**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from abuse for one resident (#3) out of 3 sampled residents. Findings included: An interview was conducted on 09/17/2025 at 10:30 a.m with Staff A,PCA (Personal Care Attendant). Staff A stated they witnessed Resident #3 being verbally abused by Staff B, CNA, whom they were training with that day. Staff A stated Resident #3, had finished receiving incontinence care from Staff B and was on the edge of the bed when Staff B voiced, Don't put your [EXPLICIT] hands on me or I'll let you fall on the [EXPLICIT] floor. Staff A stated they then saw the CNA aggressively lift up and set resident into her wheelchair and the resident was shaking after that. While assisting the resident with her shoe that had fallen off while being transferred into the chair, Staff A stated the resident voiced that the other CNA, Staff B, thought she was crazy. Staff A reported her observation to the Director of Nursing (DON), who directed them to return to the floor training with another CNA. Staff A stated the facility did an investigation, but the CNA did not know whether or not Staff B was still employed with the facility. Staff A reported being retaliated against because of reporting the abuse and stated being told when writing her statement, not to go into detail but write down the major points. Staff A stated Staff B came back upstairs and made a statement Snitches get stitches and this staff member felt it was directed to her. Staff A stated ever since that happened, the workplace has felt hostile, they talk about how some employees lie on other employees and they get fired. On 09/18/2025 at 2:55 p.m. an interview was conducted with Staff B, CNA. Staff B stated thinking Staff A, PCA, doesn't like me and she doesn't like to work because I made her get up and help change the resident and then they pulled me into the office and told me that the PCA complained about me. Staff B stated being suspended but refused to answer the question related to why she was suspended. She said she came back on the holiday and then a few days later she got suspended again because she was in the parking lot saying, snitches get stitches referring to Staff A. Staff B refused to acknowledge the allegation for Resident #3 and stated being done with the facility and not coming back to the facility. Staff B stated she already started another job and discontinued the interview. An observation of Resident #3 on 09/17/2025 at 3 p.m. revealed the resident in bed, resident appeared clean and dressed appropriately. Resident #3 presented pleasantly confused and was unable to answer questions about their care at the facility. When a CNA entered the room during the interview, the resident leaned back in the bed, closed eyes, and as though they were sleeping. The resident did not respond the CNA and discontinued the interview. Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mood disorder due to known physiological condition with depressive features, muscle weakness (generalized), unspecified protein-calorie malnutrition, sarcopenia, and anemia. A review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed the resident to have a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The MDS revealed the resident required partial/moderate assistance for oral hygiene, eating; substantial/maximal assistance for personal hygiene and upper body dressing, and was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear and revealed resident was always incontinent of bowel & bladder. Review of Resident #3's care plan focus on self-care performance revised on 10/03/2034 showed the resident has deficits related to confusion, dementia, visual deficit r/t (related to) bilateral cataracts, depression and anxiety with goal of resident maintaining current level of function through the review. Interventions showed the resident was to request from staff to turn/reposition in bed, staff to check resident's nail length and trim as necessary, resident was to be assisted by staff with dressing, eating, bathing, and oral/personal hygiene. Staff was to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.A second focus in the same care plan showed the resident was at risk for falls related to cognitive deficits, weakness, incontinence, visual deficit and side effect of medication use with goal of resident would not sustain serious injury through the next review date and interventions of 1/4 side rails (sides of bed) per consent to aid in positioning, staff would anticipate and meet the resident's needs, staff to ensure resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance, staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, staff to ensure that the resident was wearing nonskid footwear when out of bed, resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; call light within reach, personal items within reach. On 09/17/ 2025 at 5:00p.m., the DON and the Nursing Home Administrator (NHA) reviewed the incident for Resident #3. The NHA stated on 8/22/2025 at approximately 12 p.m. the DON notified them of an allegation of verbal abuse. The DON told them they were approached by Staff A alleging that Staff B used curse words and was aggressive with Resident #3 while providing care. The DON stated an investigation was completed with the staff and resident, and the resident did not have any psychosocial distress, so they deemed the investigation inconclusive. The NHA stated they did not substantiate the allegation based on their investigation and Staff B returned to work 4 days after the incident and a suspension. The NHA stated all staff who interviewed Resident #3 after the investigation found no concerns of abuse and neglect from the resident or other residents in the area. The DON stated because Resident #3 had cognitive deficits and was not able to answer interview questions, they looked for nonverbal cues or behaviors different from resident's baseline when interviewing and they did not feel any of those were present. The DON stated the reason the resident was not seen by psych until 08/28/2025 when the incident occurred on 08/22/2025 was because the PMNP was on vacation and the facility did not realize the resident had not been evaluated until their 5-day report, when they then got in touch with the psych doctor and did a telehealth evaluation. The DON stated that they use a lot of agency staff, and they just want to pass meds and leave. The DON said, They are not invested in the residents. On 09/18/25 at 3:54 p.m. an interview was conducted with Resident #3's Psychiatric-Mental Health Nurse Practitioner (PMHNP). The PMHNP stated they had signed a note for the resident dated 08/28/2025. The PMHNP stated the facility told him that there was a verbal altercation between staff and the resident. The PMHNP stated he could not remember the specific words used. He stated he conducted a telehealth visit the resident and she was extremely confused and couldn't remember anything or give him any details. He stated he believed they told him of the altercation, and he did the telehealth the same day. The PMHNP could not comment if there was any psychosocial impact as the resident was extremely confused. Review of a psychiatry progress note dated 08/28/2025 showed the resident was seen via telehealth following a reportable safety allegation from staff. During the interview, the patient appeared confused and was unable to engage in meaningful conversation. From the telehealth assessment, the patient appeared safe and stable with no immediate risk factors observed. Staff will continue to monitor. In the interview with DON on 09/17/ 2025 at 5:00 p.m. the DON stated because Resident #3 had a baseline of confusion and was severely cognitively impaired. The DON stated they relied on monitoring behavior changes and body language to determine if the resident had any psychosocial distress. A review of a social services progress note dated 08/22/2025 showed, This SW (social Worker) visited with [Resident#3] post incident in her room. She was resting with her eyes open in bed. [Resident#3] presented with no signs and symptoms of distress. She was pleasant with confusion but was able to engage in simple questions. [Resident#3] was unable to recall the incident. An interview was conducted with multiple CNAs on 09/17/2025 from 9:56 a.m. Staff D stated hearing of an instance where there was an allegation of verbal abuse to a resident. Staff D stated it was brought up in the education, but they weren't given the details. Staff D stated if they heard of any type of abuse, they would immediately report it to Risk Manager. Staff E stated hearing about an incident upstairs where one of the aides was really rough with a patient and wasn't cleaning them. Staff E stated a few weeks ago- heard it got reported and the police came. Staff F, CNA stated there was a verbal abuse incident recently and to their knowledge, that staff member was let go. Staff G, CNA confirmed hearing of the abuse incident and said one of the residents reported the CNA was was really rough with the resident, and it was reported. the CNAs all confirmed having received abuse and neglect training. An interview was conducted with resident #3's Primary Care Physician (PCP). The PCP stated they were notified of the abuse allegation the day it happened. they stated the facility stated they were investigating, and their NP (nurse Practitioner) may have seen the resident during rounds. The PCP did not have anything else to add regarding the incident. Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 09/01/2023 revealed - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A). Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individua which may include the development of or the presence of an ongoing sexually intimate relationship.Possible indicators of abuse include but are not limited to: 5.) Verbal abuse of a resident overheard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to review and revise the comprehensive care plan for one resident (#1) out of 3 residents reviewed.Based on interviews and record review the facility failed to review and revise the comprehensive care plan for one resident (#1) out of 3 residents reviewed.Findings include:Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE]. Resident was discharged on 6/14/2025 and re-entered the facility on 6/28/2025.Further review of the medical record revealed the following diagnoses with a date of 6/28/2025: Non-ST Elevation myocardial infarction, type 2 diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, dependence on renal dialysis.A review of Resident #1's active care plan revealed the following:-Focus: Resident#1 takes Plavix d/t {due to} having increased risk of blood clots, stroke, and heart attack. At risk for bleeding and bruising. -Goal: . will have no adverse effects of ASPIRIN use through next review. -Intervention: Administer Aspirin as ordered.-Focus: .is on diuretic therapy r/t {related to} edema, hypertension. -Interventions: Administer diuretic medications as ordered by physician.A review of the Order Summary Report revealed the following order: Clopidogrel Bisulfate {Plavix} Tablet 75 MG {milligram}. Give 1 tablet by mouth one time a day for blood clot prevention.There was no order for Aspirin.There was no order for diuretic medications.An interview on 7/28/2025 at 3:00 p.m. was conducted with Staff J, Licensed Practical Nurse (LPN) MDS and Staff K, Registered Nurse (RN), MDS Coordinator. They stated they are responsible for the care plans. They stated the process is to have a care plan meeting with the resident, which is usually attended by the unit manager. They do not attend the care plan meeting. They stated they do a review of the care plan when the quarterly Minimum Data Set (MDS) is completed. Staff J, LPN MDS stated Resident #1's care plan should have been updated. They stated Resident #1 should not have a diuretic therapy focus; it should not be there. They stated the care plan should have been updated to include administering Plavix, not aspirin. A review of the policy Comprehensive Care Plans with a revision date of 1/2025 Revealed the following: Policy: Policy Explanation and Compliance Guidelines:5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to assess, develop and implement a care plan related to a documented PTSD (Post Traumatic Stress Disorder) diagnosis and failed to care plan potential trauma triggers for one resident (#1) of two residents sampled. Findings included: Review of the admission Record for Resident #1 showed he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include metabolic encephalopathy, adjustment disorder recurrent, insomnia, and generalized anxiety disorder. Review of an admission level I Pre-admission Screening and Resident Review (PASARR) dated 02/29/24 showed Resident #1had a diagnosis of adjustment disorder and PTSD (Post Traumatic Stress Disorder). Review of a social services progress note dated 04/07/25 showed, Resident has a history of trauma and or PTSD. Review of a document titled Social Services Trauma Screen dated 04/10/25 showed question P: Resident has a history of trauma and or PTSD (Post Traumatic Stress Disorder). Under questions A through N, it was noted the resident did not answer Yes, or No. It was marked prefers not to answer/unable. Question O. Events that really bothered the resident, it was noted, altercation with a male CNA. The question under P. on Trauma/PTSD assessment was marked, Yes. The question if the care plan was updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization, the answer showed - N/A (Not Applicable). Review of a document titled Social Services Trauma Screen dated 01/15/25 showed: Question O, [Resident #1] communicated that he was abused and talked about as a child and all through his life by his peers . Question P. showed the resident had PTSD. The question if the care plan was updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization, the answer showed - N/A. Review of a document titled Social Services Trauma Screen dated 12/02/24 showed in J. Resident's mother passed away and it still affects him at times. In Question O: List any events that really bothered you that were not mentioned, Resident #1 answered, While in the facility, he thinks he hears rumors of the facility throwing him out, feels he is served old food, and states the Black CNAs (Certified Nursing Assistants) are abrupt and short with him. The trauma/PTSD question was marked, No. Review of a document titled Social Services Trauma Screen dated 10/02/24 showed in F. Quetion - If the resident was forced to have sexual contact - as a child? The resident preferred not to answer. In question O. List events that really bothered you, Resident #1 answered, molested as a child. Question P. on Trauma/PTSD assessment was marked No, and the care plan update was not considered. Review of a document titled Social Services Trauma Screen dated 08/12/24 showed Question F. - If the resident was forced to have sexual contact - as a child? The resident answered, Yes F(2.) Describe what happened- it is noted, molested as a young child. He never told anyone. When asked if anyone got hurt, or if the resident was afraid someone else might get hurt, and if he felt afraid, helpless or horrified, Resident #1 answered, yes to all these questions. In question P. History of Trauma and or PTSD (Post Traumatic Stress Disorder) was checked, Yes. The question if the care plan was updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization, the question was left blank. Review of a Quarterly MDS (minimum Data Set) dated 02/22/25 revealed in Section I active diagnosis, the resident did not have a PTSD or trauma related diagnosis indicated. Review of a care plan for Resident #1 initiated 08/12/24 showed a Focus, Resident #1 has experienced trauma related to adjustment issues affecting the follow sadness - sad face, affect, statements of sadness. A focus on 1/23/25 showed Resident #1 expressed feelings of being claustrophobic - being afraid in enclosed areas/places. Date Initiated: 01/23/2025. Interventions included - Ensure that door in his room is open at all times. Refer to psychiatry and psychology services for medication review and behavior management. On 4/14/25 at 10:37 a.m. an interview was conducted with the Social Services Director (SSD) Risk Manager (RM) and the Nursing Home Administrator (NHA). The SSD stated regarding the process of ensuring communication with providers she stated, If a concern that warrants the care plan to be updated is brought up, it is discussed with nursing staff and IDT (Interdisciplinary Team) to make sure they can capture what they are looking for. She stated Resident #1's history of sexual abuse was discussed with the previous DON (director of Nursing). The SSD stated the resident was referred to psych on 8/12/24. Review of the psych note revealed there was no mention of the sexual abuse history or trauma related concerns. The SSD stated a care plan was put in place related to the resident being Claustrophobic, but not related to the abuse. The SSD said, The care plan should show known triggers if they are identified. I do not know if he had any. The SSD stated the plan of care should include letting staff know to approach the resident in a non-threatening manner, give space and observe for anxiety. The SSD reviewed the care plan and stated she did not see the interventions regarding sexual abuse or trauma. During an interview on 04/13/25 at 12:05 p.m. with Staff E, Licensed Practical Nurse, he stated he was Resident #1's nurse every time he works. The LPN said, Resident #1 has problems with his brief being changed. This is a behavior that he has. Staff E, LPN stated he did not know if Resident #1 had PTSD. He looked on the admission record and said, No, there is PTSD diagnosis. It is not on his list of diagnoses so, he must not have PTSD, and no triggers have been identified. Staff E, LPN stated changing his brief was the biggest problem and also closing his door when he was in his room alone. An interview was conducted with Staff F, CNA on 04/13/25 at 12:20 p.m. She stated she worked with Resident #1 sometimes, and he refuses care related to brief changes and he absolutely hates that. She stated he frequently refuses, and she tells him he would need to let her change his brief that is soiled, at least once before her shift is over. Staff F stated no one has ever told her Resident #1 had PTSD or any history of trauma. An interview was conducted on 04/13/25 at 12:00 p.m. with Staff G, CNA. She stated she worked with Resident #1 and he does say racially and derogatory comments but as a CNA I signed up to put up with that and I just ignore it. He does refuse to change his brief often. Staff G stated most of the time she would ask him 3 or 4 times during her shift. Staff G said, This is just a behavior that he has. Staff G denied knowing if Resident #1 had PTSD or history of any kind of trauma. Staff G stated she was never told of this and had not been trained on any triggers. She stated she had been told to always have another person in with her when providing his care. Staff G said, He is usually good with me just not when it is time to change his brief he hates it and gets upset about it almost every time. Review of a care plan for Resident #1 dated 3/5/25 showed a focus, Resident #1 is resistive to care, refuses lab draws r/t (related to) Adjustment Disorder with mixed anxiety and depressed mood. Date initiated: 01/24/2025, created on and revised on 02/26/2025. Interventions included to allow Resident #1 to make decisions about treatment regime, to provide a sense of control, encourage as much participation/interaction by the resident as possible during care activities, give clear explanation of all care activities prior to and as they occur during each contact. Resident #1 resists (ADLs) Activities of Daily living, reassure resident, leave and return 5-10 minutes later. During an interview on 04/13/25 at 10:51 a.m. Resident #1 stated that he was forced to receive care by an [African American] CNA (Certified Nursing Assistant) who is a profanity, too rough and always has to have his way. Resident #1 said, I sometimes refuse care, but the [African American] CNA forced me to accept his care. When that CNA [Staff A,] comes into my room I feel a sense of panic because I know he is going to be rough with me. The resident stated it had to be the CNA's way or no way. Resident #1 stated the CNA [Staff A] forcibly crossed his arms over his chest and was mean to him by laughing at him. Resident #1 said, I do not want him again and I have not seen him since. I feel like I have the right to choose to refuse care and I have choices, and it is against my rights and the law to force me to do something. The resident stated regarding PTSD (Post Traumatic Stress Disorder), I do not want to talk about it. During this interview, an observation revealed the resident had two dressings, one on the left wrist dated 04/12/25 and one on the right back of hand dated 04/12/25. Resident #1 stated those dressings were from the incident with the CNA. Interviews were conducted with Resident #1's CNAs on 04/13/25 from 2:50 p.m. to 3:45 p.m. regarding his care and any knowledge of trauma history. The interviews revealed the following: Staff H, CNA said, Resident #1 has a problem with people. He yells at people and uses racial slurs with CNAs and the roommate. He says he has PTSD he is claustrophobic. He does not like people in his space. Staff I, CNA stated Resident #1 always asks her to hold his hand. He is always yelling. She stated she did not know of a PTSD or trauma diagnosis. She stated she was not trained on identifying triggers. Staff J, CNA stated Resident #1 refuses to be changed. He said, He used to cuss me out. I tried to be nice, I would go to the kitchen and get him sandwiches to pacify him. Staff J stated the previous nurse practitioner said to him, Do not do him alone he said you tried to kill him. Staff J stated he has heard Resident #1 calling racial slurs and did not know why. He denied knowing of a PTSD or trauma diagnosis. He stated he had not been told. He stated he did not know what would be triggering Resident #1. On 0n 04/14/25 an interview was conducted with Staff B, Registered Nurse (RN). She stated Resident #1 yells racial slurs all day. She sated he says he does not like black derogatory term. Staff B stated when CNAs say he does not want to be changed, she tries to help. She stated Resident #1 refuses to be changed because he does not like the African American CNAs. She stated they had African American CNAs on assignment most of the time. Staff B, RN stated she was unaware of any history of abuse, trauma or a PTSD diagnosis. On 04/13/25 at 2 p.m. an interview was conducted with Staff D, LPN/Unit Manager (UM). Staff D stated Resident #1 had problems with dark skinned people. She said, He yells at them, sometimes he does not want care from them, they will come to the room, and he says he does not want to be changed. When he says that, they come to me, I go to him and he says he is refusing because he is dry, but I can see he needs to be changed, or he has a smell. He then lets me change him. Staff D stated about a month earlier she became aware of the resident's history of abuse. She stated she reported it to the SSD. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 4/14/25 at 12:01 p.m. The DON stated they had one resident with a PTSD diagnosis, but was taken off the diagnosis because they did not meet criteria. The DON stated she was not aware Resident #1 had a history of PTSD or any history of sexual abuse. She stated he would have to be assessed. The NHA stated Resident #1 was inconsistent. Sometimes he is receptive to care and sometimes he was not. The DON stated psych was planning an on-site visit. An interview with Resident #1's psychiatrist on 04/13/25 at 2:35 p.m. revealed she had seen the resident on 04/08/25 following an allegation of a staff member who molested him. The psychologist stated during the visit Resident #1 mentioned very little of the incident and wanted to discuss his sleep issues instead. The psychiatrist reported being unaware of this resident's history of trauma. She said, I have not been made aware of PTSD concerns or any events that could trigger him. She stated the Psychologist would probably be the one to provide the coping mechanisms as it was not something she was aware of, or she was addressing. On 04/13/29 at 4:49 p.m. an interview was conducted with Resident 1's psychologist. The psychologist stated she had assessed the resident following concerns of high anxiety. She stated she had witnessed an incident where an unidentified CNA had raised his voice at Resident #1. She stated when that CNA walked into the resident's room that day, the resident said, this is why I am so scared, this is the guy. The Psychologist stated the CNA raised his voice again. She stated, It was not a good response. The psychologist stated she notified the psych nurse and asked her to review medications and evaluate possible PTSD. The psychologist reported the resident said, I have crazy dreams that wake me up and cause me irritability. She stated they reviewed his medications. The Psychologist said, I know he has stated he does not like to be changed as he is afraid of people. He does not trust others. He likes to be isolated, and he wished his blinds were darker. He wished to be by himself. The Psychologist said she was not aware of the resident's history of sexual abuse. She stated that could be the reason he was refusing care and could explain the fear. She stated he was also afraid of a family member who had donehorrendous things. The psychologist stated the resident had not said why he was against African American staff, but confirmed they are doing some things he does not like. The psychologist could not explain what those things were. Review of a facility policy titled Comprehensive Care Plans, dated 9/7/22 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under definitions: Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MOS (Measurable Objective Statements) assessment. All Care Assessment Areas (CAAs) triggered by the MOS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report and thoroughly investigate an allegation of abuse in a timely manner for one resident (#31) out of three residents sampled. Findings included: A review of Resident #31's admission Record showed an admission date of [DATE] with a diagnoses to include Alzheimer's disease, contracture of right knee, contracture of left knee, age-related nuclear cataract, bilateral, unspecified dementia, unspecified severity, without behavioral, psychotic, mood, and anxiety disturbances, brief psychotic disorder, cognitive communication deficit, and history of falling. A review of Resident #31's Minimum Data Set (MDS), Section GG- Functional Abilities, showed the resident dependent for eating, toileting, hygiene, shower/bathe, dressing upper and lower body and personal hygiene. Resident #31 was dependent for mobility to roll left to right or from sit to lying in bed. Resident #31 had not attempted due to medical condition or safety concerns checked for chair/bed to chair transfer. On [DATE] at 3:06 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated she had received a phone call Friday the 27th of December approximately 6:00 p.m. from Staff M, Licensed Practical Nurse (LPN). Staff M, LPN informed the DON of an alleged abuse scenario where Resident #31 was struck by Staff R, Certified Nurse Assistant (CNA) approximately two weeks ago. Staff M, LPN stated Staff N, CNA stated the information to her via her personal cell phone minutes prior to calling the DON. Staff M, LPN stated Staff N, CNA will be calling the DON to give her testimony to the events of alleged abuse. The DON stated Staff N, CNA was calling her the same time Staff M, LPN was calling her and took Staff M's call first. The DON stated it was a short conversation between her and Staff M, LPN. The DON stated she had a telephone conversation [DATE] with Staff N, CNA after her brief phone call from Staff M, LPN informing her of an alleged abuse to Resident #31. The DON stated she talked to Staff N, CNA and took her statement. Staff N, CNA told the DON she received report from Staff R, CNA and noticed a scrape Resident #31's nose and asked Staff R, CNA if the resident had a fall. Staff N said Staff R, CNA stated to her she hit the resident because he would not let go of her. The DON asked Staff N, CNA if she had reported this allegation to anyone at time and Staff N, CNA stated she had not. The DON asked Staff N, CNA why she had not reported this allegation and Staff N, CNA stated she was in fear of retribution from Staff R, CNA. The DON stated there was a connection of Staff N's child to Staff R's family. The DON stated after she had informed the NHA/Abuse Coordinator, she called Staff R, CNA. Staff R, CNA stated she had provided care for Resident #31 on a couple of occasions. Staff R, CNA denied any inappropriate physical acts towards Resident #31. Staff R, CNA stated the resident was not combative with her. Staff R, CNA told the DON an incident occurred approximately two weeks ago when she provided care for Resident #31 and he hit his face on the side rails and sustained an injury. Staff R, CNA stated Resident #31 sustained a skin tear to the bridge of his nose and immediately reported to the nurse supervisor, which the DON stated would have been Staff E, LPN/Supervisor. The DON stated Staff R, CNA was suspended pending the investigation. Staff N, CNA was not suspended and was allowed to work her normal hours as a weekend staff member. The DON stated she interviewed Staff E, LPN/Supervisor to verify she placed a note regarding the incident to Resident #31's medical record. The DON stated Staff E, LPN/Supervisor stated someone told her about the skin tear to the bridge of his nose but she could not recall who told her. The DON stated they interviewed seven residents in the same vicinity as Resident #31 and all the residents denied any concern of abuse. The NHA stated he completed the reporting side of the allegation. He contacted law enforcement on [DATE] at 7:57 p.m., and the Department of Children and Family Services (DCF) via their portal at 7:53 p.m. The NHA stated law enforcement arrived at the facility, visited the resident and called the NHA and stated no further investigation was warranted. The NHA stated DCF arrived at the facility on [DATE] and interviewed Staff N, CNA but could not state if the conversation was done via by phone or in person. The NHA stated DCF representative who came to their facility stated there is a riff between the two staff members. The NHA stated from the information they had gathered during their investigation, Staff N, CNA's conduct was done in a spiteful manner and was terminated for failure to report abuse, neglect and/or misappropriation in a timely manner. The DON stated she arrived at the facility on [DATE] and conducted a skin assessment for Resident #31. The physician was notified but unfortunately a communication lapse occurred in the notification of the family. The DON stated the family was notified on [DATE] after staff realized they were not notified immediately post allegation. The DON stated Staff R, CNA was adamant she did not hit Resident #31 and her story matched with the events documented in the resident's medical records. The facility decided to move Staff R, CNA to the first floor and terminated Staff N, CNA for failure to report the abuse in a timely manner per policy. On [DATE] at 6:35 p.m., a phone interview was conducted with Staff N, CNA. Staff N, CNA stated her normal assignments would include Resident #31. Staff N, CNA stated she normally will work doubles exclusively on the weekends from the 3-11 p.m. and 11-7 a.m. shifts. Staff N, CNA described the resident as normally confused due to his Alzheimer's/dementia, Spanish-speaking only but would understand simple questions. Staff N, CNA stated the resident has a good relationship with another CNA, Staff T, who speaks his native language and has a good relationship with the resident's family. Staff N, CNA stated she has known Staff R, CNA since 2006. Staff N, CNA stated she was on friendly terms with Staff R, CNA. Staff N stated Staff R, CNA worked the same doubles on the weekends. Staff N stated on Saturday, [DATE], she received report from Staff U, CNA. Staff N, CNA stated Staff U, CNA did not mention Resident #31's face to her. Staff N, CNA stated she started her shift as she normally would and brought linen into Resident #31's room as well as his roommate. Staff N, CNA stated Resident #31 was in his bed. Staff N, CNA stated Staff R, CNA came into Resident #31's room as she was placing linen onto Resident #31's roommate's bed. Staff N stated Staff R, CNA walked into the room behind her and stated, Did you see his face? When Staff N, CNA looked to see Resident #31's face she saw a left black eye with a gash over his left eyebrow. Staff N, CNA stated she did not receive report about concerns to the resident's face. Staff N, CNA stated she thought he had a fall but Staff R, CNA stated she punched the resident because he had her fingers bent backwards and would not let go of her. Staff N, CNA stated she had no idea why Staff R, CNA divulged this information to her. Staff N, CNA stated Staff R, CNA did this a few days ago on a Tuesday or Wednesday. Staff N, CNA stated Staff R told her she left Resident #31's room to check on another resident but she said something told her to go back and check on Resident #31. Staff N, CNA stated Staff R stated Resident #31 had a gash with blood running into his eye down his nose. Staff N, CNA stated Staff R stated she put on a pair of gloves and rubbed it into the resident's bloodied face and then took the bloodied glove and wiped it on the inside of the left side rail. Staff N, CNA stated Resident #31 tends to navigate to his left side naturally. Staff N, CNA stated Staff R, CNA stated to her she went out to notify the nurse the resident hit the side of the rail when she was rolling him. Staff N, CNA stated Staff R, CNA told her this information (alleged abuse) as she was beginning her shift the first day of the weekend, [DATE]th, 2024. Staff N, CNA stated she did not report it the day she was told but stated, It did not sit right with me. Staff N, CNA stated she could not tell upper management because, I felt it would have been swept under the rug. Staff N, CNA stated the next day she tried calling Staff M, LPN/Supervisor on her personal cell phone but she (Staff M) stated she was busy and stated she would call her back but she did return her call. Staff N, CNA stated she eventually called Staff M, LPN/Supervisor a week to a week and a half after her first attempt and explained the whole situation to her. Staff N, CNA stated Staff M, LPN/Supervisor told her to immediately call the DON and report this allegation of abuse. Staff N, CNA stated Staff M, LPN/Supervisor stated because she was told this information she now will report to the DON as well. The DON called Staff N, CNA to discuss the allegations of abuse with Staff N, CNA. After Staff N, CNA gave her statement, she was allowed to return to work the next day for her normal weekend shifts. Staff N, CNA stated DCF interviewed her. Staff N, CNA stated the DCF representative took her statement along with images of Resident #31. Staff N, CNA stated she gave the same statement. The DCF representative asked Staff N, CNA why she had waited to report the allegation of abuse in which Staff N, CNA stated she was afraid of retribution. Staff N, CNA stated she was terminated on [DATE]. On [DATE] at 11:09 a.m., an interview was conducted with Staff R, CNA related to the allegation of abuse to Resident #31. Staff R, CNA stated she will work doubles on the weekends from 3-11 p.m. to 11-7 a.m. shift. Staff R, CNA stated her normal assignment is rooms 204-211 but stated her assignment may change for the 11-7 a.m. shift depending on the number of CNAs available. Staff R, CNA stated if the number of CNAs goes down to three, she will pick up 201-211 as well as 212 around the corner. Staff R, CNA stated one night shift she was doing her room checks she noticed Resident #31's feet were hanging out of his bed, and his hand was on the left side rail. Staff R, CNA stated she went into the room and placed herself in front of Resident #31 to prevent him from falling out of the bed. Staff R, CNA stated she placed one of her arms under the resident's legs and her other hand to undo the resident's tight grip on the side rail. Staff R, CNA denied she asked for help and stated there was no one in the hallway or nurse's station to assist her. Staff R, CNA stated she was able to loosen Resident #31's hand from the side rail and basically barrel rolled him to the other side and flipped him to his right side. Staff R, CNA stated Resident #31 hit his face onto the side rail. Staff R, CNA stated she started to see a lump form on his forehead but could not describe on what side and stated there was no blood. Staff R, CNA stated she got Staff S, Registered Nurse (RN) to report the event. Staff R, CNA stated Staff S, RN examined the resident and got a gauze to see if there were any openings to his face and reported her findings to Staff E, LPN/Supervisor after she returned from her break. Staff E, LPN/Supervisor had Staff R, CNA write a statement on the events of the incident and stated Staff E, LPN /Supervisor coached her to write the letter by stating moving forward she will utilize a two -person assist. Staff R, CNA stated Staff N, CNA has a problem with her family. Staff R, CNA stated she did not have any issues with Staff N. Staff R, CNA stated she received a call from the DON the day after Christmas stating an allegation was made against her. Staff R, CNA stated DCF called her on Monday, [DATE] for an interview. During survey 13 separate interviews were conducted with various nursing staff employees. Staff directly involved with Resident #31 and others working on the same floor as the resident. All staff members stated none of them were interviewed regarding any allegation of abuse or abuse towards Resident #31. On [DATE] at 12:20 p.m., a second interview was conducted with the DON and the NHA with the facility's investigative folder regarding allegations of abuse towards Resident #31. The DON confirmed an incident report was completed by Staff E, LPN/Supervisor. The DON stated incident reports are reviewed by the Interdisciplinary Team (IDT) but this report was not reviewed. The DON stated pillows were added to Resident #31's ¼ side rails to protect his face. The DON stated a written statement was found in the nurses' station on [DATE] from Staff R, CNA regarding the incident on [DATE] of the resident sustaining injuries during ADL (activities of daily living) care. The letter was not dated. The DON stated no interviews were conducted with the nursing staff who was immediately notified by Staff R, CNA. The DON stated Staff Q, CNA who was working with Staff R, CNA the night the incident occurred, [DATE]th, 2024, was not interviewed. The DON stated Staff R, CNA was giving report to Staff N, CNA in real time on [DATE]/09/2024. A review of the time punch card for Staff N, CNA showed a punch in at 2:09 p.m. and a punch out time of 11:39 p.m. Staff N, CNA did not work on [DATE]. A review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation, implemented on [DATE], showed the following: Policy statement: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Established policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI I program 2. