart. She said she did not know if the communication problem was the facility or the dialysis center or both. UM #1 said she would also bring in the past communication sheets for the last 60 days. The director of nursing (DON) was interviewed on 7/13/21 at 11:00 a.m. She said the facility did not have any dialysis orders from a physician for Resident #36. She said she had no idea why he did not have orders to monitor his dialysis access site. She said the communication logs were incomplete for Resident #36. She said some days they were done and some days they were not. She said the dialysis center was good at doing their section with each visit. She said the facility did not consistently fill out the pre and post sections of the dialysis communication forms. She said the facility nursing staff was to fill in the pre visit section with his vitals before he left for dialysis. She said the facility was to send the communication log book with the resident to his dialysis visits. She said the dialysis center filled in his vitals at the center and returned the communication log with him when he returned to the facility. She said the facility would then fill in the post dialysis section with his vitals. She said the communication book was to be on the nurses station for each resident on dialysis. She acknowledged it was important to have coordinated care with the dialysis center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure for one (#81) of one resident out of 40 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to have accurate skin assessments and documented sign and symptoms of bleeding related to anticoagulant use for Resident #81. Findings include: I. Facility policy The Nursing Documentation policy, revised 5/5/2020, was provided by the director of nursing(DON) on 7/13/21 at 2:19 p.m. It read in pertinent part, The medical record must contain an accurate representation of the of the actual experience of the resident and include enough information to provide a picture of the of the resident's progress, including his/her response to treatment and/or services, and changes in her/his condition, plan of care goals, objectives and /or interventions. II. Resident #81 A. Resident status Resident #81, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician order (CPO) diagnosis included type 2 diabetes congestive heart failure, atherosclerotic heart disease, muscle wasting and atrophy, dependence on supplemental oxygen, presence of cardiac pacemaker, hypertension, infectious gastroenteritis (stomach flu) and hyperkalemia According to the 6/21/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required extensive assistance from staff to perform activities of daily living (ADLs). B. Resident observation and interview Resident #81 was interviewed and observed in his room on 7/8/21 at 10:01 a.m. He had multiple small scabbed sores on his left arm and one sore was open with a small amount of blood. He had a faded bruise on his left upper wrist and bilateral faded cluster bruises on bilateral forearms. He had said he had an open spot on his leg that would occasionally weep due to swelling. He said that he was bruised from blood draws at the hospital and from bumping into items in his room. C. Record review A physician order dated 6/14/21 ordered that the resident be monitored for signs and symptoms of bleeding related to anticoagulant medication use. The resident care plan, dated 6/29/21, included that the resident has a pacemaker related to atrial fibrillation and takes an anticoagulant medication and was at risk for bleeding, bruising and injury. The care plan called for the resident to be monitored for signs and symptoms of bleeding including black tarry stools, bleeding gums, bruising, and nosebleeds related to anticoagulant medication use. The care plan included that the resident required skin inspection weekly. Staff should observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. An admission skin assessment was completed on 6/14/21 documented the resident had multiple bruises and scabs from blood draws (unspecified location), bruises to inner left and right thighs and behind both knees, right upper extremity edema (swelling) and a resolving pressure injury two by 1.2 by .02 centimeters to right heel. A weekly skin assessment completed on 6/21/21 documented the resident had a healing stage 2 pressure ulcer from admission. -No other bruises, discolorations or skin issues were documented. A weekly skin assessment completed on 6/28/21 documented the resident had a rash in his groin area, multiple scabbed sores to his upper extremities, healed sore spot on his coccyx and a healing pressure ulcer to his right heel. A weekly skin assessment completed on 7/5/21 documented, bilateral upper extremity multiple scabs. -No other bruises, discolorations, wounds or skin issues were documented. A weekly skin assessment was completed on 7/12/21 documented the resident had bilateral edema, an open area to right heal and multiple skin discolorations. -The skin assessment did not identify any bruising on the resident. The July 2021 treatment administratration record (TAR) included to monitor for signs and symptoms of bleeding including black tarry stools, bleeding gums, bruising, nose bleed related to anticoagulant. The record revealed on 7/1/21, 7/2/21, 7/3/21, 7/4/21, 7/5/21, 7/6/21, and 7/7/21 the resident had no signs or symptoms. On 7/8/21, 7/9/21, 7/10/21, 7/11/21 and 7/12/21, the record did not indicate whether the resident did or did not have signs or symptoms of bleeding. -However, the resident did have bruising and bleeding on his arm (see observation above). D. Staff interviews Licenced practical nurse (LPN) #3 was interviewed on 7/12/21 at 9:50 a.m. She said that she had completed a skin assessment for Resident #81 that morning. She said that she was aware of the resident's bruises and skin discolorations. She said sometimes the resident picked his skin causing it to bleed. She said she would be able to tell from working with the resident if he had new bruises or open spots. She said she could tell by the color of the bruise it was something new or needed to be watched and if she saw anything of concern that she would document it. She said that she would not document if she knew it was an existing bruise or skin issue. She said that if a certified nurse aide (CNA) noticed any new bruises they would tell the nurse or document in a communication log. She said that staff would observe skin daily when doing showers or assisting with dressing. Certified nurse aide (CNA) #8 was interviewed on 7/12/21 at 10:30 a.m. She said that residents had weekly skin assessments completed by a nurse to monitor bruising or any skin issues. She said CNAs would alert the nurse or make a note of any skin issues as they were observed. The DON was interviewed on 7/13/21 at 10:19 a.m. She said residents who receive anticoagulant medication were monitored for bleeding/bruising during weekly skin assessments, during showers and each shift shift. She said that skin assessment should include the location of bruises or any skin issues. She said that skin assessments should be accurate to reflect the resident's current skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (#56) of two residents reviewed for hospice services out of 40 sample residents. Specifically, the facility failed to ensure: -A system was in place to maintain communication between the facility and the outside hospice care provider; -A physician order for hospice with terminal diagnosis; and, -A care plan coordinated with hospice care. The findings included: I. Facility policy The Terminal Illness, Death, and Dying, last revised 2/19/13, was provided by the nursing home administrator (NHA) on 7/13/21 at 9:15 a.m. It was read and revealed in pertinent part: Identification of the resident's prognosis and the basis for it, as well as initiating discussions/considerations regarding advanced care planning and resident choices, is addressed by the interdisciplinary team. When a resident is nearing the end of life, the physician and the interdisciplinary team reviews/updates the prognosis and reviews and revises the care plan, as necessary, to reflect the resident's change in condition and the resident's/responsible party's wishes. Periodically assess the resident for decision-making capacity, and invoke a representative if the resident is determined to not have decision-making capacity. -Empower the resident to participate in defining goals of treatment and planning interventions to the extent possible. Evaluate the effectiveness of the chosen intervention. -Utilize advanced care-planning techniques, such as a process to identify and update the resident's preferences regarding care and a treatment at a future time. -Include a situation in which the resident subsequently lacks the capacity to make his/her needs known. -Any changes to the resident's plan of care are communicated to the interdisciplinary team. -Discussion with the resident/responsible party and the physician regarding advanced care planning is documented in the physician progress notes and communicated to the interdisciplinary team. -For a resident who has elected hospice services, the facility will coordinate care planning with the hospice provider. -The coordinated care plan must identify each aspect of care the hospice provider or nursing facility is responsible for regarding the resident. -The facility will have in place a process by which it exchanges information between the facility and the hospice provider (i.e., care conferences and assessment updates.) -Document all services provided in the Social Services section of the medical records. II. