**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility did not ensure timely Activities of Daily Living (ADL) related to incontinence care for two (#1 and #2) of three residents. Findings include: On 8/08/2024 at 10:30 a.m., an interview and observation were conducted with Resident #2 in his room. Resident #2 was in his bed and when asked when was the last time his incontinence needs were addressed, he stated last night and agreed no one had come in this morning to change him. Resident #2 agreed he needed incontinence care now. On 8/08/2024 at 11:00 a.m., an interview and observation were conducted with Resident #1 in her room. She stated the last time she had her incontinence care addressed was 3:30 a.m. and currently was waiting for her morning needs to be met. Resident #1 agreed she was wet and in need of incontinence care stating, they will get around to it eventually, they are so busy. Resident #1 agreed she felt uncomfortable in her briefs but stated, there is nothing I can do about it. On 8/08/2024 at 11:15 a.m., an interview was conducted with Staff E, Certified Nursing Assistant (CNA). Staff E was unable to give a number of residents assigned to her but stated she had four residents requiring total care. Staff F, CNA refused to be interviewed. At some point, Staff F was replaced by Staff I, CNA after two days of orientation stating this was day three of her orientation. Staff E stated she would be assisting Staff I but was unable to give a number of the newly assigned residents requiring total care, stating, Some days I am able to get my work done and sometimes depending on who you work with it's a struggle. On 8/08/2024 at 11:50 a.m., an interview was conducted with Staff C, CNA and Staff D, CNA. Staff C stated she had eleven residents and of those eleven residents, five were dependent for total care. Staff D stated she had ten residents but could not state how many were total dependent but stated she had 4 more residents to take care of. A record review of Resident #1's admission Record showed an admit date of 4/23/2021 with a primary diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. Secondary diagnoses included but were not limited to adult failure to thrive, muscle wasting and atrophy not elsewhere specified, need for assistance with personal care, other reduced mobility, and history of falling. A review of Resident #1's Minimum Data Set (MDS) dated [DATE], for Section C-Cognitive Patterns showed Resident #1 did not require further mental status assessment based on the resident was able to complete Brief Interview for Mental Status. Section GG GG0130 self -care-Functional Abilities and Goals showed Resident #1 as Dependent for toileting /hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear and substantial/maximal assistance with upper body dressing, and personal hygiene. Section GG0170- Functional Abilities and Goals showed Resident #1 as Dependent for roll left to right, the ability to roll from lying on back to left and right side and return to lying on back on the bed. In Section H-Bladder and Bowel, H0300 and H0400 urinary incontinence and bowel continence showed Resident #1 as always incontinent of bladder and bowel. A review of Resident #1's care plan revised on 3/14/2024 showed a focus area of incontinence of bladder/bowel related to immobility, involuntary or unpredictable bladder and bowel elimination, intolerance of using toilet, bedside commode or urinal, refusal or resistance to participation in any kind of programs. The goal for this focus area included maintain dignity, minimize the risk of infection, and minimize the risk of skin breakdown. The Interventions/Tasks for this focus area included but were not limited to check for incontinence frequently and provide incontinence care as indicated, provide perineal care and apply barrier cream after incontinent episodes and as needed, and observe condition of skin with each incontinent episode. A focus area of ADL Self-Care performance deficit cannot complete ADL tasks independently related to impaired mobility, resident declines to get out of bed routinely. The goal for this focus area included maintaining current level of self-performance with ADLs through the next review. The interventions/Tasks for this focus area included but were not limited to two person staff when providing care, bladder and bowel incontinent and assist of one for bathing in bed. A review of the daily tasks documented by the CNAs shows on 8/08/2024 Resident #1 received toileting care at 1:10 a.m. and no further entries were documented [photographic evidence obtained]. A record review of Resident #2's admission Record showed an admit date of 7/07/2022 with a readmission date of 10/25/2022 