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation: 2. Exercising caution and handling evidence that could be used in a criminal investigation (example, not tampering or destroying evidence) 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on observation and interview, the facility failed to ensure dignity was providing by protecting and valuing residents' private space by knocking before entering one (#29) resident's room out of 31 residents sampled. Findings Included: During an observation on 12/02/2024 at 10:33 a.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an observation on 12/03/2024 at 9:00 a.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an observation on 12/04/2024 at 3:12 p.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an interview on 12/04/2024 at 3:10 p.m., Staff F, Certified Nurse Assistant (CNA), stated that she usually knocked before entering a resident's room, she also made sure that the resident's door was closed, and the privacy curtain was pulled while she was providing care. During an interview on 12/04/2024 at 3:05 p.m., Staff G, CNA, stated he provided daily care to the residents. He stated he provided dignity to residents by closing curtains, talking with the residents while providing care, and asking if it was okay for him to provide their care. He stated he would also knock on the door before entering the room. During an interview on 12/04/2024 at 3:22 p.m., Staff H, CNA, stated before she entered a resident's room she knocked on the door. She stated if the resident did not answer she would ask if she could enter the room. During an interview on 12/04/2024 at 6:20 p.m., the Director of Nursing (DON) and Regional Nurse stated Dignity should be provided for every resident. They stated staff members were expected to knock before entering a resident's room. Review of the facility's policy titled Promoting/Maintaining Resident Dignity dated 09/072022 revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and environment, that maintains or enhances residents' quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights period. 11. Respect the residents living space and personal possessions . 12. Maintain resident privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the opportunity to participate in care planning for one resident (#44) out of 8 residents sampled. Findings included: On 12/03/24 at 09:47 a.m., and 12:00 p.m., an observation was made of Resident #44. She was observed lying down in her bed with her call light in reach. She presented with no signs of distress. Resident #44 stated she would like to participate in her care plan meetings, but staff does not invite her to attend the meetings because her meetings are scheduled during the times she is out for her dialysis treatments. She stated she would like her voice to be heard. Review of the admission Record, dated 12/5/2024, showed Resident #44 was admitted to the facility on [DATE], with diagnoses to include but not limited to, End Stage Renal Disease, Type 2 Diabetes Mellitus without Complication, Multiple Sclerosis, and need for assistance with personal care Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitively Patterns, a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact On 12/04/2024 at 12:30 p.m., an interview was conducted with Resident #44's Healthcare Surrogate/ Power of Attorney. She stated she would really prefer Resident #44 be a part of the care plan meetings because she knows more about the care she is receiving at the facility. She stated the care plan meetings are scheduled on the days the resident has dialysis and that is why the resident is not invited to the meetings. On 12/05/2024 at 9:38 am. an interview was conducted with Staff V, MDS Coordinator. She stated Resident #44 is on the second floor, so her care plan meetings are held on Wednesdays. She stated the meetings are on the same day the resident goes to dialysis. She stated she does not conduct the care plan meetings, so she cannot answer questions as to why Resident #44 is not invited to her care plan meetings. She stated if a resident is not able to attend the meetings, then the Unit Manager should talk to the resident to provide an update about the meeting On 12/05/2024 at 10:00 a.m., an interview was conducted with Staff I, License Practical Nurse (LPN)/ Unit Manager (UM). Staff I stated every Wednesday she attends the care plan meetings. Resident #44 does not attend the meetings because the meeting is held on the same days she has dialysis. She stated when a resident is not able to attend a meeting, she or the Social Worker would go to the resident's room to update them about the care plan meeting. She said she has not followed up with Resident #44 about her care plan meetings. On 12/05/2024 at 1:00 p.m., an interview was conducted with Staff C, Social Service Director (SSD). The SSD stated she is provided with a list of residents who are scheduled for their care plan meeting for the week. She said care plan meetings are Tuesdays and Wednesdays. Tuesday meetings are for the first-floor residents and Wednesday meetings are for the second-floor residents. She said if a resident is not able to attend their meeting on their scheduled day, they would call the representative to inform them about the resident's plan of care. She stated she did not follow-up with Resident #44's care plan meeting because she was on vacation when her meeting was conducted. She stated nursing should have informed and followed -up with the resident about her care plan meeting. Review of the facility policy titled Comprehensive Care Plans, dated 9/7/22, showed the following: Policy Statement: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and compliance Guidelines: 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: e. the resident and the resident's representative, to the extent practicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure personal privacy was honored by providing a private space for one resident (R #16) out of 31 residents sampled to use the phone. Findings Included: During an observation on 12/03/2024 at 10:30 a.m., Resident #16 was observed sitting in a wheelchair in front of the nurse's station on the phone. During an interview on 12/03/2024 at 4:30 p.m., Resident #16 stated she did not want a phone in her room because there were plenty of other phones around the house she could use. An observation of Resident #16's room revealed Resident #16 did not have a phone in her room. Review of Resident #16's admission record revealed an admission date of 10/21/2024. Review of the Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 revealing severe cognitive impairment. During an interview on 12/4/24 at 3:59 p.m., the Resident Council President and Resident Council Secretary revealed most residents had cell phones and or a phone in their room. The Resident Council Secretary stated it was normal for residents to talk on the phone at the nurse's stations. She stated the phone had a long cord. She stated the residents could go all the way around when they need to, to get privacy. She stated most residents sat at the nurse's station and used the phone. The Resident Council Secretary stated she did not think residents or staff listened to their conversations when they were talking on the phone. During an interview on 12/03/2024 at 10:45 a.m., Staff I, LPN, Unit Manager, stated Resident #16's family called the nurses station to speak with the resident. She stated she was not able to transfer the call to the resident's room because the phone in the resident's room had connection issues. During an interview on 12/03/2024 at 6:20 p.m., the Director of Nursing (DON) stated if a family called the nurse's station to speak with a resident, the call should be transferred to the resident's room so they could have a private call. She stated if the resident decided to take a call at the nurse's station, the resident should be moved into the Unit Managers office, so they were provided with privacy. ON 12/05/2024 the facility was asked to provide a policy on Privacy and it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to accurately complete resident assessments, reflective of the resident's status at the time of the assessment, for two Residents (#77 and #113) of eight residents sampled. Findings included: 1. On 12/2/2024 1:47 PM an interview was conducted with Resident # 77, who was observed lying down in bed. She stated she is upset with the facility because they have lost two sets of her hearing aids, and nothing has been done about it. She stated she was told by staff she has to pay for her replacement hearing aids but no one has followed up with her to make the arrangements. Review of Resident #77's admission Record showed Resident #77 was admitted to the facility originally on 1/26/2023 and readmitted on [DATE]. Review of Resident #77's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed under Section B - Hearing, Speech, and Vision, the resident had adequate hearing and did not use hearing aids. The MDS Assessment also revealed under Section C - Cognitive Patterns, a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident is cognitively intact. Review of Resident #77's Chart Notes dated 5/17/2024 showed Resident #77 reported on 5/17/2024 during her audiological evaluation with the clinician she had hearing aids but did not know where they were, and she would like to have a set of hearing aids to hear better. Further review of the Chart Note showed Resident #77 showed the resident could benefit from amplification due to the resident reporting having trouble understanding conversation and the need to have people repeat what they have said. Review of Resident #77's Audiologic Report dated 5/17/2024 showed Resident #77 has moderate-severe sloping hearing loss in the right ear and mild-severe sloping hearing loss in the left ear. During an interview on 12/5/2024 at 11:00 AM., with Staff BB, Registered Nurse (RN) and Lead MDS Coordinator. Staff BB, RN stated once Resident #77 was seen by the audiologist, she should have completed an MDS assessment to show the resident has hearing loss and requires the use of hearing aids. Once a resident has been seen by audiology, Social Services should have informed MDS so they could update the resident assessment to reflect the resident hearing loss and the use of hearing aids. 2. Review of Resident #113's admission Record showed Resident # 113 was admitted to the facility on [DATE]. The admission Record also showed Resident #113 was discharged home from the facility on 9/21/2024. Review of Resident #113's MDS assessment dated [DATE] showed the following under Section A - Identification Information: - A0310. Type of Assessment - Discharge assessment-return not anticipated. - A2105. Discharge Status - Short-Term General Hospital. During an interview on 12/5/2024 at 11:00 AM with Staff CC, License Practical Nurse(LPN) and MDS Coordinator, Staff CC, LPN stated Resident #113's discharge status on the MDS Assessment showed she went to the hospital and was not discharged home. Staff CC, LPN also stated the MDS Assessment is inaccurate, which was an oversight on her part. Resident #113's MDS Assessment should have shown she was discharged home and not to the hospital. Staff CC, LPN stated the facility does not have a policy related to MDS Assessments because they use the Resident Assessment Instrument (RAI) as a guide for the MDS Assessments.

Based on observation, interview, and record review, the facility did not ensure a resident centered care plan was developed for one resident (#57) out of 31 residents sampled, related to Post-Traumatic Stress Disorder. Findings Included: During an interview on 12/2/2024 at 2:48 p.m. with Resident #57's family member (FM), he stated he is happy with the care his father is receiving and had no concerns. He stated he was unsure of any triggers regarding resident #57's Post Traumatic Stress Disorder (PTSD) and the facility, and staff are good at handling his care. Review of Resident #57's admission Record revealed an initial admission date of 3/15/2022 and a readmission date of 4/30/2024. Resident #57 was admitted to the facility with diagnoses of major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, post-traumatic stress disorder (PTSD), and unspecified mood affective disorder. A review of Resident #57's care plan revealed no focus, goal or interventions related to PTSD. During an interview on 12/5/2024 at 10:50 a.m., the Social Services Director stated, Resident #57 has a diagnosis of PTSD and is care planned. She reviewed Resident #57's care plan and stated, Resident #57 is planned for potential for mood state issues related to PTSD/Depression. She stated they observe his mood and his psychosocial status and would notify the physician if there was a change. She was not able to specify if the resident had any specific triggers related to his PTSD. She stated she would review the psych notes to determine what triggers the resident has. She was not able to answer how other staff members would know what triggers to watch for residents who have PTSD. During an interview on 12/4/2024 at 6:28 p.m., the Director of Nursing (DON) and Regional Nurse stated, residents should be care planned if they have PTSD. There is a PTSD evaluation that is done by social services and quarterly. If an evaluation is completed at shows a resident has PTSD, they would then notify psych so they can get involved and do their own evaluation. Review of the facility policy titled Comprehensive Care Plans dated 9/7/2022, showed under Policy, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed under Policy Explanation and Compliance Guidelines, 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to coordinate audiology services for one resident out of eight residents sampled (#77). Findings include: On 12/02/24 at 9:00 AM and at 01:47 PM, Resident # 77 was observed lying down in bed with her call light within reach. She stated she is upset with the facility because they have lost two sets of her hearing aids, and nothing has been done about it. She stated she was told by staff that she had to pay for her replacement hearing aids but no one has followed up with her to make the arrangements. Review of an admission Record dated 12/5/2024 showed Resident #77 was admitted to the facility originally on 1/26/2023 and readmitted on [DATE] with diagnoses to include but not limited to paroxysmal atrial fibrillation, morbid (severe) obesity due to excess. Review of Quarterly MDS assessment dated [DATE] Section C, Cognitive Patterns/ BIMS showed a score of 15 which indicated cognitively intact Review of an audiology note dated 5//17/2024 showed Resident #77 reported on 5/17/2024 during her visit with the clinician that she had hearing Aids but did not know where they were. She further reported she would like to have a set of hearing aids so she can hear better. Further review of the audiology report showed Resident #77 had moderate-severe sloping hearing loss in her right ear and mild-severe sloping hearing loss in her left ear. On 12/4/2024 at 12:30 PM, an interview was conducted with Staff I, License Practical Nurse/Unit Manager. Staff I stated when a resident is admitted to the facility with hearing aids the nurses write an order to put the hearing aid in and a time to take the hearing aid out of the resident's ear. After the residents hearing aids are taken out, they are stored on the nurse's cart. Residents hearing aids are inventoried on their inventory sheets. If a resident needs to be seen by an audiologist, she would report it to social services, and they would schedule the appointment to have them come to the facility to see the resident. She stated she is responsible for reviewing the notes once the clinician has seen the resident. She stated if a resident reports that they are missing their hearing aids and they wanted another pair to the clinician she would report it to social services. She stated she did not read the audiologist assessment note because the resident was not on her unit at that time. On 12/4/2024 at 5:00 PM., an interview was conducted with Staff C, Social Service Director. Staff C stated the facility did not have a lot of residents that requested hearing aids before. If a resident comes to social services or to nursing and says that they are not hearing right, they will have the practitioner, or the primary care see the resident to see if there is some type of wax build up to rule out any types of medical related issues. Then they would refer the resident to audiology for an evaluation if the resident were able to sit for the exam. They just had audiology come to the facility in May. Resident #77 was seen on May 17 of 2024. After the resident is seen the audiologist emails the notes. At that time if the resident is interested in hearing aids the audiologist reaches out to the resident or responsible party to coordinate in getting the resident hearing aids. Staff C stated she did not follow-up with their contract services to ensure Resident #77 received her hearing aids. She said that she should have checked with the resident to see if she was going to go through with the program to get her hearing aids. She stated that she will own that she did not follow-up with the resident after she was seen by the audiologist regarding getting her hearing aids. Resident # 77 filed a grievance on 9/5/22024 regarding her missing hearing aids. Staff C stated the solution was to refer her to audiology for possible new hearing aids. Staff C stated she dropped the ball because she did not follow-up with audiology services for Resident #77. On 12/5/2024 at 8:51 AM, an interview was conducted with the Nursing Home Administrator, NHA. The NHA stated the facility is not responsible for replacing the residents' hearing aids, but we are responsible for coordinating services to get the resident hearing aids. He stated if a resident lost their hearing aids the facility would help guide the resident through the process until they receive another set of hearing aids. Review of the facility policy titled, Social Services dated 9/7/2022 showed Policy, The facility, regardless of size, will provide medically - related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Policy Explanation and Compliance Guidelines: 4. The social worker, or social service designee, will pursue the provision of any identified need for medically-related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Service to meet the resident's needs may include d. Making arrangements for obtaining items, such as adaptive equipment, clothing, and personal items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide one (#92) of eight sampled residents with therapeutic food to meet the resident's nutritional needs. Findings include: On 12/02 /2024 at 9:10 a.m., Resident #92 was observed sitting up in her bed with her breakfast tray in front of her. She was observed having a hard time opening her containers on her tray. She stated staff did not offer her assistance with opening her food containers on her tray, and she was not provided with hand hygiene. On 12/2/2024 at 12:45 p.m., Resident #92 was observed sitting up in bed eating her lunch left on her over the bed table. She was observed spitting her meat out of her mouth, saying she could not chew her meat because it was too hard for her to chew. She stated she was on a mechanical soft diet and the meat that was provided to her was not according to her diet. Review of an admission Record dated 12/5/2024, showed Resident #92 was admitted to the facility on [DATE] with diagnoses to included but not limited to acute respiratory with hypoxia, iron deficiency anemia, unspecified, unspecified protein - calorie malnutrition, and nutritional marasmus. Review of a physician order with a start date of 7/1/2024, showed Resident #92 was on a Regular diet, mechanical soft texture, thin liquids consistency. Review of Resident #92's care plan showed a focus area of nutrition, date initiated 7/2/2024, with a revision date of 10/10/2024, Resident #92 had a potential for weight concerns, at risk for malnutrition, related to mechanically altered diet, significant weight gain on 10/10/2024. The goal showed Resident #92 would maintain stable weight through the next review date. Initiated on 7/2/2024, revised on 7/15/2024, target date on 1/1/2025. Interventions for focus areas of nutrition included the following for Resident #92: Honor food requests and preferences as applicable, date initiated 7/2/2024 Provide and serve diet as ordered, date initiated 7/2/2024 On 12/5/2024 at 12:33 p.m., an interview was conducted with Staff D, Dietary Manager. Staff D stated when a resident was initially admitted to the facility, she reviewed the resident's diet orders and cross referenced the order with the diet slips, The diet slips were given to the kitchen to ensure residents were receiving the correct diet. She stated she conducted spot checks on the tray line before trays were placed on the tray carts that were sent to each unit. She stated if a resident was on a mechanical soft diet the meat would be ground up. She stated she was not on the tray line when Resident #92's tray was prepared and placed on the cart, so she did not see the type of meat on her tray. Staff D reviewed the picture of the meal Resident #92 received on 12/02/2024 and stated that the meat was not mechanically altered. On 12/5/2024 at 12:40 p.m., an interview was conducted with Staff Y, Speech Therapist. Staff Y stated Resident #92 was evaluated because she was having trouble with chewing and orally controlling her food in her mouth. She improved in her chewing abilities and oral control abilities to the point she was able to handle some regular foods without difficulty. She said the resident requested to stay on a mechanical soft diet because of her difficulty with chewing her food. She stated when she discharged Resident #92 from speech therapy she kept the resident on a mechanical soft diet. When Staff Y reviewed the pictures of Resident #92's meal from 12/02/2024, she stated the ground meat would not be considered a mechanical soft diet. The consistency in the picture was considered soft bite size. It was a step above the mechanical soft diet. Review of the facility policy titled Therapeutic Diet Orders dated 11/5/2022 showed Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his//her goals and preferences. Policy Explanation and Compliance Guidelines: 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Photographic Evidence Obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor food choices for three (#1, #167, and #19) of forty-forty sampled residents. Findings included: 1. On 12/2/2024 at 10:00 a.m., an interview and observation was conducted with Resident #1. She was able to speak related to her daily choices, medical care, and services. She was observed seated in her wheelchair, next to her bed, and was noted dressed for the day and well groomed. She wanted to speak about some concerns she had with dietary and nursing services related to breakfast this morning, 12/2/2024. Resident #1 revealed she had been at the facility for about a month and she kept asking staff to provide ketchup for breakfast, as she liked ketchup on her eggs. Resident #1 revealed she had spoken with various aides, nurses, dietary staff, and whoever passed by the room, many times. She revealed most of the time, staff would tell her either, the kitchen is out, or I'll be right back with that. Resident #1 said first of all, she knew the kitchen was not out of ketchup because everyone received it for various things for the same day's lunch and dinner. She said secondly, most of the time staff never returned after her initial ketchup request. She said there were times she had propelled herself, while in her wheelchair, to the kitchen to get ketchup. She revealed by the time she got back, her meal was cold. Resident #1 confirmed she had spoken with dietary staff to put this request on her meal ticket, but it was never updated with her ketchup request for breakfast. On 12/5/2024 at 8:10 a.m., Resident #1 was observed in her room and seated upright in bed with the over the bed table placed in front of her. She had already been served her breakfast and she was eating unassisted. The resident appeared to have received scrambled eggs, toast, hot cereal and milk, and purple juice. The resident was not happy and revealed she again did not receive ketchup for her eggs. She revealed she had asked staff when they initially served her meal and then asked again when staff walked by the room. She revealed each time, they told her they would get it. She could not remember the names of the staff but she explained she told at least two different staff members. She revealed this was about ten minutes ago and she still had not received ketchup. Observations revealed her over the table and breakfast tray did not have any ketchup packets. Further, review of her meal ticket did not identify to provide ketchup for breakfast. On 12/5/2024 at 10:00 a.m., the resident was observed walking with a therapy staff member down the hallway and when she saw this writer, she shouted, I never got the ketchup. She said it three times aloud. The resident appeared very upset to have not received the ketchup again. She had voiced in an earlier interview of speaking to both the Unit Manager and the Dietary Manager about it but never received the ketchup as requested. On 12/5/2024 at 10:15 a.m., an interview with Staff A, Certified Nursing Assistant (CNA) revealed when she, along with other staff, pass out meal trays, they review the meal ticket for likes and dislikes prior to setting up the meal tray for the resident. She revealed also, that if residents asked for certain condiments such as creamer, sugar, ketchup, mustard, etc., they would usually have most of that on the coffee cart, but when it came to ketchup and mustard, they would have to go to the kitchen to get it. She revealed she had honored resident's requests for condiments in the past and did not know Resident #1 wanted ketchup for breakfast. There were three other unidentified Certified Nursing Assistants in the general area and all confirmed the same interview as Staff A. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] for short term rehab services. Review of the current Physician's Order Sheet for the month 12/2024, revealed a diet order to include: NAS diet, Regular texture, thin liquid (start date 11/5/2024). Review of the current admission Minimum Data Set (MDS) assessment dated [DATE], revealed: Cognition/Brief Interview Mental Status or BIMS score - 15 of 15, which indicated Resident #1 was cognitively intact. A review of the current Care Plans with a next review date 2/10/2025, revealed the following: a. Risk for impaired nutrition related to on No Added Salt NAS diet Related to History of Hypertension, with interventions to include but not limited to: Honor food requests and preferences as applicable. 2. On 12/2/2024 at 10:00 a.m., while in Resident #167's room speaking with her roommate, Resident #167 said she too was having concerns with her meal choices. She said at times, she would not receive the right condiments for coffee in the morning, and sometimes would not receive cold cereal for breakfast. Resident #167 revealed she received hot cereal in place of the cold cereal and she did not like hot cereal. She said she had spoken with both floor nursing staff and dietary staff/management about this concern, but there was no consistency of receiving what she liked on a daily basis. On 12/4/2024 at 8:10 a.m., while visiting Resident #167 in her room, she pointed to her meal tray and revealed she did not get her cold cereal again, and the kitchen just gave her hot cereal. Observations revealed her breakfast tray was placed in front of her on the over the bed table and consisted of a regular textured meal to include: Two slices of French toast with syrup, small glass of red juice, one carton of 2% milk, one cup of dark coffee, and one bowl of what appeared to be hot oatmeal. The meal ticket on her meal tray revealed: Regular diet NAS, Beverage to include 2% milk, Cranberry Juice. The meal ticket also revealed Food Likes to include: Cold Cereal. It was evident Resident #167 did not receive cold cereal for this meal as requested. Photographic evidence obtained. On 12/5/2024 at 8:10 a.m., an interview with Resident #167 revealed she received her breakfast tray today, 12/5/2024, and did not get creamer for her coffee. She had asked staff for the creamer and they never brought it. She drank the coffee but she preferred to get creamer for it. Resident #167 revealed most days when she asked staff for creamer, they told her they were out or they just never returned with any. She had reported it to aides and a several nurses, but had no names of who she spoke with. Review of Resident #167's medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. Review of the current admission MDS assessment dated [DATE] showed Cognition/Brief Interview Mental Status BIMS 15 of 15, which indicated intact cognition. On 12/5/2024 at 10:20 a.m., in an interview with the Certified Dietary Manager (CDM), she stated how the meal tray line process was conducted. There were three staff in the kitchen and at the steam table food service station, including the cook, and two dietary aides. She revealed one dietary aide had the meal ticket and called out the diet, consistency, and food items of choice to the cook. She revealed after the cook plated the food, the tray moved down the line to another aide who would place other wanted condiment items and cold/boxed cereals on the tray. The CDM revealed prior to leaving the kitchen, the two aides were the staff who reviewed the meal tickets for accuracy. She revealed the aides would review the meal ticket and plate/tray for dislikes and food allergies. She said the tray was placed in a tray cart and taken out to the floor/hallways. The CDM revealed the direct floor staff would pull the tray from the cart and review the meal ticket prior to serving the resident. She revealed that she also monitored and reviewed meal tickets and plates as part of daily audits, but usually was not on the tray line the entire meal service, for all three meal services. The CDM confirmed the resident was served hot cereal rather than cold cereal for breakfast on 12/4/2024, and that it was a mistake. 