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the 7/1/21 computerized physician orders (CPO), the diagnoses included gastro-esophageal reflux disease (GERD), stage 3 chronic kidney disease, bipolar disorder, generalized weakness, type 2 diabetes mellitus, cognitive communication deficit, chronic pain, and obsessive compulsive disorder (OCD). The 6/4/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She did not walk in her room or in the corridor. The resident was coded for hospice care. III. Record review The 5/28/21 progress note revealed the resident was admitted to hospice. The resident's comprehensive care plan documented, revised on 6/11/21 the resident had a terminal prognosis. Interventions included: Consult with physician and social services to have hospice care for resident in the facility. -The terminal prognosis was not documented. -There was no care plan for hospice care which outlined the hospice care team and services provided to the resident. The July 2021 CPO did not have a physician's order for hospice care. The resident's electronic medical record (EMR) or the written chart on the nurses station did not contain: physician documented terminal prognosis for the resident, hospice care plans, or progress notes. -There were no interdisciplinary team notes (IDT) notes concerning the resident receiving hospice. IV. Interviews Licensed practical nurse (LPN) #2 was interviewed on 7/12/21 at 10:45 a.m. She said all hospice notes were in the resident paper charts on the nurse's station. She said all visits from the hospice provider were to be placed in the last section of the charts. She did not know why the only written communication in the resident chart was only a few shower documentations from the hospice provider's certified nurse aides (CNA). She said she was unaware of where documentation might be in the resident's EMR. She said she did not know where else to look for physician orders from the hospice provider. She said the nurses may not know a hospice provider was in the facility and if the hospice provider left notes from their visit. Unit manager (UM) #2 was interviewed on 7/12/21 at 1:30 p.m. She said in the back of the paper charts were where hospice providers were to leave their communication of what happened during their visits. She said this was the facility system for communication with hospice providers. She said the nurses knew to read the hospice notes for communication between the facility and the hospice provider. She was unaware Resident #56 only had a few documented CNA notes and no other notes. Social service assistant (SSA) #1 was interviewed on 7/12/21 at 3:00 p.m. She said there were no hospice orders for Resident #56. She said she was unaware there was no written prognosis by a physician for the resident to be admitted to hospice. She said she was unaware that the resident did not have any certified physician orders concerning hospice care. She said she would try and locate the orders either in the EMR or she would call the hospice provider. -At 3:30 pm. the SSA #1 provided hospice social worker documentation from visits with the resident on 6/1/21, 6/8/21, 6/10/21 and 6/15/21. SSA #1 said she had this documentation in her computer but it was not in the resident's chart in the specific hospice section. She said the facility system for hospice provider notes was to put the notes in the very back of the resident's paper chart at the nurses station. The medical records director (MR) was interviewed over the phone on 7/12/21 at 3:10 p.m. along with the SSA #1 He said he could not find any medical records for the resident from the hospice provider in the EMR or in his office. He said the facility did not have the documentation for Resident #56 from the hospice provider. The SSA #1 was interviewed again on 7/13/21 at 10:00 a.m. She said she contacted the hospice provider yesterday afternoon. She said the hospice provider came to the facility that evening with all the documentation that was needed. SSA #1 had the physician's prognosis from 6/1/21 and all the documentation of the visits from the hospice provider. SSA #1 said she called the hospice provider and they discussed more effective ways for the facility and provider to communicate with each other. She said she would make sure the situation concerning hospice documentation was communicated to the interdisciplinary team in the facility so they were aware. She said she would make sure a house wide audit was done for all residents receiving hospice care to make sure the hospice providers were communicating to provide coordinated care. The director of nursing (DON) was interviewed on 7/13/21 at 11:00 a.m. She said all hospice provider visit notes were to be placed in the back of the resident paper charts on the nurses station. She said the facility needed to have a hospice care plan in the resident's EMR. She said the facility needed the physician's prognosis for hospice. She said the hospice providers could speak with the floor nurses and if the nurses were busy the hospice provider could always find her in the facility to verbally communicate any needs or changes. She said it was important for the communication between the facility and hospice providers to happen for the integrated care for the resident. She said the facility was ultimately responsible for a resident's care. She said without having the plan of care from hospice, she did not know exactly what care the facility provided and what hospice care provided. She said moving forward she and social service would be responsible for ensuring the charts were up to date. -On 7/13/21, no house wide audit was provided before exit of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** V. Resident #81 A. Resident status Resident #81, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 CPO diagnosis type 2 diabetes congestive heart failure, atherosclerotic heart disease, muscle wasting and atrophy, dependence on supplemental oxygen, presence of cardiac pacemaker, hypertension, infectious gastroenteritis and hyperkalemia According to the 6/21/21 minimum data set (MDS), the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required extensive assistance from staff to perform transfers, dressing and toileting; he required limited assistance to perform personal hygiene. The resident was not assessed for bathing assistance during the assessment period. B. Resident observations and interview On 7/7/21 at 9:47 a.m., the resident was observed sitting in his wheelchair wearing a white t-shirt with multiple stains on the front and was wearing underwear. His jeans were slung over the pillow on his bed and had an orange substance on them. His face was unshaven. Resident #81 was interviewed on 7/7/21 at 9:50 a.m. He said that he was not receiving showers. He said that he had requested to be given a shower, however, staff would either tell him that they did not have time to provide him with one or that would say that they would return to give him a shower after doing other tasks and then would never come back to his room. He said I get myself up and get dressed on my own as best I can, but sometimes it's harder to do; I am here because I need assistance but they just won't do it a lot of the time. He rubbed his face and said I am not used to having this much stubble. (cross reference to F725: sufficient staffing) On 7/7/21 at 11:10 p.m., the resident was observed in his room wearing the same stained white t-shirt and was wearing the stained jeans that had been observed, On 7/8/21 at 10:01 a.m., the resident was observed sitting in his wheelchair next to his bed. He was wearing the same white t-shirt and stained jeans that had worn the day prior. On 7/13/21 at 1:20 p.m., the resident was observed with his urinal on his bedside approximately 85 percent full. The resident said that the staff were supposed to empty his urinal for him, however, it had not been emptied that day. He said that staff needed to empty his urinal and he could not do it on his own. C. Record review The resident's care plan, revised 6/29/21, instructed that the resident required the assistance of one staff member to shower. He preferred two showers per week in the evening. The care plan instructed that the resident required the assistance of one staff person for dressing and to allow for sufficient time for dressing and undressing. He required the assistance of one staff person to perform toileting and personal hygiene. The resident's shower record revealed that Resident #81 did not receive a shower from 6/14/21 (date of admission) to 7/7/21. -The resident did not receive a shower out of an estimated eight opportunities for bathing based on his preference. Review of the resident's activities of daily living (ADLs) task documentation for dressing assistance revealed: -On 7/1/21 the resident received extensive assistance with dressing at 12:58 p.m. and limited assistance at 7:25 p.m. -On 7/2/21 the resident was independent with dressing. -On 7/3/21 the resident received extensive assistance with dressing at 11:24 a.m. and 8:39 p.m. -On 7/4/21 the resident received extensive assistance with dressing at 3:30 a.m.,limited assistance to dress at 12:59 p.m. and was independent with dressing at 9:43 p.m. -On 7/5/21 the resident received extensive assistance with dressing at 4:52 a.m. -On 7/6/21 the resident was independent with dressing at 12:05 p.m. and received limited assistance with dressing at 7:06 p.m. -On 7/7/21 at 2:25 the dressing task was documented as activity did not occur. The resident received limited assistance with dressing at 9:59 p.m. -The ADLs task documentation revealed the resident did not receive regular, routine assistance to perform dressing in accordance with his plan of care. VI. Resident #1 A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 computerized physician order (CPO), diagnosis included congestive heart failure, Parkinson's disease, hypertension and facial weakness. According to the 6/27/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required physical assistance from one staff member to perform bathing. She required supervision assistance to perform dressing, personal hygiene and transfers. B. Resident interview Resident #1 was interviewed on 7/8/21 at 9:40 a.m. She said she had received assistance to take showers but not regularly. She said she could dress herself and her own personal hygiene when staff would set her up. Resident #1 was interviewed again on 7/12/21 at 10:00 a.m. She said that she had specific shower days that she had selected when she was admitted to the facility; she said that staff then changed the shower days and she no longer got to choose when she received a shower. She said after the facility changed her shower schedule; she still did not receive regular showers. She said the facility did not have enough staff to provide showers (cross reference to F725:sufficient staffing) C. Record review The resident care plan, dated 3/30/21, instructed that the resident required supervision and set-up assistance to perform bathing. The resident preferred showers two to three times per week in the evening. The resident bathing record from 6/10/21 to 7/9/21 revealed the resident received one shower on 6/29/21. -The resident only received one shower out of an estimated 10 opportunities for bathing based on her preference. D. Staff interviews The minimum data set (MDS) nurse was interviewed on 7/8/21 at 4:30 p.m. She said she had identified during audits that some residents were not receiving showers during the assessment period. She said she had identified that Resident #81 had not received a shower during the assessment period. She said when she identified that a resident had not received a shower, she would follow-up with the certified nurse aides (CNAs). She said she had followed-up with the CNAs regarding Resident #81 and she did not know why he had still not received a shower but he would be offered one that day. CNA #7 was interviewed on 7/13/21 at 1:39 p.m. She said that she was the CNA assigned to Resident #81's hallway. She said that she had a number of dependent residents she had been helping throughout the day and had not been in to assist Resident #81 aside from dropping off his meals. She said that CNAs were responsible for emptying the urinal for the resident when it was full. She said they (the facility) needed more help, I do my best to run. She entered Resident 81's room during the interview and pointed to the beds not being made and said, I have not even had time to make the beds. She observed the residents urinal to be full and said she would empty it right away. (cross reference F725:sufficient staffing) E. Facility follow-up Resident #81 received physical assistance from staff to shower on 7/8/21 after the facility had performed an audit of the building to determine which residents had not received showers. Resident #1 received a shower on 7/10/21. Based on observations, interviews and record review, the facility failed to ensure four (#1, #81, #145, and #73) of five residents reviewed for activities of daily living of 40 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure: -Residents #1, #145 and #73 received regular bathing in accordance with their plan of care; and, -Resident #81 received showers and regular assistance with dressing, personal hygiene and toileting. Cross reference F677: the facility failed to ensure bathing was provided to dependent residents in accordance with their plan of care. Findings include: I. Facility policy and procedure The Activities of Daily Living policy and procedure, reviewed May 2020, was provided by the nursing home administrator (NHA) on 7/13/21 at 3:00 p.m. It revealed, in pertinent part, The resident will receive assistance as needed to complete activities of daily living. Purpose: to ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The facility must provide care and services for the following activities of daily living: hygiene - bathing, dressing, grooming and oral care. II. Resident #145 A. Resident status Resident #145, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included displaced fracture of the upper end of the right humerus. The 7/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility and extensive assistance of one person with dressing and toileting. It indicated bathing did not occur during the assessment period. B. Resident interview and observations Resident #145 was interviewed on 7/8/21 at 9:27 a.m. She said she was admitted to the facility because of a fall, from which she sustained a fracture to her right arm. She said she had not received a shower since she was admitted to the facility, on 7/2/21. She said she had not received a shower in the hospital, so her last shower was prior to her fall at home. She said the nurse told her, when she was first admitted to the facility, she would receive a shower the next day. She said she informed the nurse she was used to taking two to three showers per week. She said, every time she had asked, the certified nurse aides (CNAs) would tell her they did not have enough staff to give her a shower. She said she felt grimy and sweaty. Resident #145 was observed with white debris on her face and edges of her hairline on the forehead. Cross reference F725: the facility failed to provide sufficient staffing to ensure residents were provided showers in accordance with their plan of care. C. Record review The activities of daily living (ADL) care plan, initiated on 7/2/21, documented the resident required ADL assistance to maintain or attain the highest level of functioning. The interventions included to assist the resident with mobility and ADLs as needed and provide therapy services as ordered. The CNA assignment sheet indicated Resident #145 was scheduled to receive bathing on Sunday, Wednesday and Friday. The bathing records for Resident #145 from 7/2/21 to 7/13/21 documented the resident received a shower on 7/10/21. The resident received one shower, eight days after her admission to the facility and out of four opportunities for bathing based on her preference. III. Resident #73 A. Resident status Resident #73, age [AGE], was admitted on [DATE]. According to the July 2021 CPO, the diagnoses included displaced subtrochanteric fracture of the left femur. The 6/29/21 MDS assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 11 out of 15. She required extensive assistance with bed mobility and transfers. She required limited assistance with dressing and personal hygiene. She required limited assistance with bathing. B. Resident interview Resident #73 was interviewed on 7/8/21 at 9:00 a.m. She said she had only received two showers since her admission to the facility. She said she had to practically beg the facility staff to give her a shower. She said the staff would always tell her they could not give her a shower because they did not have enough staff (cross-reference F725). She said she was able to get the staff to give her a shower the day after her admission and two days ago. She said she was used to having at least three showers per week. C. Record review The ADL care plan, initiated on 6/29/21, revealed the resident had a self-performance deficit related to the resident's recent fall with a sustained fracture. The interventions included to provide assistance with bathing and the resident preferred a shower three times per week. The CNA assignment sheet documented Resident #73 was scheduled to receive bathing on Tuesdays, Thursdays and Saturdays. The bathing records for Resident #73 from 6/25/21 to 7/12/12 documented the resident received a shower on 6/26/21, 7/6/21 and 7/8/21. Resident #73 received three showers in 17 days since her admission to the facility out of an estimated 24 bathing opportunities based on her preference. IV. Staff interviews CNA #3 was interviewed on 7/12/21 at 12:34 p.m. She said showers were supposed to be given according to the bathing schedule at the nursing station. She said it was hard to give residents showers or baths because of how busy the CNAs were throughout the day. She said showers and baths were not being provided as they should. She said showers and baths were documented in the point of care (POC) electronic record for each resident. She said the POC system asked the CNA three questions related to bathing. She said the first question was how much assistance the resident required during the bath or shower. The second question was how much assistance the resident required in general, and the third question indicated the resident's preference between a shower, bath or bed bath. She said even if the resident was not provided a shower, the CNAs always answered question three with the resident preference. She said if a shower was not given, then the activity did not occur would be marked for the first question in the POC system. She said the first question was the only area that indicated if a shower or bath was given to the resident. The NHA and director of nursing (DON) were interviewed on 7/8/21 at 3:37 p.m. The DON said the facility had recognized showers were not being given in accordance with the bathing schedule and resident plan of care at the end of March 2021. She said the facility identified the problem of residents not getting baths or showers timely, according to the schedule, or at all. She said an audit was completed of all residents at the facility and the care plans were updated with the resident preferences. She said the facility had designated a CNA as the bath aide to ensure bathing was being provided regularly. She said the MDS nurse was responsible for auditing the bathing records to ensure showers were being completed. The NHA said she thought the showers were being completed, but the staff were not documenting correctly. She said she was not aware of the volume of residents interviewed, during the survey process, said they had rarely if ever received a shower. She said she was not aware staff were telling residents they could not be provided a shower or bath because they were short staffed. The MDS nurse was interviewed on 7/8/21 at 4:30 p.m. She said she was responsible to monitor the performance improvement plan regarding residents not receiving showers or baths according to the schedule and their plan of care. Cross reference F867: the facility failed to ensure an effective performance improvement plan was in place to address an identified concern of resident's not receiving showers or baths as directed on their plan of care. She said she would do a random audit based on the MDS assessment schedule. She said she would look at the past seven days to determine if the resident received showers or baths. She said she would talk to the CNAs if she discovered an issue. She said she did not document the audits being completed with the MDS assessment schedule. She said she did not document when she spoke with a CNA and did not report showers and baths were not being provided. She said she felt the CNAs did not listen to her when she spoke to them. She said she knew the showers and baths were a continued problem. She said the facility had yet to determine the actual problem. The NHA and DON were interviewed on 7/12/21 at 8:52 a.m. The NHA said the facility management were able to pull reports that indicated residents received showers or baths. The NHA said question three on the report indicated the residents had received a shower or a bath. The NHA acknowledged the report for question three, did not match the reports for question one, which indicated the bathing activity did not occur. She said she was not aware the CNAs were documenting the resident preference for question three, not if the resident actually received a shower or bath. The NHA said nursing management went to every resident in the facility and asked if they would like a shower. She said every resident who wanted a shower or bath was provided a shower or bath on 7/8/21-7/10/21. She said education was provided to the nursing staff on 7/9/21, which included bathing documentation and providing bathing according to the bathing schedule and resident preference.