3. On 12/2/2024 at 9:40 a.m., an interview and observation was conducted with Resident #19. He was noted seated upright in bed and had his over the bed table placed next to him, with personal belongings within his reach. Resident #19 was visibly angry and pointed to his red plastic cup of what appeared to be semi clear water. Resident #19 noted he had requested hot water for his tea and that was what was in his red plastic cup. Resident #19 revealed he was generally happy with the care and services at the facility, but he had one concern. He revealed when he was served his water for his tea, he was never provided with condiments to include creamer and sugar. He revealed he routinely asked the staff for these condiments and they always tell him, the kitchen is out, or they just never come back with his requested items. Resident #19 was upset because he knew the kitchen was never out, and he just felt staff were lazy and just did not want to walk to the kitchen to get creamer or sugar. He did not know why those normal condiments were not with the coffee cart to begin with. Resident #19 pointed to his over the bed table and plastic cup and said, see, nothing. It was observed no evidence Resident #19 was provided with creamer or sugar for his hot tea. The cup was observed full with the semi clear water/tea. Resident #19 further revealed he most likely will not drink any of it because it's cold from sitting too long. Resident #19 revealed he had been at the facility for about two months and this had been a continual problem. On 12/5/2024 at 8:15 a.m., Resident #19 was again interviewed and observed. He was seated upright in bed on the edge of the bed with the over the bed table positioned in front of him. He was also observed with his breakfast tray placed on the over the bed table. He had already eaten much of his breakfast and was noted with a red colored plastic cup of tea. The tea was observed plain and without any creamer or sugar in it. Resident #19 was asked how his meal was and he said it was fine other than he did not receive condiments for his tea. He said he had been asking staff all morning for creamer and sugar substitute for his tea. The resident began cursing regarding the situation and was visibly more and more upset because his tea was cold. Review of Resident #19's medical record revealed he was admitted to the facility on [DATE] for short term rehabilitation stay. Review of the current admission MDS assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) of 15 of 15, which indicated intact cognition. A second interview with the Certified Dietary Manager (CDM) on 12/5/2024 at 10:00 a.m. revealed if a resident wanted extra condiments, which were not brought initially to the resident, they could make a request to the nursing staff, and nursing staff would come to the kitchen for the requested condiment. The CDM confirmed they were never out of items like creamer, salt, pepper, sugars, sugar substitutes, mustard, mayonnaise and ketchup. She revealed if she or her staff were asked by staff to get those types of condiments for a resident request, they certainly would have provided that condiment/condiments. On 12/5/2024 at 1:00 p.m., in an interview with the Director of Nursing and the Nursing Home Administrator, both confirmed the facility did not have a specific resident rights for food choices policy and procedure, and it would just be a basic right for a resident to receive condiments as requested and received meal items that were per choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the attending physician, resident, and /or resident representative about a change in condition related to radiology results for two residents (#37 and #38) out of three residents sampled. Findings included: 1. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results, dated 01/12/2025 at 8:50 p.m., showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed the following: On 01/13/2025, radiology note chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note, dated 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed the following: Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/2021. 2. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray, dated 01/14/25 at 2:00 p.m., showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed the following: On 01/14/2025 at 12:127 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed the resident was on antibiotic therapy related to URI (upper respiratory infectin) as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as increases SOB and report to MD. During an interview on 01/15/2025 at 2:19 p.m. the DON (Director of Nursing) verified Resident #37 did not have documentation in her chart verifying Resident #37 or her responsible party was aware of Resident #37's x-ray reports. The DON verified Resident #38 had no documentation the medical provider, the resident nor her responsible party had been notified of Resident #38's x-ray results. The DON stated she would expect to see documentation in the progress notes the medical providers and either the residents or responsible parties had been notified of the results. The DON stated the ADON (Assistant DON) was supposed to be auditing all x-ray and lab results and confirming the results had been notified to the medical provider or resident and responsible party. If the ADON was not here it was the UMs (Unit Manager's) responsibility. During an interview on 01/15/2025 at 2:40 p.m. with the DON and the ADON, the ADON stated she had called Resident #38's medical provider and informed the resident of the x-ray results this morning (01/15/2025) but did not document it in the medical record. The DON and the ADON verified Resident #37's x-ray results were available on 01/12/2025 (Sunday). They verified the medical provider knew about the x-ray results for Resident #37 on 01/14/2025 (Tuesday). The DON and ADON verified the x-ray results for Resident #37 came to the facility on [DATE] at 8:50 p.m. The DON and ADON confirmed the medical provider was not informed for 2 days of the x-ray results for Resident #37. The DON stated the nurse may not have wanted to inform the medical provider until the next day (01/13/2025 Monday). The DON stated the supervisor should have called the medical provider over the weekend (01/12/2025) due to the results of Resident #37's x-ray showed mild pulmonary vascular congestion. The DON stated she did not know right now why they (x-ray) fell through the cracks. The ADON stated she was off on Monday sick, and she was responsible for the audits. The ADON stated the UM makes the calls to the medical provider and resident or representative as needed. The ADON stated the UM was off on Tuesday, so no calls were made. During an interview on 01/16/2025 at 12:04 p.m. the DON stated she spoke with the attending physician for Resident #38. The DON stated the physician stated if an X-ray result was normal the facility could wait until the next business hours to report to the physician. If it (x-ray result) was abnormal, they should call the on-call person. The DON stated neither resident required new orders. The DON was informed her nurse s stated on interview they were responsible to inform the medical provider and resident or representative with the results. The DON agreed the nurses had not documented they had called the appropriate persons. The DON agreed the checkers (ADON and UMs) should have been double checking the results were informed to the appropriate persons not being the staff who was to having to provide the x-ray results. Review of the facility's policy titled, Notification of Changes, dated 09/07/22 showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the residents of physician; and notifies, consistent with his or her authority, the residence representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident physician and or notify the residents family member or legal representative when there was a change requiring such notification. Circumstances require notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration and health, mental or psychosocial status. This may include: a. Life- threatening conditions, or B. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. B. Discontinuation of current treatment due to: i. Adverse consequences. II. Acute condition. III. Exacerbation of a chronic condition. Additional considerations: 1. Competent Individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. B. A family that wishes to be informed would designate a member to receive calls. C. When resident is mentally incompetent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. 2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. B. The resident should still be told what is happening to him or her. Review of the facility's policy titled, Provision of Physician Ordered Services, dated 8/25/2024, showed Policy, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Policy Explanation and Compliance Guidelines: 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents and/or resident representatives, were informed and provided written notice of the right to accept or decline medical and surgical treatments to formulate an Advance Directive for ten residents (#68, #167, #1, #93, #15, #48, #76, #43, #168, and #57) out of forty-eight residents sampled. Findings included: 1. On 12/2/2024 1:00 p.m. Resident #167 was visited while in her room. Resident #167 stated she had been at the facility for rehabilitation services for about ten days and staff members had gone over her admission packet when she was admitted . Resident #167 stated related to her Advance Directive, I'm not sure I know what exactly that is, and is that related to the decision if I want emergency staff to keep my heart going if something happens to me? Resident #167 stated she was not sure all the involvement with the advance directive and felt staff did not explain it to her in detail. She stated she was her own decision maker and only remembers signing a document to support the admission packet was gone over with her. She stated she was not told about her rights to decline medical and surgical treatments during the admission process. Review of Resident #167's medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. Review of the Advance Directive section on the face sheet revealed the resident was her own decision maker. Review of the admission Minimum Data Set (MDS) assessment, dated 11/26/2024, revealed; (Section C. Cognition/Brief Interview Mental Status (BIMS) 15 of 15, which indicated the resident was able to speak with relation to her medical care and services and all other daily decisions). Review of the medical record, under the Evaluations section/tab revealed, SUN Advance Directives, dated 11/25/2024. The Advance Directive section revealed an acknowledgement section ( C ), indicating I have received copy of center's policies on Advance Directives and have been given the chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and / or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing the center with necessary and / or legal documentation appropriate for Advance Directives. This electronic form had a section for Resident signature, Representative signature, and Center representative signature. The Resident and Resident Representative section was blank and had no documentation to indicate the resident was provided with this information. The document was electronically signed by Staff W, who was the Social Service Assistant. On 12/4/2024 at 10:00 a.m. an interview with Staff C, Social Service Director (SSD) revealed all residents are to have Advance Directives reviewed during the admission process. She stated there was a signature of understanding page at the end of the admissions packet and this acknowledgement form is to show that a resident/resident representative understood and received the admission packet during the admission process. Staff C. stated the signature of understanding did not necessarily show a resident and/or resident representative was in full understanding of the Advance Directive rights. Staff C. provided a signature page from the admission packet that Resident #167 electronically signed on 12/3/2024, which was eleven days after she was admitted to the facility. Staff C agreed this signature page still did not reveal Resident #167 was provided with, and in full understanding of her advance directives rights. 2. On 12/2/2024 at 1:00 p.m. Resident #1 was interviewed while in her room. Resident #1 stated she had been at the facility for rehabilitation services for about a month and she did remember upon her admission date, staff members had gone over her admission packet. Resident #1 did not remember staff going over advance directives with her, but she remembered signing a sheet to show she received the admission packet. Resident #1 stated the Social Worker, or the staff who works with Social Services went through the packet very quickly and it was a lot of information to take in. Resident #1 stated she did know what Advance Directive rights were, but did not remember staff going over those rights with her. She stated she certainly did not remember staff explaining she had the right to decline medical services and outside services as part of her advance directive rights. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. Review of the advance directives notes on the face page revealed Resident #1 was her own responsible party. Review of the admission Minimum Data Set (MDS) assessment, dated 11/10/2024, revealed; (Cognition/Brief Interview Mental Status BIMS - 15 of 15, which indicated the resident was able to speak to her daily decisions and medical care and services). Review of Resident #1's medical record to include the Miscellaneous tab/section, revealed, Authorization for Treatment while Residing at the Healthcare, dated 11/5/2024. Under the Resident/Responsible party signature section, it was documented; Verbal. The resident did not sign this authorization. It was only signed and dated by a staff witness on 11/5/2024. Under the Evaluations section/tab of the record revealed, SUN Advance Directives dated 11/5/2024. The Advance Directive section revealed an acknowledgement section ( C ), indicating I have received copy of center's policies on Advance Directives and have been given the chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and /or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing the center with necessary and /or legal documentation appropriate for Advance Directives. This electronic form had a section for Resident signature, Representative signature and Center representative signature. Resident and Resident Representative section was blank and had no documentation to indicate Resident #1 was provided with this information. The document was only electronically signed by the Staff C. On 12/4/2024 at 10:00 a.m. an interview was conducted with Staff C., SSD. Staff C. provided a signature page from the admission packet Resident #1 electronically signed on 11/7/2024, which was two days after she was admitted to the facility. Staff C. confirmed this signature page does not reveal Resident #1 was provided with, and in full understanding of her advance directive rights. 3. On 12/2/2024 at 2:00 p.m. Resident #15 was observed in her room and lying in bed with her Head Over Bed (HOB) approximately forty-five degrees. The resident stated she had been at the facility for many years. She stated admission process was too many years ago for her to remember in detail, but she was aware of what Advance Directives were. She stated she did not remember ever signing any paperwork to show she understood this right. Resident #15 confirmed over the past few years she had been re-admitted at the facility after she was hospitalized . Resident #15 could not remember any staff going over her Advance Directive rights when she returned from the hospital visits. Resident #15 revealed though she has her daughter who makes her medical decisions, she (Resident #15) still would have and is part of her daily decision making to include advance directive. Review Resident #15's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives section of the resident profile revealed Resident #15 had a Power of Attorney in place to make her medical decisions. Review of the current Quarterly Minimum Data Set (MDS) assessment, dated 10/11/2024, revealed: (Cognition/Brief Interview Mental Status - 15 of 15, which indicated the resident was interviewable and able to speak related to her care and services).; Review of Resident #15's medical record, under the Evaluation tab/section, it did not indicate a SUN Advance Directive. There was no evidence in the chart the resident or resident representative was informed of and offered Advance Directive information. There was no evidence in the medical record of any signature of understanding from the resident/representative related to this right. On 12/4/2024 at 1:00 p.m. an interview with Staff C., SSD. The SSD could not find documentation to support notification and receipt of Advance Directives with regards to Resident #15 4. On 12/2/2024 at 11:00 a.m. Resident #168 was interviewed related to his care and services and revealed he had been admitted at the facility for less than two weeks and he was at the facility for rehabilitation, with plans to return home. Resident #168 revealed he remembered the social worker going over his admission rights and admission packet the day or day after he was admitted . He revealed he signed a form to show he received information, but did not remember the Social Worker, or even the Admission's coordinator going over any Advance Directive rights. He confirmed he was not aware he could refuse outside medical treatment, or medical services, and or surgical treatments. He confirmed he did not sign any paperwork of understanding related to those rights. Review of Resident #168's medical record revealed he was admitted at the facility on 11/25/2024. Review of the advance directives section of the resident profile revealed Resident #168 was his own responsible party. Review of the current admission Minimum Data Set (MDS) assessment, dated 11/29/2024, revealed; (Cognition/BIMS score - 15 of 15, which indicated the resident was able to speak related to his medical care and service). Under the Evaluations section/tab of the medical record revealed, SUN Advance Directives dated 11/29/2024. The Advance Directive section revealed an acknowledgement section ( C ), indicating I have received copy of center's policies on Advance Directives and have been given the chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and/or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing the center with necessary and / or legal documentation appropriate for Advance Directives. This electronic form had a section for Resident signature, Representative signature and Center representative signature. Resident and Resident Representative section was blank and had no documentation to indicate the resident was provided with this information. The document was electronically signed by Staff C. There was no documented evidence in the chart that Advanced Directives rights were acknowledged and signed for by Resident #168. 5. A review of Resident #43's admission Record revealed an original admission date of 5/30/24 and a re-admission date of 10/12/24. The admission Record revealed diagnoses to include Chronic Obstructive Pulmonary Disease, unspecified, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, muscle weakness (generalized), and Chronic Kidney Disease, Stage 2 (mild). The admission Record revealed the following under Advance Directive, Code Status: Full Code. On 12/2/24 at 4:38 p.m., an interview with the Social Service Director revealed when a resident is initially admitted or re-admitted to facility the 3008 form from the hospital is reviewed to determine the resident's Advance Directive choices. She stated the Advance Directive is explained to the residents through the admission packet. She stated the Advanced Directive are also discussed in care plan meetings. The Social Service Director stated she talked to resident about Advanced Directive. She stated the health care surrogate election and documents the family, or resident, already has is discussed. She stated a hard copy of Advanced Directive, such as Do Not Resuscitate (DNR), are kept in her office as well as in each unit nurses' station. The Social Service Director stated Advanced Directive information can be found in the resident's care plan and in the electronic medical record. She stated the Advanced Directive documents should be uploaded to the resident's electronic medical record. She stated once or twice a month she does an audit regarding Advanced Directives. The Social Service Director stated if the resident is a non-English speaker, then she uses a tablet the facility has with a translating service to discuss Advanced Directive rights. She stated if the resident is not able to make decisions due to their cognitive level, then Advanced Directives are discussed with the health care surrogate or Power of Attorney (POA). She stated if a resident comes to the facility with an Advanced Directive of, Full code, then she would speak to them about continuing with those wishes or if they wanted to make changes. The Social Service Director stated she was not sure if a signature page or acknowledgement regarding Advanced Directive is included in the admission packet. On 12/3/24 at 10:48 a.m., an observation of Resident #43 revealed she was lying down in bed. An interview with the resident revealed she does not recall advanced directive rights being discussed with her by facility staff. She confirmed she was told she has the right to refuse services. A review of Resident #43's evaluations revealed a document titled, SUN Advance Directives, with an effective date of 10/14/24 and an admission date of 10/12/24. A review of the document under, Acknowledgement, revealed no evidence of the Resident or Resident Representative's signature. Further review of the document revealed the Social Service Director's name next to the area which indicated, Center Representative Signature. A review of Resident #43's medical record revealed no evidence of acknowledgement of advanced directive, to include their right to formulate an advanced directive, or their right to accept/refuse medical or surgical treatment. A review of the resident's medical record revealed no documented evidence the facility provided Advance Directive information. 6. A review of Resident #76's admission Record revealed an original admission date of 12/15/21 and a re-admission date of 7/25/24. The admission Record revealed diagnoses to include Type 2 Diabetes Mellitus with diabetic Polyneuropathy, muscle weakness (generalized), and moderate non-proliferative diabetic retinopathy without macular edema, bilateral. The admission Record revealed the following under Advance Directive, Full Code. On 12/3/24 at 10:52 a.m., Resident #76 was observed ambulating herself in the wheelchair from the first floor nurses' station to the common room. An interview with the resident revealed a family member handled her medical decisions. She stated the advanced directive was discussed with her and most likely her family member as well. Resident #76 stated she did not recall signing a document to acknowledge advanced directive was discussed with her. A review of Resident #76's evaluations revealed a document titled, SUN Advance Directives, with an effective date of 11/25/24 and an admission date of 7/25/24. A review of the document under, Acknowledgement, revealed no evidence of the Resident or Resident Representative's signature. Further review of the document revealed the Social Service Director's name next to the area which indicated, Center Representative Signature. A review of Resident #76's medical record revealed no evidence of acknowledgement of advanced directive, to include their right to formulate an advanced directive, or their right to accept/refuse medical or surgical treatment. A review of the resident's medical record revealed no documented evidence the facility provided Advance Directive information. 7. A review of Resident #93's admission Record revealed an initial admission date of 9/4/23, original admission date of 2/16/24, and a re-admission date of 3/15/24. The admission Record revealed diagnoses to include acute myeloblastic leukemia, not having achieved remission, systemic lupus erythematosus, unspecified, muscle weakness (generalized), other specified soft tissue disorders, conversion disorder with seizures or convulsions, and Sjogren syndrome. The admission Record revealed the following under Advance Directive, Code Status: DNR - Do Not Resuscitate. A review of Resident #93's admission Agreement, on page 6, revealed an electronic acknowledgement from the resident and her representative. The document revealed no indication the signed agreement was related to Advance Directive discussion and acknowledgement. A review of Resident #93's medical record, under miscellaneous documents, revealed signed forms to include durable power of attorney, designation of a healthcare surrogate, and a living will. Resident #76's medical record revealed no evidence of acknowledgement of advanced directive, to include their right to formulate an advanced directive, or their right to accept/refuse medical or surgical treatment. A review of the resident's medical record revealed no documented evidence the facility provided Advance Directive information. On 12/5/24 at 2:16 p.m., an interview was conducted with the SSD, the Director of Nursing (DON), and Staff K, Registered Nurse (RN) Consultant. The SSD stated the Advanced Directive acknowledgement is in the resident's admission agreement. She stated in the admission agreement, there is a section related to Advanced Directive. The SSD stated the resident welcome packet also included Advanced Directive information. She stated during the review of the admission Agreement the resident and/or resident representative are present. A review of page 14 of the admission Agreement revealed it is the acknowledgment, and the signature page related to Advanced Directive. The RN consultant stated the document titled, Sunview evaluations, is what the facility used for the Advanced Directive Acknowledgement. She stated the use of the Sunview form is a fairly new process the facility started implementing in 11/2024. The SSD stated when the resident is initially admitted or re-admitted , she reviews the code status. She stated she interviews the resident and asks them information related to choosing a health care surrogate, completing a living will, delegating a durable POA and if they have any prepared paperwork related to Advanced Directive. The SSD stated she offers assistance if residents do not have a healthcare surrogate or power of attorney in place. The SSD confirmed she reviewed and discussed Advanced Directive with residents, however, there is no evidence of the resident's signature or documentation that she did. She stated when she completes the Social Service Assessment, she includes in her documentation she reviewed Advanced Directive, but confirmed the residents did not sign the acknowledgement form. 8. During an interview on 12/02/2024 at 2:48 p.m., with Resident #57's family member (FM) he stated he is happy with the care his father is receiving and had no concerns. He stated he was unsure of any triggers regarding Resident #57's Post Traumatic Stress Disorder (PTSD). He stated the facility, and staff are good at handling his care. Review of Resident #57's admission record revealed an initial admission date of 03/15/2022 and a readmission date of 04/30/2024. Resident #57 was admitted to the facility with diagnosis of major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, unspecified mood affective disorder, PTSD and seizures. Review of the medical record under the Evaluation section did not indicate a SUN Advance Directive. There was no evidence in the chart the resident/resident representative was informed of and received information on Advance Directive. 9. Review of the admission Record showed Resident #68's initial admission date to the facility was on 10/11/24. Resident # 68's diagnoses included chronic respiratory failure, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Chronic Kidney Disease, atherosclerotic heart disease, and cardiac pacemaker. Review of Resident #68's Minimum Data Set (MDS), annual dated 10/15/24, Brief Interview for Mental Status (BIMS) revealed a score is 13 indicating, intact cognition. During an interview on 12/4/24 at 1:37 P.M., Resident # 68 was lying in bed, wearing nasal cannula and said he did not remember the facility discussing his right to accept or refuse medical treatment. A review of Resident #68's medical record on 12/2/24 and 12/3/24, revealed no signed acknowledgement of Advanced Directive were reviewed with Resident #68 or their resident representative. 10. Review of the admission Record showed Resident #48's initial admission date to the facility was on 1/9/2020. Resident # 48's diagnoses included dementia, prostate cancer, heart disease, and Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #48's medical record on 12/2/24 and 12/3/24, revealed no signed acknowledgement of Advanced Directive was reviewed with Resident #48 or the resident representative. Review of facility's policy titled, Residents' Rights Regarding Treatment and Advanced Directive, date implemented 12/1/2022 revealed the following: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refused and or discontinue medical or surgical treatment and/to formulate an advanced directive. An advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognize under State law (whether statutory or as recognized by courts of the State), related to the provision of health care when the individual is incapacitated. Compliance Guidelines includes the following: 1) On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. 2) The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. 3) Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. 4) The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. 5) The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant healthcare decisions. 6) The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7) During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make changes related to any advanced directives. 8) Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 9) Any decision making regarding the resident's choices will be documented in the resident's Medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. 10) The facility will not discharge or transfer our resident should they refuse treatment either through an advanced directive are directly unless the criteria for transfer or discharge are otherwise met. 11) Should the resident refuse treatment of any kind, the facility will document the refusal in the residence chart. 12) The facility will not initiate or discontinue any other care based on refusal of care by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/2/24 at 10:10 a.m., a portable air conditioner unit with an exhaust hose to the outside was observed in room [ROOM NUMBER]. The resident in the room said the portable air conditioner had been in her room since admission to the facility. On 12/3/24 at 11:16 a.m., the portable air conditioner unit in room [ROOM NUMBER] had a thick layer of grey dust coating the filter located on the back part of the machine. A layer of particles coated the inside of the white air conditioner portable exhaust hose. On 12/5/24 at 11:26 a.m., an observation and interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM) in the second-floor shower room. The grab bars in three of four shower stalls had various areas of reddish-brown flaky coating. The third shower stall contained a shower gurney with a blue foam pad. Staff I, LPN, UM confirmed the shower gurney was a multi-resident use equipment. The blue foam pad had an approximately five inches by 0.5-inch linear tear on the upper half. Staff I, LPN, UM said a replacement foam pad for the shower gurney would be ordered. Photographic Evidence Obtained. On 12/5/24 at 5:02 p.m., a facility tour was conducted with the Nursing Home Administrator (NHA), Maintenance Director, and the Regional Maintenance Director (RMD). The Maintenance Director said the portable air conditioner unit would be removed. When shown the dust on the filter and in the tubing, he said I see. After observation of the rusted grab bars in the shower room the Maintenance Director said, that's an easy fix. Review of a facility's policy titled Safe and Homelike Environment, implementation date not documented revealed: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and home light environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes residence independence and does not pose a safety risk. Comfortable and safe temperature levels mean that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia hyperthermia and is comfortable for the residents. Comfortable sound levels means levels that do not interfere with the residents hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is desired. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' room, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A home like environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a home like environment. A determination of home like should include the resident's opinion of the living environment. Orderly is defined as an uncluttered physical environment that is neat and well kept. Sanitary includes, but is not limited to, preventing the spread of disease- causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to equipment used in the completion of activities of daily living. Policy explanation guidelines includes: 1) the facility will create and maintain, to the extent possible, a home like environment and de-emphasize the institutional character of the setting. 1a) the facility will allow residents to use their personal belongings, including furnishings and clothing ( as space permits) to assist in creating and maintaining a home like environment. This use must not infringe upon the rights or health and safety of other residents. 1b) The social service designee, or another designated staff member, will encourage residents and their family to bring in personal belongings (within space constraints) to personalize residents' rooms. 1c) the facility will honor and document a resident's choice not to personalize his/her room. 2) The facility exercises reasonable care for the protection of the residents property from loss or theft. 3) housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 4) The facility will provide and maintain bed and bath linens that are clean and in good condition. 5) The facility will provide sufficient individual closet space in each resident room. 6) the facility will provide and maintain adequate and comfortable lighting levels in all areas. 6a) The maintenance director will perform periodic rounds to ensure functioning lights. 6b) Even light levels should be utilized in common areas and hallways to avoid patches of low light. 6c) Daylight should be utilized as much as possible. 7. The facility will maintain comfortable and safe temperature levels. 7a) the facility should strive to keep the temperature in common resident areas between 71°F and 81°F. 7b) if and when a resident prefers his or her room temperature be kept below 71°F or above 81°F, the facility will assess the safety of this practice on the resident and the resident's roommate. 7c) if and when residents who share a room do not agree on the temperature of the room, the facility will assist in negotiating a compromise that the residents agree on, or will assist in a room change. 8) The facility will maintain comfortable sound levels in the facility. Overhead paging will be limited to emergency situations and as needed for providing prompt care and treatments of residents. Based on observation, record review, and interview, the facility failed to provide a safe, clean, home like environment on one (2nd floor) out of 2 floors observed. Findings include: An observation was made on 12/2/2024 at 10:00 am. in room [ROOM NUMBER] on the second floor. The bathroom was observed with a hole in one of the ceiling tiles. Further observation showed a section of the bathroom floor tiled lifted from the floor. On 12/2/2024 at 1:00 p.m., during an observation on the second floor, three residents were seen sitting in their wheelchairs next to grab rails/chair rails near the nursing station. The rails were observed with a separated section and sharp gaps with potential to cause injuries. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 12/3/2024 at 8:50 a.m., Resident #75 was heard screaming Help from her room. During an observation on 12/04/2024 9:55 a.m., Resident #75 was heard screaming from her room. Review of Resident #75's admission Record showed Resident #75 was initially admitted on [DATE] and a readmission date of 11/25/2024 with diagnoses of unspecified dementia, unspecified severity with agitation, bipolar disorder, current episode manic without psychotic features, and major depressive disorder, recurrent. Review of Resident #75's Level I PASRR, dated 11/26/2024, showed the following: - Section I-Part A: MI (Mental Illness) or suspected MI: Bipolar and Depressive disorder were marked. Part B. ID (Intellectual disability) or suspected ID, was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption: Not a Provisional admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 4. During an interview on 12/2/2024 at 2:48 p.m. with Resident #57's family member (FM), he stated he is happy with the care his father is receiving and had no concerns. He stated he was unsure of any triggers regarding resident #57's Post Traumatic Stress Disorder (PTSD) and the facility, and staff are good at handling his care. Review of Resident #57's admission Record revealed an initial admission date of 3/15/2022 and a readmission date of 4/30/2024. Resident #57 was admitted to the facility with diagnosis of major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, unspecified mood affective disorder, post-traumatic stress disorder and seizures. Review of the Level I PASRR, dated 3/14/2022, showed the following: - Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness): major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, unspecified mood affective disorder, post-traumatic stress disorder, and seizures, were not marked. Part B. ID (Intellectual disability) or suspected ID (Intellectual disability) was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption: Not a Provisional admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 1. Review of Resident #51's admission Record showed an admission date of 7/27/2024, with diagnoses to include bipolar disorder, major depressive disorder, and claustrophobia. Review of Resident #51's Level I PASRR, dated 7/29/2024, showed the following: - Section I-Part A. MI (Mental Illness) or suspected MI: Bipolar and Depressive Disorder were marked. Part B. ID (Intellectual disability) or suspected ID was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption: Not a Provisional admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During a review of Resident #51's electronic health records, a Level II PASARR could not be located. 2. Review of Resident #66's admission Record showed an admission date of 11/23/2020, with diagnoses to include alcohol abuse, major depressive disorder, and anxiety disorder. Review of Resident #66's Level I PASRR, dated 11/29/2024, showed the following: - Section I-Part A. MI (Mental Illness) or suspected MI: Depressive Disorder and Substance Abuse were marked. Part B. ID (Intellectual disability) or suspected ID, was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption: Not a Provisional admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During a review of Resident #66's electronic health records a Level II PASARR could not be located. On 12/03/2024 at 4:38 p.m. a request was made to the Social Services Director (SSD) for copies of resident #51 and #66's Level II PASARRs. On 12/4/2024 the SSD provided resident #51 and #66's Level I PASARRs and Level II PASARRs were not provided. On 12/5/2024 at 1:34 p.m. an interview was conducted with the Director of Nursing (DON), SSD, and Regional Clinical Nurse (RNC). The SSD confirmed Level II PASARRs were not available for residents #51 and #66. 5. Review of Resident #69's admission Record showed Resident #69 was admitted to the facility on [DATE] with diagnoses to include but not limited to encephalopathy, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder recurrent, moderate, and bipolar disorder, current episode depressed, mild. Review of a Document titled Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report Administrative Closure dated 8/22/2024 showed Resident #69's review was closed due to the facility submitting an incomplete referral packet. On 12/5/2024 at 1:58 p.m. an Interview was conducted with Staff Z, Registered Nurse (RN) and 3 p.m. to 11 p.m. Supervisor. Staff Z, RN stated a Level II Preadmission Screening and Resident Review was submitted for Resident #69. The resident was triggered for a Level II due to her diagnoses. Staff Z, RN stated she reached out to KePRO regarding the Level II PASRR and was told she had to resubmit paperwork due to the lack of information submitted the first time. She stated she reached out to KePRO a while back but did not hear back from them. Review of the facility policy titled Resident Assessment - Coordination with PASARR Program, last revised on 12/20/2023, showed under the section titled Policy, this facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disabilities, or a related condition received cares and services in the most integrated sitting appropriate to their needs. The policy also showed under the section titled Policy Explanation and Compliance Guidelines, 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 6. The Social Services Director will be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Based on record review and interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) were completed accurately and updated to reflect new Mental Illness (MI), or Suspected Mental Illness (SMI) diagnoses for five residents (#51, #66, #75, #57, and #69) of forty-nine sampled residents. Findings included:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) care related to 1. removal of facial hair for one (#18) of 31 sampled residents and 2. did not ensure the cleaning and trimming of fingernails for two (#68 and #48) out of 31 residents sampled. Findings Included: 1. During an interview on 12/02/2024 at 10:26 a.m., resident was observed sitting in a wheel chair in the hallway. She stated she was leaving her room for a little while. She was observed to have strands of white facial hair on her chin. She stated if she could just get a razor, she could take care of them herself. She stated no one had offered to help her. During an interview on 12/04/2024 at 5:30 p.m., resident #18 was observed lying in bed dressed in a red sweater. She was observed to have strands of white facial hair on her chin. Resident #18 stated if they give me some tweezers I can take care of it, but I'm not sure if they even have tweezers here. During an interview on 12/05/2024 at 4:31 p.m., with the Resident #18's family member (FM), she stated she had spoken with staff about her mom having facial hair and staff has told her They were not allowed to remove it. Review of Resident #18's admission record revealed an admission date of 08/05/2023 and a re-admission date of 04/17/2024. Review of Resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #18 was dependent with supervision or touching assistance with shower/bath. During an interview on 12/04/2024 at 3:10 p.m., Staff F, Certified Nursing Assistant (CNA) stated she helped residents with their daily living activities such as brushing teeth, changing clothing, taking showers. She stated on shower days she asked the residents if they wanted their showers. She stated she liked to get most of her showers done in the morning. She stated during the showers she offered to wash the resident's hair and offered to shave the resident. She stated she would offer to help remove the facial hair from female residents as well. During an interview on 12/04/2024 at 3:05 p.m., Staff G, CNA stated he assisted residents with dressing, and bathing. He stated on shower days he checked if the resident would like to take a shower. He stated the residents did like to refuse showers. He stated he attempted a few times to get the resident to take a shower and if they do not want a shower, he wrote it on the shower sheet and then notified the nurse. He stated when he gave the residents their shower he made sure to wash their hair, their body, and asked the resident if they needed help shaving. He stated he would also offer facial hair removal to a female resident during shower time. During an interview on 12/04/2024 at 3:22 p.m., Staff H, CNA, stated on shower days they provided a shave, wash hair and wash the residents. Females with facial hair were asked if they would like it removed and was typically removed on their shower days. During an interview on 12/04/2024 at 6:20 p.m., the Director of Nursing (DON) and the Regional Nurse stated female residents who had facial hair should be asked if they would like it removed. CNAs and Nurses were responsible for asking the residents and removing the facial hair for those residents. 2. On 12/02/24 at 10:46 a.m., Resident #68 was observed lying in bed his fingernails were approximately 1/2 inch in length with a yellow and brown substance under the nails. Resident #68 said he requested to have his fingernails trimmed and it was not done. He pointed to his right thumb and said the nail tore and needed to be cut, it catches on things. Resident # 68 said he told the Certified Nursing Assistants (CNAs) and the nurses many times he would like to have his nails trimmed. Photographic Evidence Obtained. Review of the admission Record showed Resident #68's initial admission date to the facility was on 10/11/24. Review of Resident #68's annual Minimum Data Set (MDS) dated [DATE], showed Section C, cognitive patterns, Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Section GG, functional abilities showed Resident #68 required substantial/maximal assistance with shower/bath. Supervision or touching assistance was needed for personal hygiene. Review of Resident #68's Quarterly Nursing Evaluation, dated 11/28/24 showed assistance was needed for one or more Activities of Daily Living (ADL) and the resident was alert. Review of the ADL care plan showed a focus for Resident #68 as follows, has an ADL self-care performance deficit related to COPD/Chronic Respiratory failure/Obesity/Depression and Functional Quadriplegia, date Initiated, 07/15/2024. The care plan's goal was Resident #68 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 12/3/24-12/4/24 Resident #68 was observed lying in bed, fingernails remain untrimmed with yellow and brown substance under the nail beds. Resident #68 said he would like his nails trimmed. Review of Resident #68's task list titled, ADL-bathing schedule, showed the showers were given on the following dates: 11/16/24, 11/20/24, 11/25/24, 11/27/24, 11/28/24, 11/29/24, and 12/4/24. During observation and interview on 12/02/24 at 11:26 a.m., Resident #48 was sitting in his wheelchair; his fingernails were approximately one inch in length with dried yellow/orange substance under nails and nail beds. Resident #48 said he wanted his fingernails trimmed. Review of Resident #48's ADL Bathing scheduled showed he was dependent with care and had showers on the following days: 11/18/24, 11/19/24, 11/21/24, 11/25/24, 11/26/24, 11/27/24, 11/28/24, 12/2/24, and 12/3/24. Review of Resident #48's care plan focused on self-care deficit with dressing, grooming, bathing related to cognitive deficit, generalized weakness and limited endurance, initiated on 1/10/20. The care plan goal was Resident #48 will have clean, neat appearance daily through the next review date. The care plan interventions include providing hands on assistance with dressing, grooming, and bathing as needed, initiated on 1/10/20. Review of the admission Record showed Resident #48's initial admission date was on 1/9/2020. During daily observations of Resident #48's fingernails between 12/3/24 to 12/5/24 fingernails remained long, with dry yellow/orange substance under the nails. During an interview on 12/3/24 at 9:54 a.m., the Director of Nursing (DON) said residents were offered showers two times weekly and could request additional showers if preferred. During an interview on 12/5/24 at 7:49 a.m., Staff W, Patient Care Assistant (PCA), said she assisted residents with showers, she did not cut fingernails, and podiatry provided nail care. During an interview with the DON and Staff B, Registered Nurse (RN), Unit Manager (UM). The DON said the nursing assistants should provide nail care with showers, it's part of ADL care. During an interview on 12/5/24 at 11:18 a.m., Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM) said everybody is responsible for fingernail care. Review of facility's policy titled, Activities of Daily Living (ADLs), date implemented 9/7/22 revealed: Policy- the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities and ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1) bathing, dressing, grooming and oral care 2) transfer and ambulation 3) Toileting 4) Eating to include meals and snacks 5) Using speech, language or other functional communication systems. Policy explanation and compliance guidelines: 1) conditions which may demonstrate unavoidable decline in ADL include 1a) natural progression of the resident's disease state with known functional decline. 1b) Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. 1c) Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment, council and our offer alternatives to the resident or representative. 2) the facility will provide a maintenance and restorative program to assist a resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 4) The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement. 5) The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observation, record review, and interview, the facility did not ensure wound care was provided for one resident (#93) of two sampled residents. Findings include: On 12/2/24 at 9:39 a.m., Resident #93 was observed ambulating in a wheelchair towards the door of her room. She stated she had a sore on her toe and was being seen by a podiatrist not affiliated with the facility. Resident #93 stated the podiatrist ordered an antibiotic cream, but she had not received the treatment. She stated she had not received care at the facility for the toe wound. She confirmed the toe wound was not facility acquired, she stated she had it upon admission. A review of Resident #93's admission Record revealed an initial admission date of 9/4/23 and a re-admission date of 3/15/24. Further review of the admission Record revealed diagnoses included but not limited to unspecified protein-calorie malnutrition, pressure ulcer of sacral region, stage 4, osteomyelitis of vertebra, sacral and sacrococcygeal region, and systemic lupus erythematosus, unspecified. A review of Resident #93's Comprehensive Minimum Data Set (MDS), Section C - Cognitive Patterns, dated 9/8/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A review of Resident #93's Active Physician Orders revealed the following to include: Protein Liquid. two times a day for nutritional Support : Give 30 ml [milliliters] 2 times per day. May mix in beverage of choice. Record % consumed, with an order and start date of 4/17/24. Appt [Appointment]: [Physician name] DPM [Doctor of Podiatric Medicine] 12/4/24 @ [at] 2:00 PM . NEEDS TRANSPORT, with an order date of 11/27/24. Cleanse coccyx with n/s [normal saline], apply Santyl, calcium alginate loosely packed, and cover with foam dressing. Apply zinc oxide to peri-wound. every day shift for pressure ulcer, with an order and start date of 11/5/24. Complete skin check weekly on: Wednesday every day shift every Wed for Skin check Complete [Vendor name] Assessment/Evaluation, an order date of 4/10/24 and start date of 4/17/24. left heel: apply skin prep every shift for pressure ulcer, with an order and start date of 3/19/24. Santyl Ointment 250 UNIT/GM [gram] (Collagenase) Apply to Coccyx topically as needed for Coccyx, with an order and start date of 7/24/24. Santyl Ointment 250 UNIT/GM (Collagenase) Apply to Coccyx topically every day shift for Coccyx 1.3 x 0.8 x 30 (location- coccyx), with an order and start date of 7/24/24. A review of Resident #93's Progress Notes revealed the following to include: A review of a note titled, Pressure Ulcer wound progress note, dated 12/2/24 revealed the following, wound note: resident has 2 wound(s) . Offloading Boot(s) present. Heels are floated as tolerated . Pressure ulcer #1 present on admission. Pressure ulcer is a Stage 4 . admitted with Pressure ulcer #2 Wound #2 is a Stage 1 Pressure Ulcer . A review of a note titled, Skin observation progress note, dated 11/28/24 revealed the following, Skin observation progress note : Resident has existing skin impairment Resident nails cleaned and trimmed Pressure injuries to L [left] heel and coccyx, followed by wound care, orders in place. A review of a note titled, Pressure Ulcer wound progress note, dated 11/26/24 revealed the following, wound note: resident has 2 wound(s) . coccyx - zinc to peri area, Santyl, calcium alginate, foam QD [once a day] heels - skin prep q [every] shift . A review of a note titled, Physician Progress Note, dated 11/21/24 revealed the following, . She continues with reported stage 4 sacral wound, wound care following. Physical examination: . Skin: Warm, dry, no visible rash. Pressure ulcer sacrum not visualized A review of a note titled, Skin observation progress note, dated 11/20/24 revealed the following, Skin observation progress note : Resident has existing skin impairment Resident nails cleaned and trimmed Existing pressure injury. A review of a note titled, Pressure Ulcer wound progress note, dated 11/19/24 revealed the following, wound note: resident has 2 wound(s) . coccyx - zinc to peri area, Santyl, calcium alginate, foam heels - skin prep q shift . A review of progress notes from 12/3/24 to 11/1/24 revealed no documentation related to assessment, care or treatment for Resident #93's toe wound. Further review of the progress notes revealed a note titled, eMAR [Medication Administration Record] - General Note, dated 10/30/24 revealed the following, Note text : Writer has been observing/evaluation and applying treatment, as ordered, to resident Left-great toe. Area has resolved. Writer called [Podiatry office name], spoke with [staff member name], where [staff member name] confirmed if area has resolved, may discontinue order. Writer had wound nurse, re-evaluate and assess area as well. Wound nurse confirmed area healed. Writer has resolved/discontinued order as ordered. Writer will continue to monitor area to resident left-great toe for continual healing. A review of Resident #93's Weekly Pressure Wound Notes, documented by facility nursing staff, dated 12/2/24, 11/26/24, 11/19/24, and 11/13/24, revealed no documentation related to the resident's toe wound. Documentation in the pressure wound notes referenced wounds to include an abrasion to the resident's forehead, her coccyx and left heel. A review of Resident #93's Head to Toe Weekly Skin Checks dated 10/23/24, 10/30/24, 11/6/24, 11/13/24, 11/20/24, and 11/28/24, revealed no documentation related to the resident's toe wound. A review of Resident #93's care plan revealed the following interventions under the, ADL [Activities of Daily Living] Care Plan, Bathing/Showering: The resident requires assist x 1 staff with bathing. Date Initiated: 10/03/2023, Dressing: The resident requires assistance x 1 staff to dress. Date Initiated: 10/03/2023, Personal Hygiene: The resident requires assistance by 1 staff with personal hygiene and oral care. Date Initiated: 10/03/2023. Further review of Resident #93's care plan revealed the following under the, Pressure Ulcer Care Plan, Pressure Ulcer location: stage 4 coccyx and Left heel DTI [Deep Tissue Injury] Diagnosis of Osteomyelitis of vertebrae and SLE [Systemic Lupus Erythematosus]. Date Initiated: 09/05/2023. Revision on: 09/11/2024. On 12/4/24 at 10:02 a.m., Resident #93 was observed ambulating in the wheelchair from the bathroom to the bed. An interview with the resident revealed staff were aware of the wound on her toe. She could not confirm who she spoke to. Resident #93 stated there was a prescription for treatment from the podiatrist. She confirmed she received treatment at the facility for her toe wound about a month ago. Resident #93 stated she was currently not receiving treatment. The resident stated she had a podiatry appointment today, in the afternoon. Resident #93 stated she was followed by wound care for her coccyx and heel, but not her toe. She stated, I think it has something to do with double billing. An observation of the left foot, in the presence of a Registered Nurse (RN) surveyor, revealed the top of the left great toe had a wound approximately 0.5 centimeters (cm) in size. The toe wound had a scab in the center and callous on the edges. Further observation of Resident #93's toe wound revealed the periphery was pink and blanches to touch. Photographic Evidence Obtained. On 12/4/24 at 10:07 a.m., an interview with Staff J, Licensed Practical Nurse (LPN) stated she was not aware of, and no one reported to her regarding Resident #93's toe wound. She confirmed the resident was on her assignment. On 12/4/24 at 10:09 a.m., an interview and review of Resident #93's electronic medical record with Staff B, Registered Nurse (RN)/Unit Manager (UM), revealed there was no information related to the resident's toe in the last skin assessment. An observation of the resident's left great toe was conducted with Staff B, RN/UM. During the observation, Resident #93 stated her toe wound had been there for months. The resident explained to Staff B, RN/UM the toe wound started as a fungus. At the end of the observation and interview with the resident, Staff B, RN/UM stated it was an issue that there was no documentation in the skin assessment related to Resident #93's toe wound. On 12/4/24 at 10:17 a.m., interviews were conducted with Staff B, RN/UM and the Director of Nursing (DON) regarding communication from outside services. Staff B, RN/UM revealed the facility sent information with the resident, when they went to appointments, to include demographics, medication list, updated labs, and other information that was pertinent to the service or doctor they were going to. She stated the resident should return with documents to include progress notes or new medications. Staff B, RN/UM stated if the resident did not come back with documents, then the nurse or herself would call the office where the resident had the appointment. The DON stated she expected the nursing staff to put a note in the resident's medical record when the resident returned from appointments. The DON stated herself, Resident #93's physician, and Staff B, RN/UM completed an assessment on this resident last Monday. She stated they assessed the resident, but did not observe her toe. The DON stated the resident had not mentioned anything to her. She stated it was the nursing staff's responsibility to check the resident from head to toe. The DON stated it's part of their assessment. On 12/4/24 at 10:25 a.m., Staff B, UM/RN stated Resident #93's last podiatry visit was on 11/11/24, however, the resident's medical record did not have documentation, to include progress notes or prescriptions, related to the recent podiatry visit. A review of the facility's policy titled, Skin Evaluations, with an implementation and reviewed/revised date of 8/22/22 revealed the following under, Policy, It is our policy to perform a full body skin evaluation as part of our systemic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Further review of the policy revealed the following under, Policy Explanation and Compliance Guidelines, 1. A full body, or head to toe, skin evaluation will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The Evaluation may also be performed after a change of condition or after any newly identified pressure injury. A review of the facility's policy titled, Guideline : Certified Nursing Assistant Skin/Body Audits, with an implementation and reviewed/revised date of 8/25/22 revealed the following under Guideline, It is our guideline to communicate changes in skin condition to appropriate personnel as part of our systematic approach for pressure injury prevention and management. This guideline establishes responsibilities of nursing assistants in communicating changes in skin condition. Further review of the policy under, Guideline Explanation and Compliance Guidelines, revealed the following, 1. Nursing Assistance shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. 3. Skin conditions that shall be reported include, but are not limited to: . f. Skin teas g. Open areas, ulcer, lesions. 4. Notification shall be made to the nurse verbally or in writing.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Twenty-eight medication administration opportunities were observed, and seven errors were identified for four residents (#4, #15, #68 and #93) of eight residents observed. These errors constituted a medication error rate of 25%. Findings Included: 1. On 12/04/24 at 7:28 a.m., during medications administration observation with Staff P, Registered Nurse (RN), Staff P administered Fiasp FlexTouch (insulin aspart) 30 units subcutaneously (SQ) to Resident #15. Review of Resident's #15's order summary report, active orders as of 12/4/24 revealed orders to include Fiasp FlexTouch 15 unit subcutaneously in the morning for (Diabetes Mellitus (DM) and Fiasp FlexTouch 15 unit subcutaneously with meals for DM. At the time Staff P administered Fiasp FlexTouch 30 units SQ Resident #15 was not eating, and meal trays were not being served. 2. On 12/4/24 at 8:21 a.m. during medications administration observation with Staff J, Licensed Practical Nurse (LPN), Staff J administered the following medications to Resident #93: Furosemide 20 mg Hydroxyurea 500 mg Levetiracetam 500 mg Metoprolol 25 mg Multiple Vitamins with Minerals 1 tab Omeprazole 20 mg Timolol Maleate Ophthalmic Solution 1 drop in each eye. Review of Resident #93's order summary report, active orders as of 12/4/24 revealed the following orders: Furosemide 20 mg Hydroxyurea 500 mg Levetiracetam 500 mg Metoprolol 25 mg Multiple Vitamins with Minerals 1 tab Omeprazole 20 mg Timolol Maleate Ophthalmic Solution 1 drop in each eye Cholecalciferol 125 mcg Eliquis 2.5 mg Fluticasone Nasal Spray 1 inhalation in nostrils. Review of the Medication Administration Record revealed Staff J, LPN initialed the record, indicating Cholecalciferol 125 mcg, Eliquis 2.5 mg, and Fluticasone Nasal Spray 1 inhalation in nostrils was administered. The administration of Cholecalciferol 125 mcg, Eliquis 2.5 mg, and Fluticasone Nasal Spray 1 inhalation in nostrils was not observed. During an interview on 12/4/24 at 1:28 p.m. with the Director of Nursing (DON), Regional Nurse Consultant (RNC) and Staff J, Staff J confirmed she did not administer all the medications initialed on the Medication Administration Record as administered. 3. On 12/4/24 at 9:18 a.m., during medications administration observation with Staff J, Staff J administered Victoza Pen-injector Inject 1.2 mg SQ and Insulin Glargine-yfgn pen-injector Inject 30-unit SQ to Resident #4. Prior to administration Staff J failed to use the proper technique of priming [procedure to ensure the correct dose is administer] the insulin pens prior to administration. Review of Resident #4's order summary report, active orders as of 12/4/24 showed orders to include: Victoza Subcutaneous Solution Pen-injector 18 MG/3ML (Liraglutide) Inject 1.2 mg subcutaneously one time a day related to Type 2 DM with unspecified diabetic retinopathy with macular edema and Insulin Glargine-yfgn 100 unit/ml Solution pen-injector Inject 30 unit subcutaneously two times a day related to Type 2 DM with unspecified diabetic retinopathy with macular edema. During an interview on 12/04/24 at 9:43 a.m., Staff J said she did not know insulin pens should be primed prior to medication administration. During an interview on 12/4/24 at 1:28 p.m. with the DON and the RNC, the DON said the expectation was for insulin pens to be primed before administration. 4. On 12/04/24 at 1:01 p.m., Staff R, LPN was observed administrating medications to Resident #68. Staff R said all medications due to be administered at 2:00 p.m. had been administered. On 12/04/24 at approximately 1:40 p.m., the medication order reconciliation review showed Staff R documented administration of Ipratropium-Albuterol Solution 0.5-2.5 three ml by nebulizer to Resident #68. During an interview on 12/4/24 at 1:52 p.m. with the DON and Resident #68, Resident #68 said he had not received a breathing treatment for more than 24 hours. During an interview on 12/04/24 at 3:34 p.m. with the DON and the RNC, the RNC said Staff R admitted he had not administered Ipratropium-Albuterol Solution as documented on the Medication Administration Record. Review of a facility's policy titled, Liberalized and Standardized Medication Administration Schedules revealed the following: Policy: in keeping with our philosophy of person-centered care and resident rights, medications will be delivered in a manner that is least restrictive and intrusive while allowing for optimal therapeutic effect of medications.time sensitive medications are medications with a narrow therapeutic index or medications that require specific administration times for clinical safety and efficacy . Medications are considered timely as long as they are administered within one hour before or after the standard administration time . a list of suggested time sensitive medications are .insulins . Review of a facility's policy titled, Administration of Injections, date implemented 1/22/23, revealed the following: Policy: Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to notify the ordering practitioner of Radiology results for one resident out of eight residents sampled (#67). Findings Include: On 12/2/2024 at 10:00 am., Resident #67 was sitting up in her wheelchair, dressed well-groomed with her call light within reach. She was presented with no signs of distress. She stated she had an incident two weeks ago when two nursing aides pulled her up in bed. She stated she felt a sharp pain in her back and legs after they repositioned her. She stated one of the aides told the nurse about the resident complaint and was provided with an x-ray. She stated she was never told the results of the x-ray findings. Review of an admission Record dated 12/5/2024 showed Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Type 2 diabetes mellitus with diabetic neuropathy, unspecified, presence of coronary angioplasty implant and graft Review of the Quarterly Minimum Data Set, MDS assessment dated [DATE] - Section C, Cognitively Patterns- BIMS score of 10 which indicated Moderate cognitive impairment. Review of an order summary dated 11/25/2024 showed a Stat order for a Lumber X-ray for lower back pain was ordered for Resident #67. Review of Radiology Results Report dated 11/25/2024 showed procedure for X-ray exam I-s spine 2/3/views. Interpretation findings showed The study is limited by the patient's body habitus and the lack of a lateral projection. Moderate disc space narrowing and degenerative endplate changes are noted. Osteopenia is present, Conclusion: Limited study. Degenerative changes. Follow-up Anteroposterior, AP and lateral views helpful. Review of the Electronic Medical Record (EMR) showed no evidence of documentation that the ordering practitioner was notified of the x-ray results, and no follow-up x-ray was ordered. On 12/04/2024 at 4:00 pm, an interview was conducted with Staff AA, Registered Nurse, RN. She stated the CNA who took care of the resident on 11/25/2024 came to her to tell her that Resident #67 was complaining about back pain. She stated Resident #67 told her the nursing aides tried to reposition her in the bed and somehow, she hurt her back, and the pain was mostly on the waist. The nurse stated she asked the resident if she would like to have pain medication. The nurse stated the resident said she did not want anything for pain. Staff AA stated she did not know she needed to call the resident's family to tell them about the resident complaint. She stated she did not call the family or notify the doctor when the x-ray results came in, she only reported the x-rays to the nurse from the next shift. On 12/4/2024 at 4:10 pm, an interview was conducted with Staff I, License Practical Nurse/Unit Manager. She stated the x-ray report came back to the facility at 6pm, during the first shift. She stated Staff AA should have notified the doctor and the resident representative about the incident and the x-ray findings. On 12/4/2024 at 4:30 pm, an interview was conducted with the Director of Nurses, DON. The DON stated the nurse should have notified the physician, the resident and the resident representative about the x-ray findings. The nurse should have also followed the process of what the physician would have provided for the resident. She stated we will just have to do some education from this point moving forward. Review of the facility policy titled, Provision of Physician Ordered Services dated 8/25/2024 showed Policy, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Policy Explanation and Compliance Guidelines: 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented an effective Quality Improvement and Performance action plan, to correct deficient practice identified during a recertification survey conducted on 12/2/24 to 12/5/25, related to citations at F 552, F 677, F 686, F 777, and F 880. Findings included: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI), dated 08/25/2022, showed the following: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI plan. 3. the QAPI plan will address the following elements: C. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but not limited to, the following: i. Tracking and measuring performance ii. Establishing goals and thresholds for performance improvements. Iii. Identifying and prioritizing quality deficiencies. Iv. Systematically analyzed and underlying causes of systemic quality deficiencies. V. Developing and implementing corrective action or performance improvement activities. VI. Monitoring and evaluating the effectiveness of corrective action / performance improvement activities and revisiting as needed. D. The prioritization of program activities that focus on resident safety, health outcomes, autonomy, choices and quality of care, as well as high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves the facility must also consider the incidents, prevalence and severity of problems or potential problems identified. F. Process to ensure care and services delivered meet accepted standards of quality. Program Development Guidelines: 1. Program design and scope--- a. the QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. 