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure staff donned and doffed PPE (personal protective equipment) in accordance with accepted infection control practices; and, -Ensure visitors and staff wore facial coverings appropriately. Findings include: I. Professional references According to the Centers for Disease Control (CDC) website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (Retrieved 7/20/21) .enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use of respirator, gown, gloves and eye protection. When available, respirators should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring airborne precautions. The PPE recommended when caring for a patient with known or suspected COVID-19 includes: respirator or facemask, eye protection, gloves, and gowns. II. Failure to ensure PPE was donned and doffed appropriately A. Observations During a continuous observation on 7/7/21 beginning at 9:40 a.m. and ended at 11:00 a.m., the following was observed: -At 9:55 a.m. registered nurse (RN) #4 was observed donning PPE to enter a resident room which had a sign that indicated the resident was under isolation with droplet precautions. She donned a gown, an N95 mask, face shield and gloves. She entered the room to administer medications to the resident. Upon leaving the room, RN #4 doffed the gown and gloves and exited the room. Still wearing the N95 mask, RN #4 doffed and cleaned the face shield. She walked down to the nursing station and interacted with other staff members, still wearing the N95 mask. RN #4 then walked to the medication cart, halfway down the hallway from the resident's room, doffed the N95 into a bag on the side of the medication cart, and donned a surgical mask. -At 10:00 a.m. a certified nurse aide (CNA) was observed entering a resident room which had a sign that indicated the resident was under isolation with droplet precautions. She was wearing a surgical mask and did not don any other PPE prior to entering the room. -At 10:42 a.m. RN #4 was observed entering a resident room which had a sign that indicated the resident was under isolation with droplet precautions. She donned a gown, an N95 mask, face shield and gloves. She entered the room to administer medications to the resident. RN #4 was observed doffing the gown, gloves and face shield at the door to the resident's room. She entered the hallway still wearing the N95 mask. She walked down the hallway to the nursing station. She came in close contact with four staff members at the nursing station, while still wearing the N95 mask. RN #4 walked to the medication cart, doffed the N95 mask placed in a bag, and donned a surgical mask. She touched the outside of the N95 mask when she doffed it and did not perform hand hygiene prior to donning the surgical mask. -At 10:56 a.m. a staff member, with a surgical mask, was observed outside a resident room which had a sign that indicated the resident was under isolation with droplet precautions. The staff member attempted to don a gown and stopped. He walked away and entered an office. He picked up and donned goggles. He came back to the resident room and donned a gown. He performed hand hygiene with hand sanitizer for 10 seconds and then donned gloves. He touched his eyes with the gloves on, touched his nose and cheeks under the goggles. He grabbed papers out of his briefcase and entered the resident's room. He did not don an N95 mask prior to entering the resident's room. III. Failure to ensure facial coverings were worn appropriately During a continuous observation on 7/7/21 beginning at 9:40 a.m. and ended at 1:30 p.m., the following was observed: -At 10:10 a.m. a staff member was observed at the nursing station with a surgical mask pulled down with her nose exposed. -At 11:00 a.m. a visitor was observed pushing a resident in a wheelchair throughout the facility. She was not wearing a face covering. She passed by multiple staff members who did not provide her with a face covering or a reminder to wear a face covering. -At 11:20 a.m. the same visitor was observed pushing the resident down another hallway and into his room. She passed by two staff members in the hallway who said hello to the visitor. The staff did not ask the visitor to wear a facial covering or provide her with a facial covering. -At 11:22 a.m. a CNA entered the resident's room. The visitor still was not wearing a facial covering. The CNA did not remind the visitor to wear a facial covering. -At 11:25 a.m. a different visitor was observed exiting a resident's room. She was not wearing a facial covering. She walked down the hallway and asked a CNA for a urinal for the resident. The visitor waited in the hallway while the CNA retrieved a urinal. The CNA provided the urinal to the visitor and the visitor returned to the resident's room. The CNA did not remind the resident to wear a facial covering. -At 11:30 a.m. a visitor from another health care agency, wearing a facial covering, entered a resident room. She was observed sitting close to the resident, within a foot, and pulled her mask down under her chin, exposing her nose and mouth, to speak with the resident. -At 11:59 a.m. another visitor was observed leaving a resident's room. He walked down the hallway, past the nursing station and down another hallway to exit the facility. He was wearing a surgical mask pulled underneath his chin, exposing his nose and mouth. He passed by multiple staff members who did not remind the visitor to pull up his surgical mask. -At 1:21 p.m. the emergency medical services technician (EMT) was observed entering the facility, bringing a resident back to their room from the hospital. The EMT entered the facility and was not wearing a facial covering. He transported the resident through the facility and down two hallways to the resident's room, and transferred the resident to the bed. He walked back through the facility and out the front door. He passed by multiple staff members who did not provide a facial covering or remind him to put on a facial covering. On 7/12/21 at 12:45 p.m. a physician was observed sitting at the nursing station. He had a surgical mask hanging from one of his ears, with his nose and mouth exposed. He was observed interacting with multiple staff members while not wearing a facial covering. IV. Staff interviews RN #4 was interviewed on 7/7/21 at 10:54 a.m. She said the residents admitted in her hallway were under isolation with droplet precautions because they were new admissions who were not vaccinated. She said staff were required to don the appropriate PPE of a gown, N95 mask, gloves and a face shield prior to entering the room. She said she did not take off the N95 mask in the resident's room because she did not want to walk down the hallway without a mask on. She said she did not know if there were surgical masks in the isolation bin. After opening the isolation bin, RN #4 confirmed surgical masks were located in the isolation bin outside the resident's room. She said she had been told to doff the N95 mask at the medication cart during an in-service. The EMT was interviewed on 7/7/21 at 1:30 p.m. He said he forgot to put on a surgical mask prior to entering the facility. He said staff did not remind him to put on a facial covering when he walked throughout the facility. CNA #3 was interviewed on 7/13/21 at 9:53 a.m. She said facial coverings should be worn covering the nose and mouth. She said the facility staff was required to wear a surgical mask when entering the facility. She said visitors should also wear a facial covering when in the facility. The director of nursing (DON) and the infection preventionist (IP) were interviewed on 7/13/21 at 11:27 a.m. The DON said prior to entering a resident room under isolation with droplet precautions, facility staff should don a gown, gloves, an N95 mask and a face shield or goggles. She said all PPE should be doffed prior to leaving the resident room. She said the N95 mask should be doffed in the room and a surgical mask donned when entering the hallway. She said surgical masks were kept in the isolation cart. The DON said staff should remove the N95 by the straps, not touching the outside of the mask. She said after the mask was discarded, hand hygiene should be performed for 20 seconds. The DON said once PPE was donned, the facility staff should not touch their face. She said if the facility staff touched their face after donning PPE, the staff should discard the gloves, perform hand hygiene and don new gloves. The IP said all visitors and staff should wear facial coverings when in the facility. She said staff should remind all visitors they need to wear a facial covering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VII. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included quadriplegia, coronary artery disease (CAD), gout, hypotension (low blood pressure), heart failure and sleep apnea. The 5/4/21 quarterly minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with bed mobility, transfers, eating, and personal hygiene. He needed a two person assist with total dependence on staff for bathing. B. Resident interview Resident #29 was interviewed on 7/7/21 at 11:00 a.m. He said it had been a week since the facility had given him a shower. He said the facility had not been good at giving him his shower lately. He said when he asked for a shower the staff told him they were short staffed and could not give him one. He said he wanted his showers to be on Wednesday and Sunday. He said it was a week ago today that he had his shower. He said it made him really angry. He said he thought he had only had two showers in the last month. C. Record review The thirty day look back of the shower documentation log for Resident #29 was reviewed on 7/7/21 at 9:00 a.m. On 6/8/21, 6/24/21, 7/1/21 and 7/6/21 the documentation revealed: Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity. The documentation did not reveal what non-facility staff provided the care to the resident. On 6/9/21 the documentation revealed: physical help in part of the bathing activity. On 6/13/21 the documentation revealed: the resident was recorded to have a shower which required total dependence upon staff. The resident was documented as receiving six showers out of an estimated nine opportunities in 30 days. VIII. Resident #74 A. Resident status Resident #74, age [AGE] was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included anxiety, dementia without behavioral disturbances, major depressive disorder, restless leg syndrome, history of falling, hypertension (high blood pressure), unspecified macular degeneration, and tremors. The 6/13/21 quarterly minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance with bed mobility, transfers, walking in her room, dressing, toilet use and personal hygiene. The resident required one person assist with bathing. The resident was not steady on her feet and was only able to stabilize with staff help. B. Resident interview Resident #74 was interviewed on 7/7/21 at 11:20 a.m. She said showers did not happen often for her. She said the staff were so busy and they had so much to do that showers did not always happen for her. She said she did not want to bother the staff to give her a shower. She said she could not shower on her own. She said she needed staff to help her with almost everything. She said she tried to ask the staff to shower her. She said since she did not get a shower when she asked the staff, she guessed they were busy and she did not ask the staff anymore. C. Record review The thirty day look back of the shower documentation log for Resident #74 was reviewed on 7/8/21 at 11:05 a.m. The resident preferred showers two times a week, Tuesdays and Fridays. On 6/29/21 the resident was recorded to have a shower which required total dependence upon staff. The resident was documented to receive one shower during the 30 day look back period out of an estimated 13 bathing opportunities per the resident's preference.IX. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), diagnoses included hypertension, depression, osteoarthritis and chronic kidney disease. The 4/12/2021 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required extensive assistance with two people for transfers. Extensive assistance with one person assist for bed mobility, toilet use, dressing and personal hygiene. She was totally dependent on bathing and required a hoyer lift for transfers with two people. No rejection of care was documented. B. Resident observation and interview Resident #13 was observed on 7/7/21 at 1:30 p.m. She said she wanted a shower and was told by the facility staff that there were not enough staff to assist to get her out of bed for a shower (cross-reference F725). She required a Hoyer (mechanical) lift for transfers. She said her hair was greasy and she really wanted to get a shower to wash her hair and to keep her skin healthy. She said she did not want any skin breakdown to occur. She said she could not remember when she had a shower last, that was how long it had been. The resident was observed in bed, she had on a hospital gown and her hair was greasy. C. Record review The activities of daily living (ADL) care plan for Resident #13 was revised on 4/13/21, it read in pertinent part; Resident #13 had an ADL self-care performance deficit. She chose to stay in bed most of the time and would occasionally get up in the wheelchair with the Hoyer lift. She will maintain her current level of function through the review date. She preferred a shower in the evening one to two times a week and preferred the same aide each week if possible. Record review of the activities of daily living (ADL) for bathing on 7/8/21 for Resident #13 was provided by the nursing home administrator (NHA) on 7/8/21 at 2:00 p.m. The documentation revealed bathing occurred three times in May2021, five times in June 2021 and one time in July 2021. A thirty day look back of the bathing task report for Resident #13 revealed she had a shower on 6/22/21 and 7/2/21. -The resident received a shower two times out of an estimated eight bathing opportunities according to her preference. X. Resident #65 A. Resident status Resident #65, age [AGE], was admitted on [DATE]. According to the July 2021 CPO, diagnoses included Parkinson's, depression, dementia and chronic kidney disease. The 6/9/2021 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) of nine out of 15. She required extensive assistance with two people for transfers. Extensive assistance with one person for bed mobility, dressing, hygiene and toileting. Bathing required the total assistance of one person. No rejection of care was documented. B. Observations Resident #65 was observed on 7/7/21 at 10:00 a.m. to sit in her recliner chair in her room. She was fully dressed and she leaned to the right side in her chair. She said she did not remember when she had a shower last and she needed help for many things. C. Record review The activities of daily living (ADL) care plan for Resident #65 was revised on 6/17/21, it read in pertinent part; Resident #65 has an ADL self-care performance deficit. The goal documented she would maintain her current level of function with ADL tasks through the next review date. Interventions said she needed maximum assistance with one person for bathing or showers. Avoid scrubbing and pat dry sensitive skin. Check nail length, trim and clean on bath days and as necessary. Report any changes to the nurse. Provide a sponge bath when a full bath or shower cannot be tolerated. A thirty day look back of the bathing task report for Resident #65 revealed she had a shower on 6/30/21 and 7/2/21.The resident only had two showers over thirty days. D. Interviews Certified nurse aide (CNA) #3 was interviewed on 7/12/21 at 1:30 p.m. She said Resident #65 did not have consistent showers because with other residents the facility did not have enough staff to complete the showers (cross-reference F725). XI. Additional staff interviews The NHA and director of nursing (DON) were interviewed on 7/8/21 at 3:37 p.m. The DON said the facility had recognized showers were not being given in accordance with the bathing schedule and resident plan of care at the end of March 2021. She said the facility identified the problem of residents not getting baths or showers timely, according to the schedule, or at all. She said an audit was completed of all residents at the facility and the care plans were updated with the resident preferences. She said the facility had designated a CNA as the bath aide to ensure bathing was being provided regularly. She said the MDS nurse was responsible to audit the bathing records to ensure showers were being completed. The NHA said she thought the showers were being completed, but the staff was not documenting. She said she was not aware the volume of residents interviewed, during the survey process, said they had rarely if ever received a shower. She said she was not aware staff were telling residents they could not be provided a shower because they were short staffed. The MDS nurse was interviewed on 7/8/21 at 4:30 p.m. She said she was responsible for monitoring the performance improvement plan regarding residents not receiving showers or baths according to the schedule and their plan of care. Cross reference F867: the facility failed to ensure an effective performance improvement plan was in place to address an identified concern of resident's not receiving showers or baths as directed on their plan of care. She said she would do a random audit based on the MDS assessment schedule. She said she would look at the past seven days to determine if the resident received showers or baths. She said she would talk to the CNAs if she discovered an issue. She said she did not document the audits being completed with the MDS assessment schedule. She said she did not document when she spoke with a CNA and did not report showers were not being provided. She said she felt the CNAs did not listen to her when she spoke to them. She said she knew the showers and baths were a continued problem. She said the facility had yet to determine the actual problem. The NHA and DON were interviewed on 7/12/21 at 8:52 a.m. The NHA said the facility management were able to pull reports that indicated residents received showers or baths. The NHA said question three on the report indicated the residents had received a shower or a bath. The NHA acknowledged the report for question three did not match the reports for question one, which indicated the bathing activity did not occur. She said she was not aware the CNAs were documenting the resident preference for question three, not if the resident actually received a shower or bath. The NHA said nursing management went to every resident in the facility and asked if they would like a shower. She said every resident who wanted a shower or bath was provided a shower or bath on 7/8/21-7/10/21. She said education was provided to the nursing staff on 7/9/21, which included bathing documentation and providing bathing according to the bathing schedule and resident preference. Certified nurse aide (CNA) #8 was interviewed on 7/12/21 at 10:31 a.m. She said that some residents would refuse showers but it was not always documented. She said the facility had hired a bath aide to assist with showers. She said due