4. Program activities---a. All identify problems will be addressed and prioritized, whether by frequency of data collection, monitoring or by the establishment of sub-committees. Considerations include, but are not limited to: i. high- risk, high-volume, or problem-prone areas. ii. Incidence, prevalence, and severity of problems in those areas. iii. Measures affecting resident health, safety, autonomy, choice and quality of care. During an interview on 01/16/2025 at 2:05 p.m. the Nursing Home Administrator (NHA) and the DON stated they had an ADHOC (a meeting called suddenly to discuss a pressing issue) on 12/20/2024 after receiving the Statement of Deficiencies. They stated they reviewed the citations to match the education they had already started after the exit of the survey on 12/06/2024. They stated they adjusted the audit tools they had already created. They stated they determined the frequency of the audits. They discussed the findings with the Medical Director over the phone on 12/20/2024. They validated the Plan of Correction binders were prepared. The NHA left the interview and the DON continued with the interview. 1. The DON stated the F-tag 552 was related to Change in Condition notifications to the resident and resident representatives associated with x-ray results. The DON stated they educated the staff on change in condition which included the policy of notification of changes. The DON stated they started the education with the licensed staff on 12/16/2024 and completed it on 01/03/2025. The DON stated they did a look back of 30 days of labs and x-rays to ensure all had been reported to the medical providers, residents and families. The DON stated the audit did not show if they had to update anyone or not. The DON stated the ADON was to review the x-ray results to ensure the medical provider, resident and resident representative was notified. The DON stated the ADON took ownership and was responsible for the audits, Monday through Friday. The ADON was to give any results that needed to be reported to the Unit Managers for follow-up. The Unit Manager was to report or ensure the floor nurse had reported the results. The DON stated the ADON was supposed to be checking behind the staff to ensure the results were being reported. The DON stated the ADON was sick Monday (01/13/2025) and did not review and the when she returned on Tuesday (01/14/2025), the Unit Manager was off, so the labs were not reported to the appropriate people. The DON stated the ADON cannot be solely responsible. The DON stated the ADON was the checker and the floor nurse needs to notify all parties. The DON stated they would re-educate the staff regarding notifications for change in conditions. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results were dated 01/12/2025 at 8:50 p.m. showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed On 01/13/2025, radiology note showed chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note showed on 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/2021. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included but not limited to Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray dated 01/14/25 at 2:00 p.m. showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed On 01/14/2025 at 12:127 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed resident was on antibiotic therapy related to URI as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as increases SOB and rpt to MD. During an interview on 01/15/2025 at 2:19 p.m. the DON (Director of Nursing) verified Resident #37 did not have documentation in her chart verifying Resident #37 or her responsible party was aware of Resident #37's x-ray reports. The DON verified Resident #38 had no documentation the medical provider, the resident nor her responsible party had been notified of Resident #38's x-ray results. The DON stated she would expect to see documentation in the progress notes the medical providers and either the residents or responsible parties had been notified of the results. The DON stated the ADON (Assistant DON) was supposed to be auditing all x-ray and lab results and confirming the results had been notified to the medical provider or resident and responsible party. If the ADON was not here it was the UM's (Unit Manager's) responsibility. During an interview on 01/15/2025 at 2:40 p.m. with the DON and the ADON, the ADON stated she had called Resident #38's medical provider and informed the resident of the x-ray results this morning (01/15/2025) but did not document it in the medical record. The DON and the ADON verified Resident #37's x-ray results were available on 01/12/2025 (Sunday). They verified the medical provider knew about the x-ray results for Resident #37 on 01/14/2025 (Tuesday). The DON and ADON verified the x-ray results for Resident #37 came to the facility on [DATE] at 8:50 p.m. The DON and ADON confirmed the medical provider was not informed for 2 days of the x-ray results for Resident #37. The DON stated the nurse may not have wanted to inform the medical provider until the next day (01/13/2025 Monday). The DON stated the supervisor should have called the medical provider over the weekend (01/12/2025) due to the results of Resident #37's x-ray showed mild pulmonary vascular congestion. The DON stated she did not know right now why they (x-ray) fell through the cracks. The ADON stated she was off on Monday sick, and she was responsible for the audits. The ADON stated the UM makes the calls to the medical provider and resident or representative as needed. The ADON stated the UM was off on Tuesday, so no calls were made. During an interview on 01/16/2025 at 12:04 p.m. the DON stated she spoke with the attending physician for Resident #38. The DON stated that the physician stated that if an X-ray result was normal the facility could wait until the next business hours to report to the physician. If it (x-ray result) was abnormal, they should call the on-call person. The DON stated that neither resident required new orders. The DON was informed her nurse s stated on interview that they were responsible to inform the medical provider and resident or representative with the results. The DON agreed the nurses had not documented they had called the appropriate persons. The DON agreed the checkers (ADON and UMs) should have been double checking the results were informed to the appropriate persons not being the staff who was to having to provide the x-ray results. 2. Review of education/ in-service attendance log, provided by the ADON, dated 12/5/24, with objectives related to nail care/shaving included the following information: staff must ensure that resident nails are clipped and cleaned underneath, failure to properly trim and clean resident nails can lead to health issues, Certified Nursing Assistants (CNAs) and nurses can clip resident's fingernails. CNAs are not allowed to clip the nails of residents who are diabetic, Patient Care Assistants (PCA) cannot clip fingernails but can file it. The signature page included the signatures of 110 staff members. Review of a resident census report, undated, showed a full audit was complete and done. Review of audit, dated 1/8/25, related to observations of ADLs related to shaving and nail care. The ongoing monitoring included quality review of five residents related to shaving and nail care, weekly for four weeks, then monthly for two months or until substantial compliance. Ten residents were observed for clean and trimmed nails, all residents were in compliance. Review of the admission Record showed Resident # 56's initial admission date to the facility was on 8/7/23. Review of Resident #56's annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section GG, functional abilities showed Resident #56 required supervision or touching assistance with shower/bath and was independent with personal hygiene. Review of the ADL care plan showed a focus for Resident #56, as follows: Has Activities of Daily Living (ADL) performance deficit related to Alzheimer's, dementia, musculoskeletal impairment, pain and history of a stroke, date initiated 8/14/23. The care plan's goal was Resident #56 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 1/15/25 at 10:40 A.M. during interview and observation, Resident #56 was observed sitting in his wheelchair and said he did not like the length of his fingernails [it is] hard to pick up a spoon. His nails were approximately 1/8 inch in length. (Photographic evidence obtained with permission of resident). Review of Resident #56's task, titled: GG-Shower/Bathe self, showed on 1/6/25 supervision or touching assistance was provided. On 1/9/24 Resident #56 was independent with the task. Review of the admission Record showed Resident # 55's initial admission date to the facility was on 2/29/24. Review of Resident #55's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicates intact cognition. Section GG, functional abilities showed Resident #55 is dependent (helper does all the effort) for shower/bathe self and required substantial /maximal assistance with personal hygiene. Review of the ADL care plan showed a focus for Resident #55, as follows: Has and ADL self-care performance deficit related weakness, adult failure to thrive, cognitive deficit, depression and anxiety and requires maximum to dependent ADLs. Decline is expected related to terminal condition. The care plan goal was Resident #55 will maintain current level of function through the review date, created on 3/4/24. The care plan's goal was Resident #55 will maintain current level of function through the review date. The interventions included the resident required assistance by one staff with personal hygiene and personal care On 1/16/25 at 10:56 A.M. during interview and observation, Resident #55 was observed lying in bed, and said he would like to have his fingernails trimmed. His fingernails were approximately ¼ inch in length, yellowing, with dry gray and yellow substance between the nail and nail bed. Resident #55 said he prefers bed baths. Review of Resident #56's task, titled: GG-Shower/Bathe self, showed daily between 1/10/25 and 1/16/25 he was dependent (helper does all the effort) with completing this task. Review of the admission Record showed Resident # 57's initial admission date to the facility was on 6/16/22. Review of Resident #57's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section GG, functional abilities showed Resident #57 required substantial/ maximal assistance with shower/bath and required supervision or touching assistance with personal hygiene. Review of the ADL care plan showed a focus for Resident #57, as follows: Has Activities of Daily Living (ADL) performance deficit related to confusion, dementia, visual deficits, depression and anxiety created on 6/18/22. The care plan's goal was Resident #57 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #57 required assistance by 1 staff with personal hygiene and oral care. On 1/15/25 at 10 :30 A.M. during an interview and observation Resident #57's fingernails were approximately 1/8 inch in length, under the nails contained large amount of dry dark gray and black substances, and the edges between the finger and fingernail contained caked on brownish and black substances. (Photographic evidence obtained with resident permission). Review of Resident #57's task, titled: GG-Shower/Bathe self, showed daily between 1/10/25-1/14/25 the resident was dependent (helper does all the effort) for this task. During a group interview on 1/15/25 at 2:49 P.M. Certified Nursing Assistants (CNA) said they were recently provided education to offer nail care to each resident on their shower days and to document on the shower sheets. During an interview on 1/16/25 at 12:05 PM, the Assistant Director of Nursing (ADON) said Staff are expected to provide nail care with bathing. During an interview on 1/16/25 at 2:10 P.M. the Director of Nursing (DON) said nail care should be completed on shower days and documented on the shower sheets or weekly skin checks. Review of facility's policy titled, Activities of Daily Living (ADLs), date implemented 9/7/22 revealed: Policy- the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities and ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1) bathing, dressing, grooming and oral care 2) transfer and ambulation 3) Toileting 4) Eating to include meals and snacks 5) Using speech, language or other functional communication systems. Policy explanation and compliance guidelines: 1) conditions which may demonstrate unavoidable decline in ADL include 1 a) natural progression of the resident's disease state with known functional decline. 1b) Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. 1c) Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment, council and our offer alternatives to the resident or representative. 2) the facility will provide a maintenance and restorative program to assist a resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 4) The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement. 5) The facility will maintain individual objectives of the care plan and periodic review and evaluation. 3. The DON stated the F-tag 686 was related to pressure ulcers and skin sweeps. She stated they performed skin sweeps on the entire building from 12/09/2024 t 12/13/2024. She stated they looked at the whole body. They educated the nurses on treatment services to prevent and heal pressure ulcers on 12/08/2024. They educated the staff that skin evaluations must be completed by a licensed nurse weekly, wounds must be evaluated weekly by an RN. The DON stated they educated the staff the medical provider must be contacted of a new skin impairment, and well as the resident and resident representative which includes change or addition of a treatment. The DON stated they are auditing 5 residents with wounds a week for 4 weeks. The DON stated they are auditing for process, skin checks completed, skin evaluations completed weekly, evidence of responsible party and medical provider notification. The DON stated she did the audits herself and visualized the dressings also. The DON stated she did not know what happened (dressings for Residents #39 and #40). The DON stated the ADON was re-educating the nursing staff on documentation process and following through with medical provider orders. The DON stated the nurse that documented she provided care for Resident #40 on 01/15/2025 stated, She did not have time to do the care. The DON stated the nurse stated she did not do the care on 01/15/2025 even though she documented she did. The DON stated they will continue to audit after the nurses have been re-educated. The DON stated they will discuss the audit frequency during the next ADHOC meeting with the team. Resident #39 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included nontraumatic chronic subdural hemorrhage, pneumonitis due to inhalation of food, acute respiratory failure, adult failure to thrive, Peripheral vascular disease, heart failure, dementia, and hypertension. Observation on 01/16/2025 (Thursday) at 10:28 a.m. of Resident #39 with Staff B, RN (Registered Nurse) and Staff C, CNA (Certified Nursing Assistant). Staff C, CNA was already in room with gloves in place, no gown. Staff B, RN entered room after applying gloves, no gown. Resident #39 was lying in bed. He had contractures of the lower extremities. Staff B and Staff C moved his blankets down and revealed his left heel dressing. The heel was wrapped in gauze and tape but was not dated. The heel dressing had a small amount of brownish draining on the heel area. The staff lowered the head of the bed and raised Resident #39's gown. His thigh had a dressing in place dated 01/13/2025 (Monday). The staff turned the resident onto his right side, toward Staff B. Resident #39's brief was opened, and the coccyx area was observable. The coccyx wound had no dressing applied. The coccyx area was a golf ball size open area. During the turning of the resident, Staff B, RN touched her gloved hand to her right sleeve, moving it up. The resident was placed back onto his back and the head was elevated. Staff B removed her gloves and hand sanitized. Staff B, RN stated he was on enhanced barrier (precautions). Staff B stated, I do not need to use a gown because I was not changing his dressings. When asked about touching his dressings, briefs, blankets, etc. stated she, I was not changing his dressings. Staff C, CNA was asked about the resident being on enhanced barriers, she just looked at the surveyor and had no response. Staff C stated if the resident was on enhanced barriers she should have had a gown on. During an interview on 01/16/2025 at 11:25 a.m. Staff D, RN, Unit Manager stated she verified the wound care for Resident #39. She stated the thigh dressing was to be done on Monday, Wednesday and Friday. She stated his coccyx wound was to be done daily. She stated the heel dressing was to be done daily. Staff D stated it (wound care) should have been done per the physician orders. Staff D, RN stated the negative outcomes could have included an increased size in pressure ulcer, worsening, infection, sepsis, not healing. Review of the physician orders showed cleanse coccyx with normal saline, apply calcium alginate and cover with superabsorbent border dressing daily as of 01/06/2025 cleanse left lateral thigh with normal saline, apply xeroform and border gauze 3 times a week, Monday, Wednesday and Friday as of 01/13/2025. Left heel, apply Santyl, xeroform, superabsorbent, and wrap with kerlix and apply zinc for peri-wound every shift as of 01/07/2025. Review of the January Treatment Administration Record (TAR) showed Cleanse coccyx with normal saline, apply calcium alginate and cover with superabsorbent border dressing daily as of 01/06/2025. The TAR showed the dressing was changed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. The resident did not have a dressing on his coccyx during the observation. Cleanse left lateral thigh with normal saline, apply xeroform and border gauze 3 times a week, Monday, Wednesday and Friday as of 01/13/2025 (Monday). The thigh wound was observed dated 01/13/2025. Left heel, apply Santyl, xeroform, superabsorbent, and wrap with kerlix and apply zinc for peri-wound every shift as of 01/07/2025. The TAR showed the wound was performed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. Review of the care plans showed Resident #39 was on Enhanced Barrier Precautions per CDC guidelines for Gastrostomy tube, wounds as of 04/14/2024. Interventions included but not limited to persons caring for the resident and providing high-contact resident care activities will require personal protective equipment (PPE), the use of gown and gloves. As of 4/17/2024. Clear signage will be posted on wall outside of room as of 07/01/2024. Resident #39 had a pressure ulcer located on the left heel stage 3 and coccyx stage 3. Decline in skin integrity is expected related to terminal condition as of 04/04/2024, revised on 12/27/2024. Interventions included but not limited to current treatment per order as of 04/04/2024. Document weekly: stage, length times width times depth, order, progress or lack of progress as of 04/04/2024. Notify MD and family for changes in wound status as of 04/04/2024. During an interview on 01/16/2025 at 11:25 a.m. Staff D, RN, Unit Manager stated she verified the wound care for Resident #39. She stated the thigh dressing was to be done on M-W-F. She stated his coccyx wound was to be done daily. She stated the heel dressing was to be done daily. Staff D stated it (wound care) should have been done per the physician orders. Staff D, RN stated the negative outcomes could have included an increased size in pressure ulcer, worsening, infection, sepsis, not healing. Resident #40 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cancer of the prostate, urinary catheter, hypertension, bladder-neck obstruction, and unspecified protein-calorie malnutrition. Observation on 01/16/2025 (Thursday) at 10:44 a.m. of Resident #40 with Staff D, RN. Staff D applied a gown and gloves after hand sanitizing. She entered the resident room and put his bed down and pulled up his gown. His suprapubic dressing was dated 01/13/2025 (Monday), there was drainage present on the dressing. Staff D placed his gown down and walked to the door. She removed her gloves and donned a new pair of gloves without hand sanitizing. She came back to the resident's bedside and pulled the cover up from his right lower extremity. His right heel was dressed, and it was dated 01/13/2025 (Monday). The resident stated his coccyx wound was healed and did not have a dressing. Staff D removed her gloves and gown and washed her hands. Review of the physician orders showed Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing every day as of 01/06/2025 to start on 01/07/2025 and discontinue as of 01/15/2025. Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing on Monday, Wednesday, Friday as of 01/13/2025 to start on 01/15/2025. Cleanse suprapubic catheter area with normal saline, pat dry, apply silver calcium alginate, cover with superabsorbent border dressing every day as of 01/06/2025 Review of the January 2025 TAR showed Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing every day as of 01/06/2025 to start on 01/07/2025 and discontinue as of 01/15/2025 showed performed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13/25 Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing on Monday, Wednesday, Friday as of 01/13/2025 to start on 01/15/2025 (Wednesday), showed IA on 01/15/2025. Cleanse suprapubic catheter area with normal saline, pat dry, apply silver calcium alginate, cover with superabsorbent border dressing every day as of 01/06/2025 showed care performed on 01/16/25, 01/07, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. Review of the care plans showed Resident #40 had a pressure ulcer care plan due to unstageable to right heel as of 04/02/2024. Interventions included but not limited to current treatment per order; document weekly: stage, length x width x depth, odor, progress or lack of progress; Notify MD and family. During on 01/16/25 at 11:12 a.m. Staff D, RN stated the heel was supposed to be dressed on Monday, Wednesday (01/15/2024) and Friday. Staff D, RN stated the nurse documented IA on the TAR which she does not know what that is. Staff D stated she would ask the nurse what that meant. Staff D stated the suprapubic dressing was to be performed daily and her nurse documented it was done. Staff D stated the nurse reported she did not have time to perform the care and told the next shift to do it. During an interview on 01/16/2025 at 12:04 p.m. the DON stated that the staff was to perform the wound care as per the medical provider order. The enhanced barrier precautions was to be performed during direct contact. 4. The DON stated F-777 related to reporting the x-ray results to the medical provider timely. She stated they used the same education and audits as for F-552. The DON stated she will re-talk about the process with the QAPI team. The DON stated they need to educate the nursing staff again to be the persons reporting the results and the ADON as the backup. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results were dated 01/12/2025 at 8:50 p.m. showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed On 01/13/2025, radiology note showed chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note showed on 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/2021. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included but not limited to Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray dated 01/14/25 at 2:00 p.m. showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed On 01/14/2025 at 12:27 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed resident was on antibiotic therapy related to URI as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as in[TRUNCATED]

Based on observation, record review, and interview, the facility failed to follow professional standards to help prevent the development and transmission of communicable diseases and infections related to 1. hand hygiene for three (#85, #93, and #104) of eight sample residents, 2. Personal Protective Equipment (PPE) use for one (#27) of one sampled resident, and 3. cleaning of equipment for two (#4 and #27) of eight sampled residents. Findings included: On 12/3/24 at 11:58 a.m., Staff U, Certified Nursing Assistant (CNA) was observed in Resident #27's room without PPE (gloves and gown) On 12/3/24 at 12:48 p.m., Staff P, RN, Staff U, CNA entered Resident's #27 providing direct care (repositioning) without wearing PPE (gowns and gloves). On 12/04/24 at 9:21 a.m., Staff U, CNA existed in Resident #27's room without wearing PPE. Staff U, CNA said she was assisting Resident #27 with personal care (brushing her hair). Review of Resident #27's admission record showed admission date, 11/2/2024. Review of Resident #27's, order summary report, active orders as of 12/4/24 revealed contact precautions for extended-spectrum beta-lactamase (ESBL) in the urine (Urinary Tract Infection). During an interview on 12/4/24 at 9:26 a.m. Staff U, CNA said she wore gloves and used the hand gel or washed her hands before providing resident care. During an interview on 12/4/24 at 10:30 a.m., Staff B, RN, Unit Manager (UM) said she expected staff to wear gloves, gowns, and masks for residents in contact precautions. During an interview on 12/4/24 at 9:05 a.m., the DON said she expected staff to clean their hands between residents. She said multi resident use items should be cleaned and disinfected between residents and staff were expected to follow the posted PPE signs. 2. On 12/4/24 at 8:12 a.m., during medication administration observation, Staff J, LPN entered Resident #27's room, administered medication, on return to the medication cart placed the used blood pressure cuff and stethoscope on top of the medication cart. The items were returned to the case and placed in the medication cart. During an interview on 12/4/24 at 9:01 a.m., Staff P RN said blood pressure cuffs should be cleaned between patient use. On 12/2/24 during meal delivery observation for Resident #104 and Resident # 85, staff did not offer to provide or assist with hand hygiene during tray delivery. On 12/2/24 at 11:42 a.m., in an interview with Resident #104 she said she did not clean her hands before eating lunch and staff never offered or assisted with hand hygiene prior to meals. On 12/2/24 at 11:47 a.m., in an interview with Resident # 85 she said she did not clean her hands before eating lunch and staff did not offer or assist with hand hygiene prior to meals. 3. On 12/4/24 at 9:18 a.m., Staff J, LPN prepared to administer Resident # 4's Victoza and Glargine-yfgn pen-injectors. The rubber septum was not disinfected with alcohol prior to piercing with the needle and administering the medications. After administering the medications Staff J, LPN placed the pen injectors without caps in her pocket and returned the medications to the medication cart. On 12/04/24 at 8:21 a.m., during Resident #93's medication administration observation, Staff J, LPN, removed gloves from the glove box while wearing gloves that had been in direct contact with the resident. At the Resident #93's bedside Staff J, LPN, exchanged gloves. Hand hygiene was not performed after removing gloves and before donning clean gloves. On 12/5/24 at 8:33 a.m., during an interview with the Infection Preventionist (IP), Staff K, RN, and the Regional Nurse Consultant, the DON said staff were expected to clean and disinfect blood glucose machines, and perform hand hygiene before and after glove use. Review of the facility's Infection Prevention and Control Program policy, date implemented, 8/25/22, revised 7/13/23 revealed the following: Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Definitions: Staff includes all facility staff direct and indirect care functions, .who provide care and services to residents on behalf of the facility . Policy Explanation and Compliance guidelines: 1) the designated infection preventionist is responsible for oversight of the program and serves as a consultant for our staff on infectious diseases .2) All staff are responsible for following all policies and procedures related to the program. 4) . Standard precautions: All staff shall assume that all residents are potentially infected or colonized with an Organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facilities established hand hygiene procedures. All staff shall use personal protective equipment PPE according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. A resident with an infection or communicable disease shall be placed on transmission-based precautions. Review of the Centers for Disease Control and Prevention (CDC) revealed .In the absence of manufacturers' instructions, non-critical medical equipment (e.g. stethoscopes, blood pressure cuffs .,) require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination. Ethyl alcohol or isopropyl alcohol . is often used to disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials . and thermometers) and external surfaces of equipment (e.g., stethoscopes and ventilators). However, alcohol evaporates rapidly, which makes extended contact times difficult to achieve unless items are immersed, a factor that precludes its practical use as a large-surface disinfectant. Retrieved on 12/6/24 Cleaning of Medical Equipment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to honor the right of a resident to share a room for two (Resident #1 and #2) of five sampled residents. Findings include: An interview was conducted on 04/17/2024 at 10:16 a.m. with Resident #1. She was observed sitting in her wheelchair at bedside, alert, able to answer questions, and she agreed to an interview. Resident #1 confirmed her family member, Resident #2, was living at the facility. She stated she would like to room with Resident #2. Resident #1 said, They will not put us together because they will mix up the medications. Resident #1 confirmed Resident #2 lived on the same floor of the nursing home in a different hall. A review of Resident #1's clinical chart, the face sheet, documented her being admitted to the facility on [DATE]. A review of Resident #1's Psychology encounter notes, dated 02/05/2024, documented, chief complaint: depression, anxiety history of present illness: this provider is present for follow-up psychotherapy to address symptoms for depression and anxiety. Patient endorses feeling down, unhappy, frustrated, lonely. Patient reports feeling anxious and worrisome. Patient reports that feeling and being disconnected from close family exacerbates her symptoms of depression and anxiety. Patient endorses feeling the symptoms nearly every day of the week in the past 2 weeks. Summary of session: Patient endorsed experiencing feelings of anxiety and depression on the date of service. Quality of life concerns . Patient expresses desire to move in with her (Resident #2), who also lives in the facility, if possible. On 04/17/2024 at 11:14 a.m. interview was conducted with the Social Service Director (SSD). When asked about Resident #1 and Resident #2 rooming together, the SSD stated, They have asked. Nursing has concerns, the chance of a medication error with the same last name. We were afraid [Resident #1] would try to help [Resident #2]. Resident #2 is bed bound. They visit every day. When the SSD was asked if the clinical chart reflected documentation of the request and the reason it had not occurred, she was observed to review Resident #1 and #2's electronic clinical file. The SSD stated, They never came to me directly, [Resident #1 or Resident #2] to ask for the room change. I think it was nursing that told me. The SSD stated she reviewed both Resident #1 and Resident #2's clinical chart and did not see any documentation of a request for rooming together. The SSD stated, Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM) had the discussion with the family, unfortunately, she did not write it down. An interview conducted on 04/17/2024 at 1:42 p.m. with Staff A, LPN, UM. She stated, there was a conversation, one day, that she was aware of, 2-3 months ago. The conversation was between Resident #2 and Resident #1. She said, I was in the room with them. I explained to them, I worried about [Resident #1] getting up to help [Resident #2]. I told them that I am scared of the medication errors, staff not paying attention to last name and first name. I did not document. I have not talked to them separately. A review of Resident #2's clinical chart documented an admission of 07/28/2023. On 04/18/2024 at approximately 12:00 p.m., Resident #2 returned a phone call. She stated she had moved to the facility to be with Resident #1. She stated she wanted to have Resident #1 as her roommate, she had been requesting the arrangement since both had been at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a prompt effort to resolve a grievance regarding a roommate for one (Resident #1) of five sampled residents. Findings included: A review of Resident #1's clinical chart, the face sheet, documented her being admitted to the facility on [DATE]. An interview was conducted on 04/17/2024 at 10:16 a.m. with Resident #1. She was observed sitting in her wheelchair at bedside, alert, able to answer questions, and she agreed to an interview. Resident #1 confirmed her family member, Resident #2, was living at the facility. She stated she would like to room with Resident #2. Resident #1 said, They will not put us together because they will mix up the medications. Resident #1 confirmed Resident #2 lived on the same floor of the nursing home in a different hall. When asked about her current roommate, Resident #1 rolled her eyes. My roommate blinks and she gets what she wants. The television is fine right now, but she will turn it up for religious shows. She will have them turn up the temperature to 80 degrees. Resident #1 voiced she did not care for her roommate. A review of Resident #1's Psychology encounter notes, dated 02/05/2024, documented, chief complaint: depression, anxiety history of present illness: this provider is present for follow-up psychotherapy to address symptoms for depression and anxiety. Patient endorses feeling down, unhappy, frustrated, lonely. Patient reports feeling anxious and worrisome. Patient reports that feeling and being disconnected from close family exacerbates her symptoms of depression and anxiety. Patient endorses feeling the symptoms nearly every day of the week in the past 2 weeks. Summary of session: Patient endorsed experiencing feelings of anxiety and depression on the date of service. Quality of life concerns raised include feeling uncomfortable due to the level of heat in her room, stating it exacerbates her cough. Client also reported feeling uncomfortable in her current living situation due to discord with her roommate who she described as being demanding, and irritable. Patient expresses desire to move in with her daughter, who also lives in the facility, if possible. A review of the facility Grievance log from 01/01/2024 through the date of survey reflected no concerns documented regarding Resident #1's discord with her roommate. An interview was conducted on 04/17/2024 at 1:42 p.m. with Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM). When asked how Resident #1 got along with her current roommate, Staff A, LPN stated, It is an iffy situation. They do not hardly talk to each other. [Resident #1] has alleged that her stuff has been moved closer to the wall by her roommate. [Resident #1] has complained about the volume of her roommate's television. For the stuff being moved over, I myself, have moved stuff back. I have told [the roommate] to keep her stuff on her side. It has probably been a month ago. For the television, the [roommate] likes to keep her tv on all the time. I have explained to her that it should go off at 10:00 p.m. so, [Resident #1] can sleep. [The roommate] will turn it down, but she will not turn it off. I have not heard [Resident #1] say anything about the tv at night. When Staff A was asked if she had reviewed the concerns documented in the 02/05/2024 Psychology encounter notes, she stated she had not looked at the psych notes, I will from now on. A review of the facility's Resident and Family Grievances policy and procedures, last revised 03/02/2023, documented the policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The procedure included: a. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form b. Forward the grievance form to the Grievance Officer as soon as practicable. c. The Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . d. The Grievance Officer, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. .The facility will make prompt efforts to resolve grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure care and services for intravenous (IV) sites was provided in accordance with professional standards of practice for two (#6 and #7) of three residents sampled for intravenous therapy. Findings included: A review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, bipolar disorder, and dementia. A review of Resident #6's physician's orders revealed an order, dated 2/1/2024 for Ertapenem Sodium solution 1 gram intravenously (IV) every morning for infection, for a duration of seven days. Resident #6's physician's orders did not reveal orders related to the assessment, patency, or changing of dressings for Resident #6's IV site. A review of Resident #6's progress notes did not reveal notes related to the assessment, patency, or changing of dressings for Resident #6's IV site. A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of hypertension, anxiety disorder, and venous insufficiency. A review of Resident #7's physician's orders revealed an order, dated 2/3/2024 for Avycaz 2.5 grams intravenously (IV) every morning for urinary tract infection, for a duration of ten days. Resident #7's physician's also revealed an order, dated 2/2/2024 for normal saline flush of 10 milliliters (ml) IV, every shift and as needed for urinary tract infection. Resident #7's physician's orders did not reveal orders related to the assessment or changing of dressings for Resident #7's IV site. An interview was conducted on 2/5/2024 at 1:15 PM with Staff C, Licensed Practical Nurse (LPN) and Unit Manager (UM), who was Resident #6's assigned nurse on 2/5/2024 for the 7:00 AM to 3:00 PM shift. Staff C, LPN UM stated residents with IV sites should have orders for dressing changes of the IV site, flushing of the IV line to ensure patency, and assessment of the site every shift. Staff C, LPN UM reviewed Resident #6's physician's orders and addressed Resident #6 did not have orders related to the assessment, patency, or changing of dressings for the IV site. An interview was conducted on 2/5/2024 at 1:34 PM with Staff D, LPN, who was Resident #7's assigned nurse on 2/5/2024 for the 7:00 AM to 3:00 PM shift. Staff D, LPN stated Resident #7 was receiving IV antibiotics due to being diagnosed with a UTI and the resident should have orders in place for dressing changes of the IV site, flushing of the IV line to ensure patency, and assessment of the site every shift. Staff D, LPN reviewed Resident #7's physician's orders and addressed Resident #7 did not have orders related to the assessment or changing of dressings for Resident #7's IV site. Staff D, LPN stated nursing staff should be documenting assessment of the IV site every shift. A telephone interview was conducted on 2/6/2024 at 11:30 AM with the facility's Director of Nursing (DON). The DON stated unit managers and the Assistant Director of Nursing (ADON) should be ensuring IV related orders are in place and residents with IV's should have orders for monitoring the site for signs and symptoms of infection or infiltration every shift. The DON also stated residents with IV's should have orders in place to change the IV dressing weekly and to flush the IV line to ensure the line is patent. A review of the facility policy titled Intravenous Therapy, with an implementation date of 12/2/2023, revealed under the section titled Policy the facility will adhere to accepted standards of practice regarding infusion practices. The policy also revealed under the section titled Compliance Guidelines IV sites are changed every 72 hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs and symptoms of phlebitis. In the event the IV is left in place for longer than 72 hours, IV site care will be done every 24 hours. The policy also revealed a doctor's order is obtained before starting IV therapy and IV documentation is recorded in the nurse's notes and/or Medication Administration Record (MAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control and prevention program to prevent the spread of infection by 1.) failing to ensure a sufficient supply of Personal Protective Equipment (PPE) was made available outside of resident rooms under transmission based precaution for two (#8 and #9) of six residents in the facility under transmission based precautions; 2.) failing to ensure staff donned appropriate PPE before entering the rooms of residents on transmission based precautions for two (#8 and #9) of six residents in the facility under transmission based precautions; 3.) failing to ensure residents under transmission based precautions had physician's orders in place for two (#8 and #9) of six residents in the facility under transmission based precautions; and 4.) failing to ensure a resident with a transmissible disease was placed on transmission based precautions for one (#6) of seven residents in the facility with transmissible diseases. Findings included: A review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, bipolar disorder, and dementia. A review of Resident #6's Lab Results Report revealed a urine culture dated 1/30/2024. The urine culture revealed Resident #6's urine tested positive for presence of Extended Spectrum Beta-Lactamase (ESBL). A review of Resident #6's physician's orders revealed an order, dated 2/1/2024 for Ertapenem Sodium solution 1 gram intravenously (IV) every morning for infection, for a duration of seven days. Resident #6's physician's orders did not reveal orders related to transmission based precautions. A review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses of peripheral vascular disease, type 2 diabetes mellitus, and anxiety disorder. A review of Resident #8's emergency department documents dated 1/27/2024 revealed Resident #8 presented to the emergency room from the facility with cough, shortness of breath, and increased weakness. Resident #8 tested positive for influenza A and was returned to the facility on 1/27/2024. A review of Resident #8's physician's orders did not reveal orders related to transmission based precautions. A review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses of congestive heart failure, cerebral palsy, and hypertension. A diagnosis of hemophilus influenza was added on 1/28/2024. A review of Resident #9's progress notes dated 1/28/2024 at 8:39 PM revealed Resident #9 was readmitted from the hospital with diagnoses of acute respiratory failure and hypoxia. A review of Resident #9's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form with an admission date of 1/26/2024 and a discharge date of 1/28/2024, revealed under Section F: Infection Control Issues, Resident #9 was being returned to the facility under contact and droplet isolation precautions. A review of Resident #9's physician's orders did not reveal orders related to transmission based precautions. A tour of the facility was conducted on 2/5/2024 at 12:10 PM. A observation of Resident #6's room revealed the resident was not under transmission based precautions. No PPE or signage was observed outside of Resident #6's room. An observation of Resident #8's room revealed signage indicating the resident was on contact/droplet isolation precautions. Instructions on the sign revealed staff perform hand hygiene, don an isolation gown, don a mask and eye cover, and don gloves when entering the resident room. An caddy containing PPE was observed outside Resident #8's room. The caddy contained isolation gowns, a box of large sized gloves, and a box of extra large sized gloves. Eye protection and masks were not observed on the caddy outside of Resident #8's room. Staff A, Certified Nursing Assistant (CNA) was observed entering Resident #8's room. Staff A, CNA was not observed donning any PPE before entering Resident #8's room. An interview was conducted with Staff A, CNA upon exiting Resident #8's room. Staff A, CNA stated Resident #8 was on transmission based precautions due to testing positive for influenza A. Staff A, CNA also stated she did not don any PPE before entering Resident #8's room because she was told by Staff C, Licensed Practical Nurse (LPN) and Unit Manager (UM) the PPE was not required unless they were giving care to the resident. Staff A, CNA stated she was only going into the room to check on the resident and did not perform care on the resident. During the interview, Staff B, Personal Care Assistant (PCA) was observed entering the room of Resident #9. An observation of Resident #9's room revealed signage indicating the resident was on contact/droplet isolation precautions. Instructions on the sign revealed staff perform hand hygiene, don an isolation gown, don a mask and eye cover, and don gloves when entering the resident room. An caddy containing PPE was observed outside Resident #9's room. The caddy contained isolation gowns and a box of surgical masks. No gloves or eye protection were observed in the caddy outside of Resident #9's room. Staff B, PCA was observed walking out of Resident #9's room and looking at the signage outside of the room indicating Resident #9 was on contact/droplet precautions. Staff B, PCA was observed walking down the hallway, then re-entered Resident #9's room without donning any PPE before entering. An interview was conducted following the observation with Staff B, PCA. Staff B, PCA stated they are educated to don appropriate PPE before entering the room of a resident on transmission based precautions and the PPE should be donned any time they enter the room. Staff B, PCA also stated he did not don PPE before entering Resident #9's room because he did not see the signage outside of Resident #9's room. During the interview with Staff B, PCA, Staff C, LPN UM was observed entering Resident #9's room. Staff C, LPN UM did not don PPE before entering Resident #9's room. An observation was conducted on 2/5/2024 at 1:15 PM outside of Resident #9's room. Staff C, LPN UM was observed donning an isolation gown and a surgical mask before entering Resident #9's room. Staff C, LPN UM was wearing eye glasses at the time of the observation but was not observed donning eye protection before entering Resident #9's room. An interview was conducted with Staff C, LPN UM following the observation. Staff C, LPN UM stated Resident #9 was on contact/droplet isolation precautions due to a diagnosis of influenza A and staff must don a mask, gloves, and an isolation gown before entering the room. Staff C, LPN UM also stated she did not don eye protection because she was told her eye glasses were sufficient as eye protection. Staff C, LPN UM stated she sanitized her eye glasses with hand sanitizer after leaving the room of a resident under transmission based precautions, but that was not part of her infection control training. Staff C, LPN UM stated any resident under transmission based precautions should have a physician's order in place for the precautions. Staff C, LPN also stated if staff entered the room and were not providing direct care to the resident, they were not required to don PPE when entering the room of a resident on transmission based precautions. Staff C, LPN reviewed Resident #8 and Resident #9's physician's orders and addressed the residents did not have orders in place for transmission based precautions. Staff C, LPN also reviewed Resident #6's urine culture dated 1/30/2024 and addressed Resident #6 should be placed on contact isolation precautions due to ESBL in the urine. An interview was conducted on 2/5/2024 at 3:19 PM with the facility's Infection Control Preventionist (ICP). The ICP stated any resident diagnosed with influenza would be placed on droplet precautions. The ICP also stated to enter a room of a resident on droplet isolation precautions, staff would have to don a mask and an isolation gown before entering the room. The ICP stated she was not sure if eye protection was required to enter the room of a resident on droplet precautions and stated I'll have to check. The ICP also stated if staff were unsure of what they needed to don before entering the room they could speak to herself or the facility's Director of Nursing (DON). The ICP stated either the floor nurses, supervisors, or the central supply staff should be ensuring the isolation carts outside of the resident rooms have a sufficient stock of PPE and carts should be stocked before staff enter the resident's room. The ICP stated facility staff were only required to don PPE if they were providing direct care to a resident and stated droplets could not be transmitted if the staff member is only going into the room to collect a meal tray. The ICP also stated all of the guidance she provides related to infection prevention and control is based on the facility policy. A telephone interview was conducted on 2/6/2024 at 11:28 AM with the DON. The DON stated if a resident had a urine culture test positive for ESBL, the resident would be placed on contact isolation precautions. The DON also stated if a resident tested positive for influenza, the resident would be placed on droplet isolation precautions. The DON stated she would expect facility staff to don a face shield, mask, isolation gown, and gloves any time they enter the room because they are exposing themselves before they go into the room. The DON also stated regular eye glasses are not considered eye protection and a face shield or goggles should be worn over the eye glasses. The DON stated PPE is kept in the central supply room but any staff member can get PPE for the carts when they need it. The DON also stated the facility infection control practices are based on Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) guidelines. A review of the facility policy titled Infection Prevention and Control Program, last revised on 7/13/2023, revealed under the section titled Policy the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines all staff are responsible for following all policies and procedures related to the program. The policy revealed under the section titled Isolation Protocol a resident with an infection or communicable disease shall be placed on transmission based precautions. A review of the facility policy titled Transmission-Based (Isolation) Precautions, with no effective date, revealed under the section titled Policy it is the facility policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen's mode of transmission. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines facility staff will apply Transmission-Based Precautions in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The policy revealed the following under the section titled Initiation of Transmission-Based Precautions: - An order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. - The order for transmission-based precautions/isolation will specify the type of precautions and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. The policy revealed the following under the section titled Contact Precautions: - Contact Precautions is intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. - Healthcare personnel caring for a residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. - Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. The policy revealed the following under the section titled Droplet Precautions: - Droplet precautions is intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Photographic evidence was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care consistent with professional standards of practice related to assessments and promoting the healing of pressure ulcers for two (#1, #2) of three sampled residents. Findings included: 1. A review of clinical records showed Resident #1 was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the admission face sheet showed diagnoses which included but was not limited to displaced transverse fracture of shift of right tibia, displaced fracture of lateral malleolus of right fibula, orthopedic aftercare, end-stage renal dialysis, muscle weakness, protein-calorie malnutrition, and a history of falling. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact); Section GG, Functional Abilities and Goals showed dependent in toileting and bathing; Section M, skin conditions showed Resident #1 did not have one or more unhealed pressure ulcers / injuries which included unstageable, Deep tissue injury; showed she had a surgical wound. Review of the admission / readmission Nursing Evaluation dated 10/25/2023 revealed under C. Skin Integrity: dialysis port to right upper chest, AV fistula in right upper arm, fracture to right foot (had surgier), redness to left leg and left heel and redness/ discoloration to right arm from IV. Very moist skin. Completely immobile. Review of physician order summary and the October and November 2023 Treatment Administration Records (TAR) showed the following: -Bilateral buttock, cleanse with normal saline, pat dry, apply calcium alginate and foam dressing every night for Moisture-associated skin damage (MASD) as of 10/31/23 to 11/04/23 -Bilateral buttock, cleanse with normal saline, pat dry, apply calcium alginate and foam dressing daily for MASD from 11/04/23 to discharge. Bilateral buttock wound care was not documented as performed on 11/03/2023. -Left heel: cleanse with normal saline, pat dry and apply foam dressing every night Monday, Wednesday, Friday for Deep Tissue Injury (DTI) as of 11/01/23 to 11/04/2023. Left heel wound care was not documented as performed on 11/03/2023. -Left heel: cleanse with normal saline, pat dry and apply foam dressing every Monday, Wednesday, Friday for DTI as of 11/06/23 to discharge. Review of the attending physician's new admission note dated 10/26/2023 and 10/30/20 23 showed resident recently hospitalized for RLE [right lower extremity] break secondary to MVA [motor vehicle accident]. She has a cast on her right lower extremity. Skin: no suspicious lesions, warm and dry. Review of the wound care physician initial (new admission) progress note dated 10/30/2023 showed Resident #1 with displaced transverse fracture of the shaft of the right tibia. The resident was presenting with a wound of the left heel, the left buttock, and the right buttock. The resident had a right leg orthopedic cast, making it unable to remove for exam. The left leg with removable ortho boot- able to remove for exam. The DTI of the left heel was 3.5 x 3 x 0.1 centimeters (cms), and it was complicated by the ortho boot in place. The wound was expected to have a delay in healing. The left buttock, MASD, was 1.7 x 1.7 x 0.1, had 100% granulation tissue and was expected to heal. The right buttock, MASD, was 1 x 0.7 x 0.1, had 50% epithelial and 50% granulation tissue and was expected to heal. Review of the wound care physician follow up visit on 11/06/2023 showed the resident resting in bed. Her right leg cast was removed. She currently had ortho boots on bilateral legs. She evaluated the left heel wound, right and left MSDA wounds. The DTI of the left heel was 4.5 x 4.3 x 0.2 with 90% necrotic tissue and 10% granulation tissue in place. The wound was expected to have a delay in healing. The left heel ulcer was debrided during the visit. The left buttock, MASD, was 0.3 x 0.3 x 0.1, had 100% granulation tissue and was improving and expected to heal. The right buttock, MASD, was 2.5 x 2.5 x 0, had 100% epithelial tissue and had no change and was expected to heal. Review of the state form, AHCA-5000-3008, dated 10/16/2023 showed section T, skin care was blank. Review of the Weekly Pressure Wound Note dated 10/31/2023 and 11/06/2023 showed Resident #1 was admitted with the left heel pressure ulcer / DTI. Review of the care plans showed Resident #1 had DTI pressure ulcer to left heel or potential for pressure ulcer development related to immobility as of 11/01/2023. The goal was for the pressure ulcer to show signs of healing and remain free from infection. Interventions included but not limited to administering treatments as ordered and monitor for effectiveness as of 11/01/23. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document stats of wound perimeter, wound bed and healing progress report improvement and declines to the MD as of 11/01/2023. Follow policies / procedures for het prevention / treatment of skin breakdown as of 11/01/2023. Treatment to left heel three times a week as of 11/01/2023. Care plan related to having potential/actual impairment to skin integrity related to right lower extremity surgical wound, MASD to bilateral buttocks. Goals included for skin injury to right lower extremity will be healed. Interventions included but not limited to following facility protocols for treatment of injury as of 11/01/2023. Weekly treatment documentation included measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations as of 11/01/2023. Review of the nursing progress notes revealed the following: On 11/03/2023, Skin Observation progress note showed resident had existing skin impairment. Resident being followed by wound care. On 11/06/2023, an Interdisciplinary team meeting occurred, the resident was currently on therapy services. She was non-weight bearing to the right lower extremity and partial weight bearing to the left lower extremity. An interview was conducted with the Wound Care Physician (WCP), the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 12/11/20223 at 1:25 p.m. The WCP stated she saw Resident #1 twice. The resident had a cast on her right leg and a removable boot on her left leg. The WCP stated she does not see post-surgical wounds for at least 90 days post operative. For the first 90 days the resident belongs to the surgeon. The WCP stated she does not change the surgeon's orders or give any orders related to the surgical site. The surgeon will evaluate the surgical site and give any new or changed orders. The DON stated Resident #1 was admitted on [DATE] and verified there were no wound care orders for the wounds until 11/01/2023. The DON verified after reviewing the medical record there was no documentation of an assessment or description of the left heel on admission except the left heel had some redness. The DON verified there was no documentation related to the buttocks on the admission even though the first wound care note dated 10/30/2023 referred to the buttocks MASD being present on admission. The DON stated the admission was performed by the Licensed Practical Nurse (LPN) and a Registered Nurse (RN) note was not found showing a skin assessment was performed including staging of the left heel pressure area. The DON stated the left heel and buttocks MASD should both have been considered wounds on admission. The DON stated there was not an assessment nor orders put into place for the heel or buttocks from 10/25/23 to 10/31/23. The DON verified she was unable to find any reference to the boot on the left lower extremity on the admission. There was no documentation regarding the boot or cast on her lower extremities. Continuing the interview with the DON at 3:30 p.m. she stated the nurse performing the admission should be assessing the wound / pressure ulcer, including describing it at the time and obtaining wound care orders. If an LPN performs the admission, then an RN should reassess for staging of the wound. The DON stated, We have an RN in the building every day. She stated when a wound needed consultation, a referral was sent to the WCP, including the face sheet and an order was put into place for the wound consultation. She stated they discuss all admissions in the morning meetings and a wound admission would generate a wound care consult order. Review of the facility's policy, Wound Treatment Management, implemented on 08/25/2022 showed that to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 5. Treatment decisions will be based on: a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental. iv. Atypical. B. characteristics of the wound: i. pressure injury stage. ii. Size-including shape, depth, and presence of tunneling and / or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. C. location of the wound. D. goals and preferences of the resident / representative. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Considerations for needed modifications included: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. Review of the facility's policy, Skin Evaluations, dated 08/22/2022 showed it is our policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. Policy and Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin evaluation will be conducted by a licensed or registered nurse upon admission / re-admission, and weekly thereafter. The Evaluation may also be performed after a change of condition or after any newly identified pressure injury. 3. Consider the general status of the resident's skin. A. color. B. temperature. C. moisture status. D. sensory perception. E. skin texture / turgor. F. perfusion. 7. Documentation of skin assessment: a. includes date and time of the assessment, your name, and position title. B. document observations. C. document type of wound. D. describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). E. document if resident refused assessment and why. F. document other information as indicated or appropriate. Review of the facility's policy, Comprehensive Care Plans, dated 09/7/2022 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. 3. the comprehensive care plan will describe, at a minimum, the following: a. the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. F. resident's specific interventions that reflect the resident's needs and preferences . 2. Review of the clinical record revealed Resident #2 was initially admitted to the facility on [DATE] with a readmission on [DATE] after a hospital admission. Resident #2 diagnoses included End Stage Renal Disease with Dialysis, Type 2 Diabetes Mellitus, Intestinal Fistula and multiple ulcerations of both right and left feet and toes. A review of the quarterly Minimum Data Set Assessment completed on 09/22/2023 identified the resident as having intact cognition (Brief Interview for Mental Status score of 13/15) and four venous and/or arterial ulcers. A review of the state form AHCA-3008, dated 10/09/2023, identified three areas of concern under the section of Skin Care - Stage & Assessment. The first area listed was open on sacrum. The second and third area identified open areas on the resident's right toes and an abdominal abscess. Further review of the hospital documentation for the resident's hospital admission which ended on 10/09/2023 did not identify a new treatment order for the open area on his sacrum. Upon readmission to the facility, a Licensed Practical Nurse (LPN) completed the Admission/readmission Nursing Evaluation form on 10/09/2023. Under the Vital Signs section of the form, the nurse added under a comment section: pressure ulcer at coccyx. The resident was identified as requiring assistance with his ADLs (activities of daily living to include bed mobility, transfers, dressing, eating, and toileting). Under the Skin Integrity section, the nurse included the pressure ulcer at the sacrum. A review of the nurse's notes from 10/09/2023 when the resident was readmitted until 10/16/2023 revealed no reference to the resident's new open area to the sacrum. Documentation by the WCP on 10/16/2023 revealed evaluation/assessment of eight areas of skin concerns, including the new pressure wound on the sacrum. The pressure wound on the sacrum was described as a deep tissue pressure injury, measuring 1.5 cm x 1.2 cm, without any measurable depth with 100% epithelial tissue. Treatment recommendations for the sacral pressure wound included twice a day zinc application. An interview was conducted with the Director of Nurses (DON) on 12/11/2023 at 3:45 p.m. The DON reported the WCP would have seen Resident #2 due to his history of multiple areas of skin breakdown to his feet and toes. She confirmed the WCP had been following Resident #2 prior to his transfer to the hospital on [DATE] and return on 10/09/2023. The DON confirmed the WCP assessed the open area to the resident's sacrum and ordered the treatment. The DON confirmed it was not apparent an RN provided follow up to the LPN's admission evaluation of the resident. She confirmed there had been no assessment of the new open area on the resident's sacrum until the WCP's assessment on 10/16/2023 and there was no treatment order for the sacrum until 10/16/2023. An interview was conducted with the Director of Nurses (DON) on 12/11/2023 at 3:45 p.m The DON reported the Wound Doctor would have seen Resident #2 due to his history of multiple areas of skin breakdown to his feet and toes. She confirmed the Wound Doctor had been following Resident #2 prior to his transfer to the hospital on [DATE] and return on 10/09/2023. The DON reported the Wound Doctor conducts a full body scan of residents when they return from a hospital admission when she evaluates on going skin concerns. The DON confirmed it was the Wound Doctor who assessed the open area to the resident's sacrum and ordered the treatment. The DON confirmed it was not apparent a Registered Nurse provided follow up to the LPN's admission evaluation of the resident. She confirmed there had been no assessment of the new open area on the resident's sacrum until the Wound Doctor's assessment on 10/16/2023 and there was no treatment order for the sacrum until 10/16/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility did not ensure resident rooms were maintained in a clean and sanitary manner in one (200 Hall) of two halls with housekeeping concerns identified in eight (Rooms 201, 205, 206, 207, 208, 215, 217 and 223) of 31 rooms. Photographic evidence was obtained. Findings included: During a facility tour on 10/17/23 at 09:43 a.m., observations were made of resident rooms with dirt, debris, ants, stained walls, stained floors, ceiling vents with debris and linens/clothes on the floor. room [ROOM NUMBER] was observed with clothes/linens on the floor, bagged and set by the trash can. Ants and food remnants were noted on the floor. room [ROOM NUMBER] was observed with an oversized chair positioned in the corner of the room. The chair was noted soiled, stained and with uncleanable surfaces. room [ROOM NUMBER] was observed with ants on the floor, by the head of the resident's bed. room [ROOM NUMBER] was noted with a bedside table appearing wet on the surface. The resident stated his urine spilled on his table earlier that morning. A spoon was noted on the floor. The floors were noted with dirt and debris. room [ROOM NUMBER] -A bed was noted with two serving size opened butter containers, stashed inside a drawer that was open. Small flying insects were noted flying over and resting on the butter. room [ROOM NUMBER] -B bed was observed with a food plate cover set on the floor by the right side of the bed. The plate cover was noted with dried fluid like substance, indicating it had been sitting there a while. The left side of the bed was noted with yellow, dried clustered matter. room [ROOM NUMBER] was observed with clean clothes/linens set on the floor by a trash can. room [ROOM NUMBER] was noted with clothes on the floor underneath the resident's wheelchair. An observation was made of resident gowns, towels, and personal effects on the floor. room [ROOM NUMBER] was noted with stained floors, walls, and debris under the bed. The bathroom was noted with stained floors, toilet base with brownish matter and the ceiling vent covered with dust and debris. 04/17/23 at 10:26 a.m., an interview was conducted with Staff F, Housekeeping Aide. She confirmed she was assigned the entire second floor by herself. She stated she was cleaning about thirty rooms. Staff F said, it's a lot for one person. It is hard to do a thorough job. We should have at least two people. Staff F stated they were looking for a replacement. On 4/17/23 at 4:43 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) and Staff E, Registered Nurse, Unit Manager. Staff E reviewed photographic evidence obtained and said, we will need to get some work done in these areas. It is not up to our standards. I do not know what is happening with the staffing in the housekeeping department. It is not an excuse. The ADON stated they were in the process of hiring a manager for the housekeeping department. On 4/18/23 at 11:00 a.m., an interview was conducted with Staff G, Housekeeping and Laundry Aide. She stated her responsibility was to schedule staff while they await the hiring of a new manager. She stated they normally have three housekeeping staff working, but one of the staff did not show up. Staff G said, we were short. We were just trying to get by. We do not have a manager. The aides are trying. It is hard for one person to cover the entire floor, there are too many rooms. One staff would not be thorough. I understand. It does not look sanitary up there. On 4/18/23 at 10:45 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing, (DON). The NHA stated they did not have a housekeeping manager and they were in the process of hiring a replacement. He stated that may have an affect on operations. The NHA stated a lead staff member was assisting in managing schedules. The DON stated they had started a thorough cleaning and it would be on-going. The NHA stated they had issues with a call-in and he heard the rooms had housekeeping concerns. The DON said, The new manager will address the issues. One Housekeeper could not have covered all the rooms. I know the floors are stained. They need a good cleaning. We can do better. On 4/18/23 12:51 p.m., an interview was conducted with the Director of Maintenance (DOM). He stated he would go into the rooms, clean up, and get rid of containers with open foods. He stated he normally checked, if after cleaning, they needed to spray for pests/insects. The DOM stated the housekeeping staff cleaned the resident rooms daily. He stated they should not leave open foods because they generate flies. He stated he would follow -up with housekeeping and nursing staff. The DOM stated they treated pests to include ants once a month. He stated they had a contractor who came if they had a problem. The DOM said, This is definitely not up to my standards. I will definitely take care of the ants and get the rooms cleaned. The chair in room [ROOM NUMBER] should not be in the resident's room. It is not cleanable. Review of a facility policy titled, Safe and Homelike Environment, dated 04/01/23, showed in accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Under policy explanation and compliance guidelines, (3.) Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Review of a facility policy titled, Resident Environment Quality, dated 04/03/23, showed the facility is designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. (9.) Maintain an effective pest control program so the facility is free of pests and rodents.