to the CNA work load, it was often difficult to ensure that clinical documentation and charting was completed (cross-reference F725). CNA #3 was interviewed on 7/12/21 at 12:34 p.m. She said showers were supposed to be given according to the bathing schedule at the nursing station. She said it was hard to give residents showers or baths because of how busy the CNAs were throughout the day. She said showers and baths were not being provided as they should. She said showers and baths were documented in the point of care (POC) electronic record for each resident. She said the POC system asked the CNA three questions related to bathing. She said the first question was how much assistance the resident required during the bath or shower. The second question was how much assistance the resident required in general, and the third question indicated the resident's preference between a shower, bath or bed bath. She said even if the resident was not provided a shower, the CNAs always answered question three with the resident's preference. She said if a shower was not given, then the activity did not occur would be marked for the first question in the POC system. She said the first question was the only area that indicated if a shower or bath was given to the resident. IV. Resident #27 A. Resident status Resident #27, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 computerized physician order (CPO) , diagnoses included respiratory failure, dysphagia, insomnia and traumatic subdural hemorrhage (brain bleed). According to the 4/27/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required extensive assistance from two staff members to perform transfers. The resident required extensive assistance from one staff member to perform personal hygiene and bathing. B. Resident observation and interview Resident #27 was observed in her bed on 7/8/21 at 11:07 a.m. Her hair appeared to be greasy and was not brushed. She was wearing a hospital gown. Resident #27 was interviewed on 7/12/21 at 9:37 a.m. She said that she would wear a hospital gown because it made it easier to clean her up in bed after episodes of incontinence. She said she would get cleaned up in bed. She said she had received showers but she was not sure how often they were occurring. C. Record review The resident care plan, revised 3/9/21, instructed that the resident required maximum assistance from staff to perform bathing. The resident preferred to shower in the evening two to three times per week. The resident bathing record from 6/10/21 to 7/8/21 revealed the resident had no documented showers during that time. -The resident did not receive a shower out of an estimated nine opportunities for bathing according to her preferences. V. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July CPO diagnosis included acute and chronic respiratory failure, type two diabetes, congestive heart failure, cellulitis of left and right lower limbs, morbid obesity, abnormalities of gait and mobility, dependence on enabling machines or devices and non pressure chronic ulcer of skin. According to the 4/12/21 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance from two staff members to perform transfers. The resident required extensive assistance from one staff member to perform personal hygiene and bathing. B. Resident observation and interview Resident #9 was observed sitting in her wheelchair in her room on 7/7/21 at 12:43 p.m. She had bits of white debris in her hair and it appeared to be unwashed. Resident #9 was interviewed on 7/8/21 at 10:23 a.m. She said she had received showers, however, not regularly. She said that the nursing staff did not always have time to give showers. (cross-reference to F725). C. Record review The resident care plan, revised 2/23/21, instructed that the resident required the assistance of one staff person to perform showers. The resident preferred to receive a shower after 2:00 p.m. and preferred showers two to three days per week. The bathing task record from 6/10/21 to 7/6/21 revealed the resident received physical help from staff to perform showers on 6/15/21 and 6/17/21. -The resident received two showers out of an estimated seven opportunities for bathing according to her preference. D. Facility follow-up Resident #27 received total assistance from staff to receive a shower on 7/9/21 after a facility wide audit was conducted to determine which resident had gone without a shower since 6/10/21. Resident #9 received physical assistance from staff to perform a shower on 7/10/21, who last received a shower on 6/17/21. VI. Resident #70 A. Resident status Resident #70, age [AGE], was admitted to the facility on [DATE]. According to the July 2021 computerized physician order (CPO), diagnoses included type two diabetes, congestive heart failure, absence of left leg below knee and end-stage renal disease. According to the 6/11/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance from two staff members to perform transfers. The resident required extensive assistance from one staff member to perform personal hygiene, transfers and dressing. Bathing assistance was not assessed during the assessment period. B. Resident observation and interview Resident #70 was interviewed on 7/7/21 at 11:54 a.m. He said care was often delayed or not received. He said he did not receive regular showers. He said he would ask for assistance and it seemed like the nurse on his unit, just didn't want to do it and would not come back. The resident ' s hair was greasy and unwashed. C. Record review The resident care plan, revised 7/11/19, instructed that the resident preferred to shower in the afternoon two to three times per week. The resident required the physical assistance of one staff person to perform all other activities of daily living. -The care plan did not include how many staff were required to provide bathing assistance. The resident bathing record from 6/10/21 to 7/8/21 revealed the resident had received total dependent shower assistance on 6/27/21 and 7/1/21. -The resident only received two showers out of an estimated 10 opportunities for bathing according to his preferences. Based on observations, record review and interviews, the facility failed to ensure eight (#13, #74, #68, #9, #65, #70, #29 and #27) of eight dependent residents reviewed for assistance with activities with daily living (ADLs) out of 40 sample residents received appropriate treatment and service to maintain personal hygiene. Specifically, the facility failed to ensure dependent Residents #13, #74, #68, #9, #65, #70, #29 and #27 received regular bathing in accordance with their plan of care. The failure to ensure bathing was provided in accordance with plans of care for dependent residents affected all eight sample residents and was recognized to affect all other residents who were dependent on staff for bathing. Observations, record review and interviews showed the facility had a lack of staffing which impacted the residents who required total assistance with bathing needs. Cross-reference F725 for insufficient staffing. Cross-reference F676: the facility failed to ensure non-dependent residents were bathed in accordance with their plans of care. Findings include: I. Facility policy and procedure The Activities of Daily Living policy and procedure, reviewed May 2020, was provided by the nursing home administrator (NHA) on 7/13/21 at 3:00 p.m. It revealed, in pertinent part, The resident will receive assistance as needed to complete activities of daily living. Purpose: to ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The facility must provide care and services for the following activities of daily living: hygiene - bathing, dressing, grooming and oral care. II. Resident bathing needs The Resident Census and Condition of Residents report, dated 7/7/21, was signed by the director of nursing (DON). The resident census was 88. The residents had the following care needs: -For bathing, 37 residents required the assistance of one or two staff, 14 were dependent and two were independent. A total of 53 residents were accounted for their bathing assistance needs; the bathing status of 35 residents was not accounted for in the report. A total of 51 residents required the assistance of staff for bathing accounted for in the report. III. Resident #68 A. Resident status Resident #68, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), the diagnoses included fracture of the left acetabulum, fracture of the femur, fracture of parts of the lumbosacral spine and pelvis and adjustment disorder with mixed anxiety and depressed mood. The 6/11/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required extensive assistance of two people with bed mobility, transfers, and toileting. She required extensive assistance of one person with dressing and personal hygiene. She required total assistance with bathing. B. Resident interview and observations Resident #68 was interviewed on 7/7/21 at 4:38 p.m. She said she had received only one shower since she was admitted to the facility. She said she would often ask the facility staff when she would get a shower. She said she was told they were short staffed and she would have to wait until they had time. Cross reference: F725: the facility failed to provide sufficient staffing to ensure resident's received bathing according to their plan of care. She said she was doing therapy during the day and would get sweaty. She said she felt gross. She said she was used to showering at least once to twice per week. Resident #68 was observed lying in bed. The back of the resident's hair was pushed up and in disarray. The resident had white debris observed near the corners of her nose, mouth, and in between her eyebrows. [NAME] debris was also observed throughout the top of the resident's head. The resident's hair had an odor. C. Record review The ADL care plan, initiated on 6/23/21, revealed the resident had a self-care performance deficit due to a recent fall and pelvic fracture. The interventions included the resident requiring maximum assistance with bathing and showering. The CNA assignment sheet indicated the resident was scheduled to receive bathing on Sundays, Wednesdays and Fridays. The bathing documentation from 6/7/21 to 7/8/21 documented that the resident received a shower on 6/11/21. The resident received a shower one time in 31 days since her admission to the facility on 6/7/21 out of an estimated 15 bathing opportunities based on her preference.