Based on observation, interview, and medical record review, the facility failed to report an allegation of injuries of an unknown source in a timely manner for one (Resident #3) of three sampled residents. Finding included: On 04/17/2023 at 10:30 a.m., Resident #3 was observed sitting up in her Geri-chair in the monitoring room watching staff and peers going in and out. One of the staff members that was present stated in this room they're [residents] monitored at all times. They're high risk for falls. Resident #3 appeared comfortable with her bilateral lower extremities slightly elevated and covered with a blanket. She was not able to answer questions appropriately, cognitive deficit was noted. At 12:15 p.m. Resident #3 was in the dining room positioned at a table. She was using a built-up spoon in her right hand as she was eating her lunch independently. Her right hand was noted with a slight tremor as food occasionally dropped onto her clothing protector. A staff member approached her and was over heard as she asked her if she wanted additional fluids. Resident #3 stated yes. She was not able to verbalize which flavor she wanted as three different options were offered. Resident #3's facial expression changed as she grimaced and clenched tightly to her spoon, she looked at the staff member and in a loud voice stated, leave me alone. On 04/17/2023 at 1:00 p.m., Resident #3 was observed sitting in the monitoring room. The Director of Nursing (DON) was asked about Resident #3 legs. Resident #3's bilateral lower shins were observed bare at the time. Her shins revealed multiple areas of scattered discolorations of pale purple, tan, green, and yellow. Additionally, the hem of her pants contained an elastic material that was embedded into the skin. The DON adjusted the resident's hem of her pant legs and confirmed swelling was present. She additionally confirmed her feet were swollen and instructed staff members her legs should be elevated. On 04/18/2023 at 10:00 a.m., Resident #3 was observed lying in bed as a staff member stated he was going to transfer her into her chair. The resident appeared confused as she watched the staff member. Her hands were clenched on the bed canes. The bed control was clipped on the right bed cane. The call light cord was draped over the head of the bed. Resident #3's bilateral lower extremities from the top of her knees to the bottom of her shins revealed pale purple, tan, green and yellow areas that covered over 80 % of the skin. Review of the admission Record form reflected Resident #3 had resided at the facility for over three years. The form listed primary diagnoses as unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and hypertension. Review of Physician orders reflected two routine oral medications. One for diabetes mellitus and the second one for constipation. Further review of medical records reflected no history of edema or swelling to the lower extremities, and no history of diuretic or anticoagulant (blood thinner) use. Taber's Medical Dictionary: A traumatic injury (usually to the skin but sometimes to internal organs) in which blood vessels are broken but tissue surfaces remain intact. Discoloration, swelling, inflammation, and pain are typical signs and symptoms. Fresh bruises on the skin are often red or purple. Older bruises may turn green and then yellow or brown, as the blood products within them age and are reabsorbed, but gauging the age of a bruise by its color is imprecise, at best. Bruising in older adults is more often an indication of the use of anticoagulant drugs. https://www.tabers.com/tabersonline/view/Tabers-Dictionary/767873/all/bruise. Review of Progress notes dated 04/03/2023 at 5:34 p.m. (17:34), revealed Type: Skin observation progress note Resident skin is clear no impairment. On 04/07/2023 at 05:03 a.m. Type: Skin observation progress note Resident skin is clear no impairment. On 04/09/2023 at 1:43 p.m. (13:43), complain of bilateral lower extremity discomfort. Author: Staff A Registered Nurse. On 04/10/2023 at 1:16 p.m. (13:16) This writer was notified that [family member] was upset about discoloration on [the resident's] lower legs and not being notified. This writer apologized and updated [family member] with findings of discoloration and not being notified. Physician (MD) was notified and new orders received for an x-ray of bilateral legs due to pain and discomfort and order to scheduled Tylenol BID for general discomfort. On 04/10/2023 at 3:37 p.m. (15:37), Due to bill [sic] pain. New ordered received. X-ray to bill [sic] knees. Order fax to radiology. On 4/11/2023 at 8:02 p.m. (20:08) Type: Skin observation progress note: Resident has a new skin impairment. Existing bruise Right lower leg (front) -Bruising: Width=, Left lower leg (front) -Bruising: Width=, Resident has new skin impairment. Right lower leg (front) -Discoloration BLE, Left lower leg(front)- Discoloration bilateral lower extremities (BLE) Responsible party notified Author: Assistant Director of Nursing. On 04/11/2023 at 02:33 a.m. Type: Orders Progress Note X-ray of bilat knees done results in at this time showing nothing really acute with resident please update MD in am. Osteopenia to both knees. On 04/11/2023 at 1:18 p.m. (13:18), This writer spoke with POA about X-ray results and update on [resident's] current condition. POA was happy that Tylenol was effective and updated at this time Author: Director of Nursing. On 04/16/2023 at 2:26 p.m. (14:26) Type; Narrative Nursing Note Resident noted to have swelling to left foot and ankle. Shoes removed and non-skid socks applied, and feet elevated in chair on pillow. Md made aware and family at bedside. On 04/17/2023 at 3:45 p.m., an interview was conducted with the Assistant Director of Nursing (ADON), Interim Director of Nursing, (DON), and the Nursing Home Administrator (NHA). The ADON stated, On 04/09/2023 the [family member] stated that [the resident] was complaining of knee discomfort. She saw the discoloration on both legs. Her shins were yellowish and green in color. The [family member] was upset that she was not informed. The ADON said, We think it was from the over the bed table. She indicated the table had matched up the same to both legs. She said on the same day statements were started. We went back to check on her the next day 04/10/2023 and the resident was playing with the bed remote, and the table was on her legs. She said the agency nurse did not call the DON, NHA nor the ADON. On 4/10/2023 we talked to the [family member] about the bruising and swelling and told her we would look into it. The ADON said we had spoken to the [family member] two separate times. She was okay, the only concern was that she was not informed of the injury/bruises. The [family member] seemed fine. The NHA stated, On 4/14/2023 I was under the impression after the multiple conversations that were conducted with the [family member] it was resolved. The NHA confirmed there was a delay in reporting an allegation of abuse. The ADON went on to say that the [family member] seemed fine. Then on 04/14/2023, we got a notification that the police were in the building and taking pictures. The NHA stated that was when we filed the immediate reporting, indicating it was five days after the injuries were first identified. On 04/18/2023 at 10:26 a.m., a phone interview was conducted with Staff A, Registered Nurse she said she knew Resident #3 and recalled her [family member] had approached her on 04/09/2023. She said, I was standing in the hallway at the medication cart when she asked me about [the resident's] legs. I went into the bedroom, and she showed me her [the resident's] legs. She confirmed both of the resident's lower extremities were discolored, it looked like it could be bruising, but not fresh bruising like it had been already reported. There appeared to be swelling as well. Staff A stated, I palpated, her shins above the ankle, I saw her facial grimacing as she stated 'ow'. Staff A stated I notified the on-call person right away to see if there was going to be an investigation and what I needed to do. Staff A said the House Manager came to the unit and looked at the resident. Staff A said the House Manager informed me she contacted the Manager on Duty. Staff A said she wrote a statement as requested and let the [family member] know they would be looking into the matter. She went on to say she sent text messages to the Manager on Duty, asking what she needed to do going forward in the process. Staff A said, I was notified by the Manager on Duty it would be taken care of. On 04/18/2023 at 10:30 a.m., an interview was conducted with Staff H, Scheduler. She confirmed she was the House Manager on 04/09/2023. She said she was notified by Staff A of a family member asking about [Resident #3]. She said she went to the resident's bedroom and saw the marks on her legs. She said, I called the Manager on Duty and was advised to get statements from the staff members that worked that day and the previous staff members as well. Staff H stated, After I took a picture of [Resident #3 legs], I texted it to the Manager on Duty. The Manager on Duty said she was going to contact the ADON and they handled it from there. On 04/18/2023 at 10:43 a.m., an interview was conducted with Staff I, Licensed Practical Nurse, Unit Manager. She confirmed on 04/09/2023, she was the Manager on Duty and was notified about Resident #3's change in condition. She said the House Manager (Staff H) contacted her and she said she instructed her to look at the resident. Staff I said the House Manager had sent her a picture of Residents #3 legs. Staff I said the picture looked like the bilateral legs were discolored not purple but bluish yellow. It looked old. Staff I went on to say she was the Unit Manager of Resident #3's hall and denied knowing of any incident or accident that had occurred to the resident. She was unaware of what could have caused the bruising to her legs. She said I forwarded the picture to the ADON who said she would take care of it. On 04/18/2023 at 11:17 a.m., a phone interview was conducted with the ADON. She confirmed she was notified about Resident #3's change in condition on 04/09/2023. She said the[family member] was visiting the resident and was complaining of not being notified of the bruising. She stated I spoke with my regional nurse. She asked me if I had notified anyone yet, and to do skin sweeps to see if any other residents had concerns. The ADON stated, most likely it was from the chair. Also, ninety percent of the time her legs are crossed. And most of the time she is in the bed. She is rarely out of bed. The ADON went on to say she [Resident #3] fights a lot; she yells in the shower. Then she stated, I talked with the regional nurse it was determined it was the over the bedside table. She was informed Resident #3's medical record failed to reflect concerns with the over the bedside table and the resident's legs. She stated, not everything like that is documented. She said she was aware of the two-hour reporting, but had direction that they had twenty-four hours to figure out where the bruises came from. She said the [family member] was not alleging abuse only that no one told her about it. The ADON confirmed she did not come into the faciltiy to assess the resident. She stated, I assumed it was from the table. The ADON went on to say she also called and spoke with the DON and Staff A to determine where the bruises came from. She confirmed she did not know at that time where the bruises came from. The ADON said the DON told her they would continue the investigation on Monday. The DON was present during the phone interview with the ADON. She stated, I was not notified of [Resident #3's] bruises until the following day, Monday at the morning meeting. She reiterated that was the first time she had heard about it from the ADON. She went on to say I was out of the state on 04/09/2023 and was unreachable. On 4/18/2023 at 1:15 p.m. the NHA indicated abuse reporting should have been initiated. He said the Abuse Prevention Coordinator was the DON. On the weekend of the incident, it was the ADON. Review of the facility policy titled, Abuse, Neglect and Exploitation date implemented 9/7/22. Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to 1. Resident, staff or family report abuse. 3. Physical injury of a resident, of unknown source. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be in a criminal investigation; 3. Investigating different type of alleged violations; 4. Identifying and interview all involved persons; including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but no later than 2 hours after the allegation is made, it the events that caused the allegation involve abuse or result of serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards for for (Residents #2, #14, #11, and #15) of eight residents related to 1. failure to schedule a medical appointment for Resident #2, 2. delayed assistance after meal for Resident #14. 3. ensuring catheter dignity for Resident #11, and 4. inappropriate dentures storage for Resident #15. Findings included: 1. On 04/17/23 at 3:40 p.m., Resident #2 was observed in her room with long unkempt toenails. Resident #2 could not explain if she had received any nail care during her stay. A review of the resident's electronic medical record did not show any evidence of podiatrist appointments. On 04/17/23 at 3:42 p.m., an interview was conducted with Staff E, Registered Nurse (RN), Unit Manager (UM). Staff E observed Resident #2's toenails and stated they did not look like they had been trimmed recently. She stated she had noticed the nails were long and had asked the SSD (Social Services Director) to put her on the list of residents to be seen by the podiatrist. She stated the podiatrist came once a month, but they have had problems with them rescheduling. She stated she would make sure the resident was seen. Staff E confirmed the resident's long toenails should have been trimmed. Review of Resident #2 admission record showed the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, unspecified dementia and need for assistance with personal care. A minimum data set (MDS) dated [DATE], showed C, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive response impairment. Section G, Resident #2 requires extensive assistance for Activities of Daily Living (ADLs) and required one-person physical assistance for personal hygiene and bathing. Review of Resident #2's active physician orders, dated 04/18/23 did not show orders to consult with podiatry. A care plan for Resident #2 dated 10/25/22 showed the resident had an ADL self-care deficit related to Alzheimer's, dementia, and impaired balance. Interventions indicated Resident #2 required staff assistance by one for personal hygiene and oral care. The interventions did not indicate interventions for nail care. On 04/17/23 at 3:55 p.m., an interview was conducted with the SSD. She stated she could not find any documentation showing the resident had seen a podiatrist since her admission. The resident was originally admitted on [DATE] and was readmitted on [DATE]. She stated she just put the resident on the podiatrist list the previous week because a family member had asked that she be seen because her toenails were long. 2. On 04/17/23 at 10:00 a.m., Resident #14 was observed lying on his bed, awake. He stated he had eaten breakfast earlier in the morning. Resident #14 was observed still wearing a clothing protector from breakfast. The clothing protector was noted with breakfast foods on the surface. The resident could not remove the clothing protector by himself. Review of an admission record for Resident #14 showed the resident was admitted to the facility on [DATE] with diagnoses to include metabolic Encephalopathy, abnormal posture, need for assistance with personal care, muscle weakness, hemiplegia, unspecified affecting left non dominant side, contracture, left elbow and functional quadriplegia. A MDS for Resident #14 dated 01/17/23, showed section G, functional status showed the resident required extensive assistance for dressing and personal hygiene. A care plan for Resident #14 dated 05/20/21, showed the resident had a self -care deficit with dressing and grooming, related to impaired left upper/lower extremities ROM (range of motion), generalized weakness, (CVA) cerebrovascular accident with left hemiparesis, hemiplegia, chronic pain syndrome and contractures. Interventions included providing hands on assistance with dressing, grooming, bathing s needed. 3. During a facility tour on 04/17/23 at 10:02 a.m., Resident #11's catheter was observed from the hallway, exposed, and without a cover. Resident #11 was unaware his catheter was visible to the public. A review of Resident #11's admission record showed the resident was admitted to the facility on [DATE] with a primary diagnosis of subsequent encounter of displacement of other urinary catheter, other retention of urine. A MDS dated [DATE] showed Resident #11 had a BIMS score of 04, which indicated severe cognitive impairment. Section G showed the resident required extensive assistance for ADLs (activities of daily living) and was dependent on staff for toilet use and personal hygiene. Review of active physician orders for Resident #11 showed to monitor and secure catheter to prevent pulling, position catheter below bladder, cover with dignity bag, position away from the view if urine is visible in bag, order date 10/12/22. A care plan for Resident #11 dated 05/06/22 showed an ADL focus indicating the resident has a self-care deficit related to generalized weakness, dementia, and recent fall. Interventions showed the resident required assistance of one for ADLs and required assistance of one for toileting. On 04/17/23 at 10:03 a.m., an interview was conducted with Staff B, Certified Nurse's Assistant (CNA). She stated Resident #11's catheter should not have been exposed. She stated she would get a privacy bag. 4. During a tour on 04/17/23 at 10:04 a.m., Resident #15 was observed in his bed. The resident did not respond to the interview. Resident #15's dentures were noted in a clear plastic bag inside the top drawer of his bedside table. The resident did respond to the question if he wore them or not. A review of Resident #15's admission record showed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified protein-calorie malnutrition and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A MDS dated [DATE] showed under section C, the resident had severe cognitive impairment. Section G, functional status showed Resident #15 required extensive assistance for personal hygiene, with one-person physical assist. A care plan for Resident #15 showed the resident had a self-care deficit with dressing, grooming, bathing related to CVA with right hemiparesis/hemiplegia. Interventions included providing total staff assistance with dressing, grooming, and bathing. On 4/17/23 at 4:43 p.m., an interview was conducted with the Assistant director of nursing (ADON) and Staff E, RN Unit Manager (UM). The ADON stated she had spoken to Resident #2's family member. She wanted to see when the resident could be seen by a podiatrist. The ADON stated the SSD had added her to the list of residents to be seen. Staff E confirmed she saw Resident #2's toenails and had noted they were overgrown. The ADON stated the process was for the CNA to report concerns to the nurses, the nurses followed up with the UM, and then the ADON. The ADON stated the nurses were expected to make note of the area of concerns on their communication board for follow -up and add the resident to the list of residents to be seen. Staff E confirmed resident's catheters should not be exposed. Staff E said, it is supposed to have a cover for dignity reasons. She stated she would follow -up and make sure all catheters had covers. On 4/18/23 12:20 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated he could not believe Resident #2 had not had a podiatrist appointment. He stated he would follow -up with the SSD. The DON said, No, catheters should not be exposed. We have ordered more bags and covers. I made sure all catheters in house have privacy bags. The DON stated, resident's dentures should be on them during the day, unless there are concerns. The DON said, They should have them on while eating. They should not be stored in plastic bag inside a drawer. She stated she would follow -up. Review of a facility policy titled, Promoting/Maintaining Resident Dignity, dated 09/07/22, showed it is the practice of this facility to protect and promote residents right and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines showed an expectation to (6) respond to requests for assistance in a timely manner. (9) groom and dress residents according to resident preferences (12) maintain resident's privacy. Review of an undated facility policy titled, Resident Rights, showed the resident has the right to a dignified existence, self-determination, in communication with an access to persons and services inside and outside the facility. Under planning and implementing care, the resident has the right to receive the services and/or items included in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility did not ensure call lights were within reach in one (Hall 200) of two halls, for five (Residents #9, #10, #11, #12 and #13)of ten residents. Findings included: 1. On 04/17/23 at 09:43 a.m., Resident #9 was observed in his room in bed. The resident did not respond to the interview. Resident #9's call light was observed on the floor between his bed and the bedside table. Review of Resident #9's admission record showed the resident was admitted on [DATE] with diagnoses to include Alzheimer's, Dementia, psychotic disorder, and history of falling. A Minimum Data Set (MDS) dated [DATE] showed resident #9's Brief Interview for Mental Status (BIMS) score was not indicated. Section C1000 indicated the resident was severely impaired. Section G showed the resident required extensive assistance for ADLs (activities of daily living) and was dependent on staff for bed mobility and transfers. A care plan dated 10/24/22 showed an ADL focus which indicated the resident had a self-care deficit related to Alzheimer's, Dementia, mood disorder and anxiety. Interventions included encouraging resident to keep call light within reach and to provide ADLs assistance as needed. 2. On 04/17/23 at 10:01 a.m., Resident #10 was observed in his bed and his call light was on the floor. Review of Resident #10's admission record showed the resident was admitted on [DATE] with diagnoses to include lymphedema and muscle weakness. A MDS dated [DATE] showed Resident #10's BIMS score was not evaluated. A care plan dated 06/08/21 showed a self-care deficit with dressing, grooming, and bathing related to impaired mobility related to generalized weakness and limited endurance. Interventions included providing hands-on assistance as needed. 3. On 04/17/23 at 10:02 a.m., Resident #11 was observed in bed. The resident did not respond to the interview. Resident #11's call light was noted clipped to the foot of the bed, not within reach. A review of Resident #11's admission record showed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, muscle weakness, major depressive disorder, and a history of falling. A MDS dated [DATE] showed resident #11 had a BIMS score of 04, which indicated severe cognitive impairment. Section G showed the resident required extensive assistance for ADLs (activities of daily living) and was dependent on staff for bed mobility and transfers. A care plan dated 05/06/22 showed an ADL focus which indicated the resident had a self-care deficit related to generalized weakness, dementia, and recent fall. Interventions showed the resident requires assistance of one for ADLs. 4. On 04/17/23 at 10.11 a.m., Resident #12 was observed in his bed. The resident did not respond to the interview. Resident #12's call light was noted under his bed, not within reach. A review of Resident #12's admission record showed the resident was admitted to the facility on [DATE] with diagnoses to include metabolic Encephalopathy, morbid (severe) obesity, muscle weakness, repeated falls, difficult in walking, major depressive disorder, and brief psychotic disorder. A MDS dated [DATE] showed Resident #12 had a BIMS score of 03, which indicated severe cognitive impairment. Section G showed the resident required extensive assistance for ADLs (activities of daily living) and was dependent on staff for bed mobility and transfers. A care plan dated 10/28/22 showed an ADL focus which indicated the resident had a self-care deficit related to weakness, cognitive impairment, dementia, mood disorder, anxiety, and recurrent falls. Interventions showed the resident required assistance of one for ADLs, do not fall signage as a reminder to call for assistance, encourage resident to use bell to call for assistance. 5. On 04/17/23 at 10.28 a.m., Resident #13 was observed in her bed with the call light under her bed. The resident did not respond to the interview. A review of Resident #13's admission record showed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, major depressive disorder, generalized anxiety and need for assistance with personal care. A MDS dated [DATE] showed Resident #13 had a BIMS score of 99, which indicated the resident was severely impaired and unable to complete the interview. Section G showed the resident was totally dependent on staff for transfers and required extensive assistance for ADLs. A care plan dated 07/06/22 showed an ADL focus which indicated the resident had a self-care deficit related to Alzheimer's, confusion, and dementia. Interventions showed the resident required assistance of one for ADLs. On 04/17/23 at 10:03 a.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She confirmed the residents' call light should be placed within reach, per their practice. On 04/17/23 at 10:37 a.m., Staff C, CNA was observed responding to call lights and turning them off. She stated to a resident, I'll be back. In an interview with Staff C, she stated she turned off the call lights because she knew the resident's routines and had a system of how she managed her assigned tasks. She stated the expectation was to ensure resident's call lights were placed where they could reach them. She stated she made sure she reset the call lights and clipped it where the resident could reach it. On 04/17/23 at 10:55 a.m., Staff D, CNA was observed responding to a call light. Staff D confirmed all residents should have access to their call lights. She stated they were normally clipped to the residents head of the bed, or where they can easily access them. On 04/17/23 at 4:43 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) and Staff E, Registered Nurse (RN) Unit Manager (UM). The ADON stated call lights should be within reach at all times. She said, Even after beds are made, the position of the call light should be visible. Staff E stated she would conduct a walk-through and ensure all call lights were operational and within reach. On 4/18/23 at 12:20 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated residents' call lights should be within reach and answered in a timely manner. They stated they would address the issue. The DON stated call lights should be accessible so the residents could alert staff of their needs. The DON stated Staff E had initiated in-services and ensured all call lights were within reach. Review of a facility policy titled, Call Light: Accessibility and Timely Response, dated 03/03/23, showed the purpose is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure an appropriate response. Under policy explanation and compliance guidelines, (3). Staff will ensure the call light is within reach of resident and secured as needed. (4). The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. (5). the call system should be accessible to a resident lying on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and record reviews, the facility failed to provide the Resident/Resident Representative with a copy of medical records within two working days for two residents (#1 and #2) of eight sampled residents. Findings include: A review of the facility's policy and procedure titled Release of Medical Records, dated [DATE], indicated the following: Policy: Medical records will be released with a valid request and in accordance with state and federal laws. Explanation and Compliance Guidelines: 1. Medical Records are a collection of documents prepared and maintained during the course of a resident's stay in the facility that records the clinical/medical care of the resident. These documents can be written or electronic information and include progress notes, physician orders, nursing notes, consultations, laboratory and diagnostic reports, and plans of care . 2. Requests for records should be referred to the Director of Nursing or Administrator, or another staff member previously designated by the facility. 3. Upon request to access or obtain copies of the medical record, the facility should review the authorization to ascertain access rights of that person. Authority to access or release records is only granted by the resident or the resident's legal representative. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records. .6. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that records are available 2 days after receipt of payment of the copies . Access Rights to Medical Information are as Follows: 1. The Resident (current resident)-the resident's record is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following an oral or written request. The resident is encouraged to review the record in the presence of attending physician or a representative of the facility. the resident may have designated a legal representative who can exercise the same rights as the resident. The resident or his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made . On [DATE] at 4:14 p.m., a phone interview was conducted with Resident #1's family member. She reported she had requested Resident #1's medical records from the facility. I did not receive her medical records, filled out umpteen forms. A review of Resident #1's admission record, documented an admission of [DATE], with a readmission of [DATE]. The record reflected she was discharged from the facility on [DATE]. The admission record reflected Resident #1 had a family member who was listed as the Emergency Contact #1, Responsible Party, and Health Care Proxy. On [DATE] an interview was conducted with the Social Service Director (SSD) and the Social Service Assistant (SSA). They provided a grievance form, dated [DATE], submitted by Resident #1's family member, which indicated one of her grievances was wants medical records. The grievance form did not have an indication of whether the grievance was marked resolved or unresolved, but it was signed by the Nursing Home Administrator on [DATE]. A review of the facility Grievance log indicated the grievance was resolved as of [DATE]. During the interview with SSD and SSA, the SSA stated the grievance form indicated the medical records had been provided. A review of Resident #2's medical record reflected an admission of [DATE] and subsequent discharge of [DATE]. On [DATE] at 3:45 p.m., a phone interview was conducted with Resident #2's family member. She reported she had requested Resident #2's medical records from the facility. She stated she had been Resident #2's Health Care Surrogate. She said, she had filled out a form to request the medical records, originally, and provided it to the facility in July or [DATE]. It took them so long to communicate back with me, but, when they did, she was told the form was outdated, and another form would need to be filled out. She said the form had more intense questions she was unsure of. She had meant to follow up with the person at the facility, (the Medical Records Clerk). She said she could not remember if she had provided the facility the 2nd form or not. The last time she communicated with the facility was [DATE]. On [DATE] at 9:30 a.m., an interview was conducted with the Medical Records Clerk. When asked if she maintained a log of the medical record requests, she stated, somewhat. She indicated she could get a list together. She stated some of the requests, she may not have, corporate would have fulfilled the request. On [DATE] at 11:24 a.m., the Medical Records Clerk provided a log, Authorization for Release of Medical Records log, for the time period of [DATE] through the date of survey, [DATE]. Residents #1 and #2 were not on the list. When asked if the records had been requested for either of these residents, the Medical Records Clerk stated, she recalled a request had been made for both of the residents. She confirmed neither was on the list that was provided. For Resident #1, she would look. For Resident #2, she stated, she thought they were just waiting on something from the daughter's lawyer. She stated, when the resident is deceased , there is an additional step that has to be fulfilled. She thought the daughter had POA (Power of Attorney), but, then the resident died. The Medical Records Clerk was asked to provide any documentation of communication with the family members. On [DATE], 12:01 p.m., an interview with the Medical Records Clerk was conducted. She provided an additional Authorization for Release of Medical Records log, with two names on the list, Resident #1 and Resident #2. For Resident #1, the log indicated a request had been submitted on [DATE], and the release of records date column, indicated a date of [DATE]. For Resident #2, the log indicated a request had been submitted on [DATE], and the release of records date column, indicated a date of [DATE]. When asked if she had any document, receipt, that would indicate the resident or family member had signed for the medical records, she stated the date of release of record date was when she had forwarded the request to the corporate office and she herself had not actually provided the medical records to the family. No documentation of a receipt from the family member was provided during the survey.