Based on observation, interviews and record review, the facility failed to provide sufficient nursing staff to ensure residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically,that facility failed to consistently provide adequate nursing staff to ensure that residents received regular and routine showers and/or baths and assistance with activities of daily living. Cross-reference the following citations: F676 and F677: the facility failed activities of daily living to residents that impacted residents facility-wide. The facility failed to provide resident bathing according to their preference to residents who required supervision to be fully dependent on staff to meet their bathing needs. Due to the lack of staffing, resident and staff interviews revealed that showers were not being completed. F688: the facility failed to provide restorative services for residents that required a program to maintain their abilities. According to staff interviews, the restorative aides scheduled to provide restorative programs were often pulled from their work to provide care to the residents as certified nurse aides due to short staffing. Findings include: I. Facility policy The Staffing policy, reviewed 5/5/2020, was provided by the director of nursing (DON) on 7/13/21 at 2:19 p.m. It read in pertinent part, The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by the resident assessments ad individual plans of care and considering the number, acuity and diagnosis of the facility resident population in accordance with the facility assessment. II. Resident census and conditions The Resident Census and Condition of Residents report, dated 7/7/21, was signed by the director of nursing (DON). The resident census was 88. The residents had the following care needs: -For bathing, 37 residents required the assistance of one or two staff, 14 were dependent and two were independent. A total of 53 residents were accounted for their bathing assistance needs; the bathing status of 35 residents was not accounted for in the report. -For dressing, 73 residents required the assistance of one or two staff and three residents were independent. A total of 76 residents were accounted for their dressing assistance needs; the dressing status of 12 residents was not accounted for in the report. -For transferring, 68 residents required the assistance of one or two staff and seven residents were independent. A total of 75 residents were accounted for their transferring assistance needs; the transfer status of 13 residents was not accounted for in the report. -For toilet use, 67 residents required the assistance of one or two staff, two residents were dependent and six residents were independent. A total of 75 residents were accounted for their toileting assistance needs; the toileting status of 13 residents was not accounted for in the report. -For eating, 23 residents required the assistance of one or two staff, and 56 residents were independent. A total of 79 residents were accounted for their eating assistance needs; the eating status of 9 residents was not accounted for in the report. -Due to the facility inaccuracies of resident census and condition report with the assistance needs not being documented for many residents, the facility did not have an accurate count of their staffing needs according to the residents ' care level and acuity. In addition, the following was reported as additional resident census and care needs: -There were 65 residents who had occasional or frequent bladder incontinence. -There were 35 residents who had occasional or frequent bowel incontinence. -There were 34 residents who had a diagnosis of dementia. -There were six residents who had had an unplanned, significant weight loss. -There were 37 residents who required respiratory treatment. -There were 76 residents who required preventive skin care. III. Resident interviews and observations Residents were identified as interviewable by facility and assessment. Resident #81 was interviewed on 7/7/21 at 9:50 a.m. He said that he was not receiving showers. He said that he had requested to be given a shower, however, staff would either tell him that they did not have time to provide him with one or that would say that they would return to give him a shower after doing other tasks and then would never come back to his room. He said I get myself up and get dressed on my own as best I can, but sometimes it's harder to do; I am here because I need assistance but they just won't do it a lot of the time. He rubbed his face and said I am not used to having this much stubble. The resident was observed sitting in his wheelchair wearing a white t-shirt with multiple stains on the front and was wearing underwear. His jeans were slung over the pillow on his bed and had an orange substance on them. His face was unshaven. Resident #50 was interviewed on 7/7/21 at 10:28 a.m. She said, I'm not sure how staffing works but it seems like they (the facility) are always short. No particular time of day; there are just not enough people to do the care. She said that she would not receive showers regularly unless she repeatedly asked to receive one. She said when she had asked for a shower she was told by staff that they did not have time to provide one. She said with the temperature and these hotter days, they need to have enough CNAs (certified nurse aides) working to give showers. She said the facility had hired a bath aid when it had been identified as an issue several months prior, however, she said not receiving showers was still a problem. Resident #43 was interviewed on 7/7/21 10:59 a.m. She said she had not received showers at the facility. She said she would have to shower at her family's house (who she visited and lived nearby). She said that staff would ask her if it was her shower day and she would reply yes and then they would never return to assist her to the shower. She said when she would ask for showers, staff would tell her they were busy or would agree to give her one and then never return. She said they need more help around here. Resident #13 was observed on 7/7/21 at 1:30 p.m. She said she wanted a shower and was told by the facility staff that there were not enough staff to assist to get her out of bed for a shower . She required a Hoyer (mechanical) lift for transfers. She said her hair was greasy and she really wanted to get a shower to wash her hair and to keep her skin healthy. She said she did not want any skin breakdown to occur. She said she could not remember when she had a shower last, that was how long it had been. The resident was observed in bed, she had on a hospital gown and her hair was greasy. Resident #25 was interviewed on 7/7/21 at 4:35 p.m. She said she had not showered in a while. She said the staff were too busy to assist her to get in the shower room. Resident #68 was interviewed on 7/7/21 at 4:38 p.m. She said she had received only one shower since she was admitted to the facility. She said she would often ask the facility staff when she would get a shower. She said she was told they were short staffed and she would have to wait until they had time. The resident was observed lying in bed. The back of the resident's hair was pushed up and in disarray. The resident had white debris observed near the corners of her nose, mouth, and in between her eyebrows. [NAME] debris was also observed throughout the top of the resident's head. The resident's hair had an odor. Resident #73 was interviewed on 7/8/21 at 9:00 a.m. She said she had only received two showers since her admission to the facility. She said the staff would always tell her they could not give her a shower because they did not have enough staff. Resident #145 was interviewed on 7/8/21 at 9:27 a.m. She said she was admitted to the facility because of a fall, from which she sustained a fracture to her right arm. She said she had not received a shower since she was admitted to the facility, on 7/2/21. She said she had not received a shower in the hospital, so her last shower was prior to her fall at home.She said the nurse told her, when she was first admitted to the facility, she would receive a shower the next day. She said she informed the nurse she was used to taking two to three showers per week. She said, every time she had asked, the CNAs would tell her they did not have enough staff to give her a shower. She said she felt grimy and sweaty. Resident #145 was observed with white debris on her face and edges of her hairline on the forehead. Resident #1 was interviewed on 7/12/21 at 10:00 a.m. She said that she had specific shower days that she had selected when she was admitted to the facility; she said that staff then changed the shower days and she no longer got to choose when she received a shower. She said after the facility changed her shower schedule; she still did not receive regular showers. She said the facility did not have enough staff to provide showers. Resident #28 was interviewed on 7/12/21 at 10:05 a.m. She said there just isn't enough staff; I was a nurse; how can two people do all of our care as well as give everyone showers? This year I once went eleven weeks without a shower so I would do my own bed bath, they were too busy. I did ask for help, it did not happen, so I just gave myself a sponge bath. I should not have to keep asking staff to please take care of me. The staff we do have work doubles for days in a row. That is asking too much (of a staff person), and what about our safety? They cannot expect two CNAs to care for 40 people. IV. Record review The daily staffing record was reviewed from 6/1/21 to 7/12/21. It revealed that each unit of three units would be scheduled to have two or three CNAs and two nurses. One bath aide for all three units was scheduled for day shifts Monday through Friday. The restorative aide section of the staffing record often revealed no restorative aide scheduled. Review of staffing daily reports for the past three months revealed nursing