Based on record reviews and interviews, the facility failed to ensure a prompt resolution was provided for a grievance related to a medical records request, and an allegation of missing money, for one resident (#1) of eight sampled residents. Findings include: On 2/06/2023 at 3:24 p.m. an interview was conducted with the Social Service Director (SSD) and the Social Services Assistant (SSA) . A review of a grievance dated 8/12/2022, for Resident #1, submitted by the resident's family member was conducted. The grievance indicated the family member wanted Resident #1's medical records and indicated Resident #1 had $100.00 missing from her account. During the interview, the SSA stated the grievance form indicated the medical records had been provided. A review of the grievance form reflected documentation, medical request docs provided. The form was signed by the Nursing Home Administrator on 9/12/2022. For the $100.00 missing, the form had no indication of when the money had gone missing or a resolution. During the interview, the SSD stated, the nursing facility had changed hands in 5/01/2022 and there was a discrepancy in the monies. The SSD said, this meant, the previous ownership of the facility had a mishandling of funds. Once the company changed hands . (she trailed off), the administrator can better clarify that situation. The SSD said, according to the paperwork, she could not say if a resolution had been found regarding the missing $100.00. A review of Resident #1's Patient Trust Account, for the period of 5/24/2022 thru 2/01/2023, reflected on 5/24/2022, Resident #1 had a starting balance of $87.81. The account reflected no credits or debits up until 2/01/2023. An interview was conducted with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) on 2/07/2022 at 1:20 p.m. and the BOM stated she was only able to see the patient trust value back until 5/24/2022. This was due to the company changing ownership. A review of Resident #1's admission record, documented an admission of 10/28/2021, with a readmission of 6/02/2022. The record reflected she discharged from the facility on 12/09/2022. The admission record reflected Resident #1 had a family member who was listed as the Emergency Contact #1, Responsible Party, and Health Care Proxy. On 2/03/2023 at 4:14 p.m., a phone interview was conducted with Resident #1's family member. She reported she had requested Resident #1's medical records from the facility. I did not receive her medical records, filled out umpteen forms. On 2/06/2023 at 9:30 a.m., an interview was conducted with the Medical Records Clerk. When asked if she maintained a log of the medical record requests, she stated, somewhat. She indicated she could get a list together. She stated some of the requests, she may not have, corporate would have fulfilled the request. On 2/06/2023 at 11:24 a.m., the Medical Records Clerk provided a log, Authorization for Release of Medical Records log, for the time period of 6/01/2023 through the date of survey, 2/06/2023. Residents #1 was not on the list. When asked if the records had been requested for Resident #1 the Medical Records Clerk stated, she recalled a request had been made for Resident #1. She confirmed Resident #1's name was not on the list provided but she would look. The Medical Records Clerk was asked to provide any documentation of communication with the family member. On 2/06/2023 at 12:01 p.m., an interview was conducted with the Medical Records Clerk. She provided an additional Authorization for Release of Medical Records log, that had two names on the list, Resident #1. For Resident #1, the log indicated a request had been submitted on 8/04/2022, and the release of records date column, indicated a date of 8/26/2022. When asked if she had any document, receipt, that indicated the resident or family member had signed for the medical records, she stated the date of release of record date was when she had forwarded the request to the corporate office and she herself had not actually provided the medical records to the family. No documentation of a receipt from the family member was provided during the survey. A review of the facility's policy and procedure titled Resident and Family Grievances, dated 01/22/23, indicated the following: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance.g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09/12/22 at 10:00 a.m. an observation was made on Resident # 42 lying flat in his bed, underneath a flat sheet, dressed in his night clothes. Resident #42 was not assisted out of bed and was not engaged in any activities. On 09/12/22 at 11: 00 a.m., Resident #42 was observed in bed lying flat, dressed in his night clothes. When asked what time he would be getting up today, Resident #42 stated he would like to get out of bed but would not be able to get up until next week because he uses a Hoyer lift to get up, and he has to wait on his friend to come to the facility to push him around in his wheelchair. On 09/14/22 at 11:30 a.m. Resident 42 was observed in bed lying flat. Resident #42 expressed he would like to get out of bed and restated he would have to wait on his friend to come to the facility so he can get around in the wheelchair. Review of resident # 42's EMR showed resident # 42 was admitted to the facility on [DATE] with diagnosis, Metabolic Encephalopathy, Myocardial Infarction, Obstructive and Reflux Uropathy, need for Assistance with Personal Care, Contracture, Left Hip, Contracture, Left Knee, Disorder if the Autonomic Nervous System, Unspecified. A quarterly minimum data set (MDS) for Resident #42, dated 7/17/22 Section C revealed a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Section B - revealed for bed mobility Resident #42 requires extensive assistance, one-person physical assist. Resident #42 is totally dependent with two-person physical assist for ADLs to include transfers and dressing. Under Functional limitation, Resident #42 has upper and lower extremity impairment on one side. Section O revealed the resident is not on any special treatment, procedures, and programs The resident is not receiving any therapy services. A care plan for Resident # 42, dated 7/21/22 revealed the resident has an alteration in comfort related to neuropathy, diagnosis of Cerebrovascular accident, contractures, wounds, generalized discomfort, chronic pain syndrome, and impaired mobility. The goal showed resident will voice an acceptable level of comfort thru the next review date. The Intervention showed activities as tolerated, observed for proper body alignment when in bed/chair; assist with repositioning as needed. A focus under falls showed Resident #42 is at risk for falls and or fall related injury related to generalized weakness, is non ambulatory, uses a wheelchair as primary mode of locomotion with an intervention to assist Resident #42 wheel to destinations. On 09/15/22 at 10:54 a.m. an interview was conducted with Staff M, CNA. Staff M assisted Resident 42 and out of his bed today. Staff M said the last time he got Resident #42 out of bed was three weeks ago when he was assigned to him. On 09/15/22 at 11:32 a.m., an interview was conducted with Staff N, Lead CNA, Staff N stated she has not seen Resident# 42 up out of bed recently. On 09/15/22 at 11:46 a.m. an interview was conducted with Staff O, CNA. Staff O said today was her first time seeing Resident #42 out of his bed. On 09/15/22 at 11:53 a.m., an interview conducted with Staff B, LPN agency. Staff B stated she has only seen resident #42 out of bed one time when a family member was visiting. 09/15/22 at 12:46 p.m. an interview was conducted with the DON. The DON confirmed Resident #42 expressed to her that he would like to get out of bed. The DON stated that the resident reported having difficulty pushing his wheelchair around and was waiting on his friend to come and assist him. The DON stated the resident was anticipating his friend to visit the following week. The DON stated she notified Resident #42 that staff would be able to get him out of bed. The DON stated staff would assist Resident #42 ambulate as needed. The DON stated residents have the right to get out of bed if they wish, and that staff should assist. Review of a facility policy titled, Activities of Daily Living (ADL's) dated , 9/7/22, Showed the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living (2) Transfer and ambulation. Under policy Explanation and Compliance Guidelines: (3) A resident who is unable to carry out activities of daily living will receive the necessary services . 3. On 09/12/22 at 7:58 a.m. Staff I, Certified Nursing Assistant (CNA) left Resident #102's breakfast tray at the bedside to assist the roommate into the hallway. Staff I returned to feed Resident #102 and went back out of the room for a second time to get a gown to cover the resident during her breakfast meal. When Staff I returned to feed Resident #102, Staff I was observed kneeling at bedside on Resident 102's right side. Review of the admission Record revealed Resident #102 was admitted to the facility on [DATE] with diagnoses to include a history of Parkinson's disease, and neurocognitive disorder with Lewy Bodies. Review of the September 2022 physician's orders for Resident #102 showed a Regular Diet with regular texture and thin liquids and fortified foods at all meals, with a start date of 2/26/22. A review of the Quarterly Minimum Date Set, dated 08/22/22, showed in Section G - Functional Status for eating Resident #102 was Total dependence - full staff performance every time during entire 7-day period, with one person physical assist. The current care plan for Resident #102, dated 03/02/22 and with a revision date of 06/07/22, showed [Resident #102] was at risk for an alteration in nutrition and/or hydration r/t (related to): anemia, significant weight loss, Parkinson's disease, Lewy Body Dementia, and variable PO (by mouth) intake. Interventions included to provide tray set up and assist as needed. On 09/14/22 at 11:52 a.m., Resident #102's lunch tray was observed at the bedside and Resident #102 was awake and stated she had a big appetite. A continued observation at 12:10 p.m. revealed the lunch tray still at the bedside and no one was present to assist Resident #102 with her meal. On 09/14/22 at 12:25 p.m. Staff K, CNA entered into the room to assist Resident #102 with the meal. On 09/14/22 at 12:40 p.m. Staff K was observed standing over Resident #102 feeding her. Staff K stated Resident #102 took her time but did eat most of her food. On 09/14/22 at 1:50 p.m. an interview was conducted with Staff I, CNA and Staff K, CNA and they both stated hand hygiene was to be done and they are to sit facing the resident when feeding a resident. Both Staff I and Staff K confirmed all CNAs assist with handing out trays and then whoever is assigned to a resident that needs to be fed; they will then go to feed them. On 09/14/22 at 2:46 p.m. an interview was conducted with the Registered Dietician, (RD). The RD stated Resident #102 was noted as total assistance with meals. On 09/14/22 at 3:01 p.m. an interview was conducted with the Director of Physical Therapy who stated Resident #102 had a decline in physical ability and was not capable of feeding herself. On 09/14/22 at 3:14 p.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff E stated the staff was to sit facing the resident while they fed them. Based on observations, interviews and policy review, the facility failed to ensure meals were served in a dignified manner related to staff standing when assisting residents with meals, during 2 of 2 observations for Residents #14 and #102, and failed to ensure assistance out of bed was provided per resident's choice for Resident # 42. Findings included: 1. On 09/14/22 at 08:58 a.m. an observation was made of Staff L, certified nurse's aide, (CNA) [name of agency]. Staff L was observed standing over Resident #14 during breakfast meal assistance. Resident #14 was observed already assisted to her whole bowl of oatmeal. Staff L stated resident was eating well this morning. Resident #14's room was noted not having a chair. A follow -up interview was conducted on 09/14/22 at 09:11 a.m. with Staff L. Staff L states she has been an agency CNA many years and understands the expectations related to meal assistance. Staff L stated Resident #14 is fully dependent on staff for feeding. Staff L said, I was supposed to have sat when assisting her with the meal. Staff L stated when she started assisting Resident #14 with meal, she had noticed there was no chair in the room. Staff L said, I didn't get it. Staff L states she likes to stand sometimes. Staff L said, they tell us to sit at eye level. Review of the electronic medical record (EMR) for Resident #14 showed the resident was admitted on [DATE] with a diagnosis to include vascular dementia, unspecified, Dysphagia, need for assistance with personal care, type 2 diabetes, unspecified atrial fibrillation, heart failure, peripheral vascular disease, age related osteoporosis, other recurrent depressive disorders, and essential hypertension. A care plan for Resident #14 initiated on 07/06/22 showed an activities of daily living (ADL) deficit related to Alzheimer's, confusion, and dementia. An intervention initiated on 07/06/22 showed Resident #14 requires assist x1 staff for eating. On 09/14/22 at 09:07 a.m., Staff N, CNA observed Staff L standing while assisting Resident #14 with her breakfast meal. Staff N stated she [Staff L] should not be standing. Staff N went got a chair from the room next door and brought it to Staff L. Staff N confirmed CNAs should sit during meal assist. Staff N said, we should sit for dignity reasons. An interview was conducted with Staff Q, personal care attendant (PCA) on 09/14/22 at 09:08 a.m. Staff Q stated she does not assist residents with meals but knows from training that CNAs should not be standing over residents. On 09/14/22 at 09:18 a.m., an interview was conducted with Staff R, licensed practical nurse (LPN). Staff R stated the expectation is they (CNAs) to sit at eye level. Staff R stated she is an agency nurse and was not sure if this facility has a different expectation. States, generally you sit at eye level. On at 09/14/22 at 09:24 a.m. a follow up was conducted with Staff P, LPN, Unit Manager (UM). Stated for meal assistance, staff are to make sure the bed is elevated, resident is positioned accordingly and then sit at eye level when assisting with meal. Staff P stated their expectation is to provide a dignified experience. When asked how agency CNAs are supposed to know this, Staff P stated, when they come in the morning, they tour with a lead CNA and are orientated to their resident's needs and the unit expectations. States before they come to the building, the assistant director of nursing, (ADON) conducts an orientation which includes reviewing facility policies. On 09/14/22 at 12:54 p.m., an observation was made of Staff S, CNA assisting Resident #14 with lunch meal while standing. It was noted there was no chair in the room. In a follow -up interview with Staff S, on 09/14/22 at 12:59 p.m., Staff S, stated she should be sitting at eye level. Staff S stated she should have grabbed a chair. On 09/14/22 at 01:05 p.m., an interview was conducted with Staff T,CNA Staff T stated the meal service protocol is to knock, wash hands and assist resident with set up. If they need feeding assistance, you sit down and assist them with meal. Staff T stated the expectation is to sit at eye level. Staff T said, it is undignified to stand. An interview was conducted on 09/14/22 at 12:59 p.m. with Staff D, LPN. Staff D stated CNAs should definitely sit and be at eye level. States the expectation is to not stand. Staff D stated she would follow -up with the aide. A follow -up was conducted on 09/14/22 at 04:49 p.m., with the director of nursing, DON. The DON was notified of dignity concerns during meals for two residents. The DON stated the CNAs should not be standing over residents. The DON stated the expectation is for the CNAs to sit at eye level. The DON stated they have been trained. On 09/14/22 at 04:50 p.m., a follow up was conducted with the Regional Clinical. The Regional Clinical stated Agency staff are expected to know the basic health care protocols such as hand hygiene and not standing over residents. States when they come to the facility, they review facility policies. The Regional Clinical stated maybe they should put together a short, quick bullet point presentation with the basics that agency staff should review prior to starting the shift. A facility policy titled, meal supervision and assistance, dated 09/07/22 showed the resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes identifying hazards and risks, evaluating, and analyzing hazards and risk, implementing interventions to reduce hazards and risk, monitoring for effectiveness and modifying interventions when necessary. Review of a facility policy titled, Promoting / maintaining Resident dignity, dated 9/7/22, showed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under compliance guidelines, (5.) when interacting with a resident, pay attention to the resident as an individual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow their policy to store medications appropriately in four of six medication carts (First and Second Floor Halls), failed to appropriately secure medications for two (Residents #49, and# 67) of two residents; and did not ensure removal of one expired medication from one (Memphis Hall Cart) of six medication carts and one medication from one (First Floor Medication Room) of two medications rooms. Findings included: 1. On 09/13/2022 at 9:36 a.m., an observation of Resident #49's room was observed. During the observation, a glove was seen next to the resident's arm while he was lying in bed. The resident was asked about the glove, and he stated, No it's my medicine. Resident #49 moved the glove to show a clear medication cup with two round white pills in it. Resident #49 revealed that he was saving the Melatonin tablets from the previous night's mediation administration at bedtime, to take later in the day. Staff A, Licensed Practical Nurse (LPN)-Agency, confirmed the presence of the unsecured medications, and stated I did not know they were there. During a record review of active physician orders, Resident #49 did not have a physician order to self-administer medications. On 09/15/2022 at 10:15 a.m., an observation of a medication cart on the Memphis Hall included one expired over the counter medication Glucosamine Chondroitin, with expiration date 08/22, in the first drawer from the top of the medication cart. Further observation of the medication cart revealed in the second drawer from the top, seven loose pills, and in the fourth drawer from the top of the medication cart, 4 loose pills. Staff B, (LPN)- Agency confirmed the presence of eleven loose medications, and one expired medication. Photographic evidence obtained On 09/15/2022 at 10:35 a.m., an observation was made of a medication cart located on the Atlanta Hall, that included one loose orange capsule in the second drawer from the top of the medication cart. Staff C, (LPN) Agency confirmed the presence of the loose medication. On 09/15/2022 at 10:45 a.m., an observation was made of a medication cart located on the New [NAME] Hall, included ½ white loose tablet in the second drawer from the top of the medication cart. Staff R, (LPN) confirmed the presence of the loose medication On 09/15/2022 at 11:00 a.m., an observation of a medication cart located on the Natchez Hall included eleven and a half loose pills in the medication cart, and one tube of Santyl Collangeses Ointment on the side of the drawer, next to oral punch card medications. Staff D, (LPN)-Agency confirmed the presence of the loose medications and tube of ointment and stated, This is my first day working this cart. Observation of the Medication Room located on the first floor was conducted on 09/15/2022 at 11:29 a.m., with Unit Manager, (LPN). During the observation one expired medication of C Tubercul PPD unit/0.1 Milliliters (ML) with expiration date of 09/12/22. Photographic evidence obtained. On 09/15/2022 at 12:29 p.m., an interview was conducted with the Director of Nursing (DON). She was informed of all observations made. The DON indicated staff informed her prior to the interview, of expired medications, and unsecured tablets found in the medication carts on both floors of the facility The DON revealed her expectation would be nursing staff checked medication carts when they came on the assignment, and supervisors checked on the 3:00 p.m.-11:00 p.m. and 11:00 p.m.-7:00 a.m. shifts. The DON further revealed the Unit Managers should check during the medication carts during their rounds, and daily audits should be conducted to make sure there were no expired medications in the carts. 1. A facility provided policy titled Medication Storage, dated 08/25/22, Page 01 of 02 under Policy Explanation and Compliance Guidelines revealed: 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) b. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication's storage area/cart. 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications. 2. On 09/14/22 at 8:27 a.m., Resident#67 during an interview was complaining of an upset stomach and burping. A round orange pill that was broken in half was observed laying on the resident's breakfast tray. Resident #67 stated it was from last night and he would take it later. Staff H, Licensed Practical Nurse (LPN) was called into resident's room to show her the medication found on Resident #67's breakfast tray. Staff H stated she did not give the resident any medication today and then told the resident he could not hold medications. Staff H picked up the medication, which she stated was an antacid, and said she would place the medication in the pill buster. On 09/14/22 at 11:50 a.m. Resident #67 stated he had been belching for a couple of days now and was waiting for the doctor to call the nurse with an order. On 09/14/22 at 11:52 a.m. during an interview with Staff H, LPN she stated she spoke with Resident #67's doctor and was able to get an order for Pepcid daily and Staff E Unit Manager/ (Licensed Practical Nurse) brought the pill buster and the medication found at Resident #67's beside was disposed of. Review of the admission Record revealed Resident #67 was admitted to the facility on [DATE] and then was readmitted on [DATE]. Resident #67's diagnoses included Type 2 diabetes mellitus without complication, atrial fibrillation (new diagnosis from 9/1/22 readmission), anemia in chronic kidney disease, and chronic kidney disease stage 3. Review of the physicians' orders for September 2022 did not show did not show an order for antacids or an order for the resident to self-medicate.

Based on observations, staff interviews, and facility file review, the facility failed to ensure a safe, clean, comfortable, and homelike environment in one of two main dining rooms and two of two community showers/shower chairs as evidenced by 1. The tables where residents eat were not cleaned and wiped down between and after each meal service during two of four days observed, 4/12/2021 and 4/13/2021. 2. The facility also failed to ensure that shower chairs were cleaned between and after resident use, during four of four days observed, 4/12/2021, 4/13/2021, 4/14/2021 and 4/15/2021. Findings included: 1. On 4/12/2021 at 11:30 a.m., the second floor main dining room was observed with two rooms, one large and one small. Staff were observed to assist resident seating in both rooms with ensuring the residents were socially distant from one another. Observations revealed that five out of eleven tables were not wiped and sanitized prior to this lunch meal. Observations revealed small piles of spent food debris, red sticky substance and brown sticky substance. Photographic evidence was taken. There were thirteen residents seated at nine of the eleven tables, five of which were soiled. On 4/13/2021 at 7:51 a.m., the second floor main dining room was observed. During that time, there were no residents in either of the small or large rooms. However, observations revealed that three of the five tables from the previous day, were still soiled with the same food debris and pink, brown sticky substances. It was noted, after using a wet paper towel, the red sticky areas were not stains on the table, but rather a dry/sticky liquid substance. On 4/13/2021 at 9:15 a.m., an interview with the Housekeeping Director revealed that it was the housekeeping staff's responsibility to clean the dining rooms after each meal service. She confirmed the tables were sticky with red liquid substance and food debris. She indicated that she did have newer staff on the floor but all areas needed to be routinely cleaned by staff. She did not have specific documented cleaning schedules to show how often the dining room was cleaned. 2. On 4/13/2021 at 9:43 a.m., the second floor community shower room was observed. There were three shower stalls with white and blue plastic and blue fabric shower chairs. Observations revealed two of two shower chairs had pink, yellow, and black biogrowth at and near the four legs and joint areas near the wheel castors. The blue fabric netting was observed with brown biogrowth and the netting was fraying. Photographic evidence was taken. On 4/13/2021 at 9:54 a.m., the first floor shower room was observed with three shower stalls and one white and blue plastic and fabric shower chair. Observations revealed the four legs and joints were observed with heavy black and pink biogrowth. Photographic evidence was taken. Observations during two more tours in both the first floor and second floor community shower rooms on 4/14/2021 at 8:20 a.m. and again on 4/15/2021 at 8:25 a.m., revealed that all three community shower room shower chairs had the same black, pink and yellow biogrowth in the same areas as observed the previous day. On 4/15/2021 at 9:30 a.m., the Housekeeping Director indicated that housekeeping staff were responsible for the deep cleaning of shower room equipment to include shower chairs. She said that nursing staff were responsible for sanitizing after each use, but the housekeeping staff would do deep cleaning for each shower chair on a monthly basis. She confirmed that the shower chairs had black, pink and yellow biogrowth on all four legs and near the wheel castors. She did not have a policy and procedure related to cleaning expectations of community shower chairs.

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #84) of three sampled residents received wound care consistent with professional standards for two in house acquired wounds. Findings Included: Wound care for Resident #84 was observed on 4/15/21 at 10:34 a.m. with Staff E, Registered Nurse (RN) and Staff F, Licensed Practical Nurse (LPN) assisting. Staff E, RN donned gloves without hand hygiene and used bleach wipes to clean the resident's bedside table then doffed gloves. He washed his hands and donned a gown before he began to gather supplies of sterile water, [antimicrobial wound cleanser] solution with 4 x 4' s' for soaking, wound cleanser, cotton tipped applicator, and xeroform with two large foam dressings. At 10:44 a.m., Staff E, RN removed the wound dressing, dated 4/14/21, from Resident #84's lower back and exposed her spine with a wound about the size of a nickel. Staff E, doffed gloves, washed hands, donned gloves, and cleaned the wound pouring the sterile water over the spine onto the 4 x 4' s', then used the wet 4 x 4' s' to clean the wound before drying it. Using the same gloves, he applied Santyl to the cotton tipped applicator and applied it to the wound. He then picked up the saturated gauze to manipulate and place directly on the wound over the Santyl before he applied the 4 x 4 gauze and doffed gloves. Without performing hand hygiene, he removed a pen from his left front shirt pocket and signed the dressing on the resident's back. He washed his hands. Staff E, RN started the right ankle dressing change at 10:53 a.m. He donned gloves and removed the right ankle dressing dated 4/14/21, doffed gloves, washed hands, donned gloves then cleaned the wound with wound cleanser. The wound was the size of a dime with a line of slough in the middle. The wound was dried with a 4 x 4. Staff E, RN used the same gloves to remove more 4 x 4' s from a reusable package, pulled out 3 more 4 x 4' s, and dried the wound. Wearing the same gloves, he cut the xeroform and applied it to the wound then covered it with a large border dressing. Staff E, RN doffed his gloves and gown, without hand hygiene, he donned gloves to get bleach wipes and clean the scissors and the tray table. He doffed gloves and without performing hand hygiene, he took the garbage and emptied it in the dirty utility room. On 4/15/21 at 11:07 a.m., during an interview with Staff E, he confirmed that he should have doffed gloves after cleaning the wound and washed his hands prior to donning new gloves to apply the medication. He confirmed he should not have use contaminated gloves in the reusable 4 x 4 bag. Staff E confirmed that the right ankle wound came from Resident #84 laying on her side trying to stay off her back wound. Staff E, stated he was told by the wound care physician to use sterile water to clean the wound on the spine since he was using Santyl on the wound. Review of physician orders revealed: Right ankle: cleanse with normal saline, apply xeroform and foam dressing every day shift for trauma dated 4/5/21. Cleanse wound on spine with normal saline, apply Santyl then cover with 1/4 strength [antimicrobial wound cleanser] dampened gauze and foam dressing daily, every day shift for wound dated 3/22/21. Review of the skin and wound evaluation dated 4/5/21 revealed an abrasion to the right lateral malleolus. In-house acquired on 4/5/21. The wound measured 0.5 cm x 0.9 cm x 0.7 cm. Review of the skin and wound evaluation dated 4/12/21 revealed an abrasion to the right lateral malleolus. In-house acquired on 4/12/21. The wound measured 0.2 cm x 0.5 cm x 0.5 cm. Review of the skin and wound evaluation dated 4/12/21 revealed pressure wound, unstageable to the spine. In-house acquired a week ago. The wound measured 0.8 cm x 1.1 cm x 1.0 cm. Review of the care plan revealed open area to lower back/spine and coccyx resolved on 9/23/20. Initiated on 8/19/20. Interventions: medications for wound healing as ordered: observe for effectiveness and for side effects. Perform wound care treatments as ordered. (no date initiated) During an interview with the Director of Nursing on 4/15/21 at 2:15 p.m., she confirmed wound dressings should have hand hygiene performed after removing the dressing, cleaning the wound , before applying the medication and dressing, and before and after glove use. Review of the facility policy for wound care, revised October 2010, two pages, revealed: 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. Review of the facility policy for handwashing/hand hygiene, revised August 2019, two pages, revealed: The facility considers hand hygiene the primary means to prevent the spread of infections. 7.k. After handling used dressings, contaminated equipment. 7.m. After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure that respiratory care was provided consistent with professional standards of practice for one (Resident # 37) of two residents reviewed for oxygen use. During a facility tour on 04/12/21 at 9:35 a.m., Resident #37 was observed in her room, oxygen noted in use. Resident #37 stated that she used oxygen as needed, probably about three times a day. Resident #37 was noted to have an oxygen concentrator in her room with cannula and tubing in place. Resident #37 was also observed with a portable oxygen unit behind her wheelchair bag. A review of Resident #37's EMR (Electronic Medical Record) on 04/13/21 revealed no physician's order for oxygen. The EMR revealed only an order to replace oxygen tubing on Tuesday night as needed, initiated on 01/05/21. The record did not indicate any on-going assessment of Resident #37's respiratory status, response to oxygen therapy, or indication for use to include monitoring of rate flow. Resident # 37 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Type 2 diabetes, heart failure, atherosclerotic heart disease, hypertension, and chronic respiratory failure. On 04/13/21 2:51 p.m., an interview was conducted with Staff B, RN, MDS (Registered Nurse, Minimum Data Set.) She was asked if Resident # 37 was on oxygen. Staff B stated, Yes, she has the unit in the room and a portable unit on her wheelchair. Staff B confirmed that Resident #37 was wearing her oxygen at that moment. Staff B also stated that the portable concentrator and the unit in the room are set on 2 liters. Staff B explained that Resident #37 uses her oxygen PRN (as needed.) When asked if she would expect to have a physician's order to administer oxygen, Staff B replied, Yes there should be one in [the] file. After reviewing the EMR with staff B, there was no order for oxygen administration for Resident #37. Staff B stated that she would contact the doctor and get an order. A follow-up interview was conducted with the DON (Director of Nursing) on 04/13/21 at 3:02 p.m. The DON stated that if a resident was on oxygen, there should be a physician's order. The DON stated that the physician's order must be active. She was informed that Resident #37 did not have an order for oxygen. She confirmed that Resident #37 should have had an order. The DON stated that they would contact the doctor to get one. She stated that she would in-service the nurses to ensure there was an order prior to any oxygen administration. A review of the facility's policy titled, Oxygen Administration, Revised October 2010, under title Preparation: (1) Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Under title Documentation: after completing oxygen set up or adjustment, the following information should be recorded in the resident's medical record: (3) The rate of oxygen flow, route, and rationale. (5) the reason for PRN administration. (6) all assessment data obtained before, during and after procedure. (7) How the resident tolerated the procedure. A review of the facility's policy titled, Medication Orders, Revised November 2014, under title Supervision by a physician: (2) a current list of orders must be maintained in the clinical record of each resident. Under title Recording Orders: (3) Oxygen order - when recording orders for oxygen, specify the rate of flow, route, and rationale.

Based on observations, staff interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by 1. failed to ensure one of one low temperature dish machine was operating effectively and per the machine specifications during one of four days observed. 2. failed to ensure one of three facility refrigerators, used by staff and residents, were clean and maintained with packaged outside source food items properly labeled and dated. Findings included: 1. On 4/12/2021 at 9:15 a.m., the initial kitchen tour was conducted with the Certified Dietary Manager (CDM). The CDM revealed the dish cleaning machine was a low temp machine with chemical sanitizer. He along with the kitchen aide, Employee G, confirmed the machine was working and they had already begun washing dishes. Employee G confirmed that the wash cycle temperature should reach 130 degrees F (Fahrenheit) or above and the rinse cycle should reach to 130 degrees F. and above. She was asked to do a demonstration and the following was observed: At 9:20 a.m., the wash cycle reached 130 degrees F and rinse cycle reached 130 degrees F. The CDM provided the aide with a test strip to test the sanitizer. She indicated it should read at 200 PPM (parts per million) . There was a sheet of paper taped to the machine that read; PPM = 50 - 200 ppm. She put the strip in the water return basin and the strip did not turn color, it stayed its original white color. The CDM gave her another strip and again it did not turn color. The CDM provided another type of strip and she tested a fully washed/rinsed basket of tray lids. Again, the strip did not change color. Photographic evidence was taken. The CDM tried to test with a strip himself twice by placing test strips in the water return basin and then once again using a test strip on a newly washed tray lid. Again, the strips did not change color. There was no evidence that sanitizer was getting through to the machine. The CDM confirmed that the strips are not changing in color. One of the strip containers read with an expiration date of 10/2019. He revealed he did not know that the strips expire. It was determined that the test strips were a year and a half past expiration. He said all dishes that had been washed this morning, would be rewashed through the three compartment sink. He said he would call the dish machine maintenance company to come out and take a look at the machine. The CDM was asked to provide the temperature and sanitizer test logs for review during the months of 4/2021 and 3/2021. For the month of 4/2021 all three meal services for days 1 - 11 were documented with sanitizer reaching 200 ppm. There were no variations and staff documented only 200 ppm. For the month of 3/2021 all three meal services for days 1 - 31 were documented with sanitizer reaching 200 ppm. There were no variations and staff documented only 200 ppm. The white sheet of paper taped to the front of the dish machine revealed, PPM (White test strips): 50 - 200. The sheet further indicated, Dip the strip in water after wash/rinse cycle is complete. Compare to outside of dispenser to determine PPM. The CDM revealed that the machine had routine maintenance by the technician about one week prior and he did not indicate there were any problems. The CDM revealed he was fairly new at the facility and thought since the technician did not have any issues, then the PPM was ok to be between a range of 50 - 200 ppm. The CDM agreed that 50 - 200 was a large range. The CDM provided the facility's dish machine installation and operation manual for review. Review of the manual revealed: page #4, Required minimum water temperature to reach 120 degrees F. and recommended water temp to reach 140 degrees F. This would indicate the machine is a low temperature with chemical sanitizer. The manual indicated on page #11, Use only commercial grade detergents and rinse aids recommended by your chemical professional. Do not use detergents and rinse aides from formulated and residential dishwashers. Low Temperature chemical-sanitizing dish machines must not exceed 6% sodium hypochlorite solution (bleach) as the sanitizing agent. Higher levels my damage stainless or components. Follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses. Concentration should be 50 ppm minimum and 100 ppm maximum. If concentration is incorrect contact your chemical supplier. The CDM revealed when the machine technician was out about a week ago, he had to unclog some lines. He said he would call them out again to take a look at it. On 4/13/2021, the technician came out to work on the dish machine. The Dishwashing Preventative Maintenance Report dated 4/13/2021, revealed that the machine sanitizer (low temp only) was at 100 ppm. The CDM revealed that the technician told him that the sanitizer should be between 50 - 100 ppm and not between 50 - 200 ppm. 2. On 4/13/2021 at 8:00 a.m. and 1:37 p.m., the first floor dining/activity room was observed. There was a refrigerator in the room and was observed with no temperature log. Upon opening the refrigerator, there were many unlabeled outside food source containers. There were five containers of what appeared to be outside restaurant food left overs. None of the containers were observed with a date, resident name, or resident room number. Photographic evidence was taken. During a tour of the same first floor dining/activity room with the CDM on 4/14/2021 at 1:45 p.m., he revealed that it was brought to his attention that there was left over food items in the refrigerator the day before. He said that one of his staff members cleaned them out and threw them away today. He said that the refrigerator was usually maintained by nursing and kitchen staff. He indicated kitchen staff log and maintain internal temperatures. The CDM said that there should not be any unlabeled or undated food items in this refrigerator. If food was brought in by family or from outside sources, the left overs should be labeled with room number and date that the resident received the item. Policies and procedure for outside food source and food storage was provided for review. The Foods brought by family/visitors policy with last revision date 10/2007, revealed; Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The interpretation and implementation section, #1 revealed, Family members and visitors are requested to inform nursing staff of their desire to bring foods into the facility. #7 revealed, Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. #7b revealed, Perishable foods must be stored in re-sealable containers with tightly fitted lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.