staffing, even at the current levels, was not able to sufficiently meet the needs of the resident population which staff and residents stated were insufficient and evidenced by showers not being completed/lack of restorative programs being completed. V. Staff interviews The NHA and director of nursing (DON) were interviewed on 7/8/21 at 3:37 p.m. The DON said the facility had recognized showers were not being given in accordance with the bathing schedule and resident plan of care at the end of March 2021. She said the facility identified the problem of residents not getting baths or showers timely, according to the schedule, or at all (cross reference to F867 for quality assurance). CNA #8 was interviewed on 7/12/21 at 10:30 a.m. She said that she was on light duty and so could not assist residents with physical tasks. She said that sometimes there would be three CNAs scheduled per unit but more recently it has been two CNAs scheduled to each unit. She said that the nurses working her unit were willing to help out with showers and answering calling lights. She said that two CNAs were responsible for the care of 34 residents. She said that two residents required a Hoyer (mechanical) lift to perform transfers.She said that a bath aide was scheduled to assist during the day shift Monday through Friday. Registered nurse (RN) #2 was interviewed on 7/12/21 at 10:35 a.m. She said the CNAs on the unit worked very hard to try to meet the resident's needs. She said that resident showers on the units where there high acuity needs had to occur during nurse down time so that the nurses could also help with showers (however, not according to the resident preference). She said residents were told that they could receive a shower when the staff were about to provide them. The restorative director (RD) was interviewed on 7/12/21 at 10:30 a.m. She said she oversaw the restorative program for residents. She said she documented the progress for each resident from the communication she had with the restorative aide (RA). She said the restorative program was not consistent due to the RA getting pulled to work on the floor due to short staffing. She filled in on the days the RA was pulled to the floor. She said she was pulled more often than not and ideally the restorative program should have two restorative aides to cover the residents care needs. Licenced practical nurse (LPN) # 1 was interviewed on 7/12/21 at 10:40 a.m. He said that nurse scheduling was based on the number of residents in the facility. He said the number of certified nurse aides (CNAs) scheduled was the same regardless of the acuity of the residents. He said that some units of the facility had more residents who required a two-person transfer and were higher acuity than others. He said individual time management was important to making sure all of the resident care needs were met. Certified nurse aide (CNA) #3 was interviewed on 7/12/21 at 12:34 p.m. She said showers were supposed to be given according to the bathing schedule at the nursing station. She said it was hard to give residents showers or baths because of how busy the CNAs were throughout the day. She said showers and baths were not being provided as they should. CNA #3 was interviewed again on 7/12/21 at 1:30 p.m. She said residents did not have consistent showers because the facility did not have enough staff to complete the showers. CNA #7 was interviewed on 7/13/21 at 1:39 p.m. She said they (the facility) needed more help, I do my best to run, but there is not enough time. She entered a resident's room during the interview, pointed to the beds not being made and said, I have not even had time to make the beds. The restorative aide (RA) was interviewed on 7/13/21 at 12:30 p.m. She said she was supposed to be the restorative aide five times a week to assist the residents with their programs but she was pulled to work the floor as a CNA because of short staffing. The staffing director (SD) was interviewed on 7/13/21 at 12:57 p.m. She said that nurse staffing was based on resident census, however, was not based on resident acuity. She said the facility had not used agency staff in several months. She said that staffing levels at the facility had fluctuated. She said they would call staff in and have unit managers fill in if a shift was not covered. The NHA was interviewed again on 7/13/21 at 2:47 p.m. She said that the staffing needs were determined by multiplying the targeted hours of combined care per resident per day (PPD) which was 3.70 by the total resident census. She said that the facility's daily staffing schedule did not account for the bath aide hours. She said that the facility reviewed the resident care needs daily and would schedule nursing staff based on acuity. -However, the SD and NHA said their staffing was appropriate based on the resident census in the facility but based on observation, resident interviews and staff interviews (see above) there was not accurate staffing based on the acuity and care needs of the residents. Due to inadequate staffing levels, resident bathing preferences and restorative programs were not being offered according to their preference and comprehensive plan of care in order to meet their highest practicable level of physical, mental, functional and psycho-socal well-being (cross-reference F676, F677 and F688).

Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify a QAPI plan, which was in place, to address residents not receiving showers in accordance with their plan of care, was unsuccessful and put new interventions into place to successfully address the concern. Cross reference F676: the facility failed to ensure showers were provided to residents in accordance with their plan of care. Cross reference F677: the facility failed to ensure showers were provided to dependent residents in accordance with their plan of care. Findings include: I. Facility policy and procedure The Quality Assessment Performance Improvement Plan policy and procedure, January 2021, was provided by the nursing home administrator (NHA) on 7/7/21 at 10:00 a.m. It revealed, in pertinent part, Our facility's QAPI plan serves as guide for our overall quality improvement program and initiatives. The decision making within the facility will be driven by quality assurance performance improvement principles. These decisions will assist in promoting quality of care and quality of life of residents. In addition, these principles will lead to an emphasis on resident choice, person directed care and resident transitions. Any system that affects the satisfaction of residents, families and associates will be considered an area of opportunity. This will include systems affecting the quality of care, quality of life and safety of residents. The QAPI Committee prioritizes performance improvement activities and monitors for improvement. In addition, the QAPI Committee will implement any performance improvement project topics indicated by data analysis. Performance improvement projects are completed in order to affect systematic changes. By affecting change positively, this will have an impact on the quality of life and quality of care for residents in our facility. II. Record review The 4/7/21 bathes/showers performance improvement plan (PIP) documented the following: Corrective action taken for the identified area: Untimely/not done showers or baths. Baths and showers are not being completed per schedule. 100% (percent) of the residents were being affected. An audit was completed by the MDS (minimum data set) coordinator on 3/27/21. Systemic changes made to prevent the potential deficient practice from reoccurring: Bath/shower aide was added to the schedule to assist with the completion of bathing/showering; unit manager would update the CNA (certified nurse aide) assignment sheet for bathing/showering schedules. -It did not document a completion date. Monitoring of systemic changes: Shower/bath schedules to be placed in point of care (POC, electronic medical record) and monitored by the MDS coordinator/unit manager for completeness; and the unit manager or designee to audit and observe for accuracy and completion. -The completion date indicated on-going. III. Staff interviews The NHA and director of nursing (DON) were interviewed on 7/8/21 at 3:37 p.m. The DON said the facility had recognized showers were not being given in accordance with the bathing schedule and resident plan of care at the end of March 2021. She said the facility identified the problem of residents not getting baths or showers timely, according to the schedule, or at all. She said an audit was completed of all residents at the facility and the care plans were updated with the resident preferences. She said the facility had designated a CNA as the bath aide to ensure bathing was being provided regularly. She said the MDS nurse was responsible for auditing the bathing records to ensure showers were being completed. The MDS nurse was interviewed on 7/8/21 at 4:30 p.m. She said she was responsible to monitor the performance improvement plan regarding residents not receiving showers or baths according to the schedule and their plan of care. She said she did not document the audits being completed with the MDS assessment schedule. She said she did not document when she spoke with a CNA and did not report showers and baths were not being provided. She said she felt the CNAs did not listen to her when she spoke to them. She said she knew the showers and baths were a continued problem. She said the facility had yet to determine the actual problem. The quality assurance (QA) interview with the NHA was conducted on 7/13/21 at 1:50 p.m. She said the facility identified there was a concern with residents not receiving showers in accordance with their plan of care at the end of March 2021. She said it was clear, during the survey process, the performance improvement plan (PIP) that was put into place was not effective. She said the PIP was not specific enough to drill down and determine the real problem. She said the audits did not include parameters, which also resulted in the PIP being ineffective. She said the audits also did not include monitoring to ensure they were being documented and completed.