with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Secondary diagnoses included but were not limited to dysphagia following cerebral infarction, muscle wasting and atrophy not elsewhere classified left lower leg, and need for assistance with personal care. A review of Resident #2's Minimum Data Set (MDS) dated [DATE], for Section C-Cognitive Patterns showed Resident #2 had a Brief Interview for Mental Status of four which indicated severe cognitive impairment. Section GG GG0130 self-care Functional Abilities and Goals showed Resident #2 as substantial maximal assistance for toileting /hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, eating, oral hygiene, upper body dressing and personal hygiene. Section GG0170- Functional Abilities and Goals showed Resident #2 was Dependent for toilet transfer, tub shower transfer, sit to stand, chair/bed-to-chair transfer, and Substantial/maximal assistance for roll left and right, sit to lying, and lying to sitting on side of bed. In Section H-Bladder and Bowel, H0300 and H0400 urinary incontinence and bowel continence showed Resident #2 as always incontinent of bladder and bowel. A review of Resident #2's care plan revised on 5/28/2024 showed a focus area for incontinence of bladder/bowel and was not a candidate for a toileting program related to involuntary or unpredictable bladder and bowel elimination, decreased cognition. The goal for this focus area was to maintain dignity through next review, minimize the risk for infection and the risk for skin breakdown. Interventions included but were not limited to check for incontinence frequently and provide care as indicated and observe for foul smelling, cloudy urine, change in urinary output, mental status change, changes in bowel pattern and report as needed. The care plan showed a focus area of ADL Self-Care performance deficit related to impaired mobility related to cerebral vascular accident with left-sided weakness and decreased cognitive status. The goal for this focus area would be to maintain current level of self -performance with ADLs through next review. Interventions included but were not limited to personal hygiene, bladder (incontinent) and bowel (incontinent), eating, bed mobility with assist of one. A review of the daily tasks documented by the CNAs shows on 8/08/2024 Resident #2 received toileting care on 8/07/2024 at 7:13 p.m. and 8/08/2024 at 2:59 p.m. and 4:36 p.m. [photographic evidence obtained]. On 8/08/2024 at 5:10 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated staffing was based on the census, and we go above and beyond our numbers, we have an expectation of every two hours to check on residents and to document incontinence care. On 8/08/2024 at 10:40 a.m., an interview was conducted with Staff A, CNA and Staff B, CNA. Staff A stated her current assignment was twelve residents and of those twelve, nine were dependent for total care. Staff B stated her assignment was twelve and of those twelve, nine were dependent for total care. Both CNAs stated the night shift did not get residents up before they started their shift but stated they were fine with this because they both knew they did a good job in ensuring their residents were properly cleaned and groomed. Staff A stated, I have to rotate my residents when I get them up because it is too much, I try to get my residents up at least twice a week by a rotation process. Staff A and Staff B both agreed they worked well together but still had more residents to attend to and stated it's just too much. Staff A stated, I have to prioritize my morning but I am always in and out of my residents' rooms checking in on them. On 8/08/2024 at 11:30 a.m., an interview was conducted with Staff G, CNA and Staff H, CNA. Staff G stated she had fourteen residents and of those fourteen, eight were dependent for total care. Staff H stated she had thirteen residents and of those thirteen, nine required total care. Both stated they were still trying to complete their assignments for their residents. Both CNAs stated they worked well together but one sick call could mess up the whole day. On 8/08/2024 at 12:30 p.m., a third tour was conducted. Staff G, CNA stated a CNA was pulled from each hallway to assist in the main dining area. When the CNA returned to their assigned hallway, the remainder of trays that were served to residents in their room was completed and then the CNAs would assist those residents that required assistance. Staff G stated she had one more resident to attend to for ADL care. Staff H, CNA returned to her assigned hallway and stated she was able to complete her care of dependent residents right before she had to go to the main dining. Both CNAs stated it put a lot of stress on the CNAs to have one taken away from the hallway to assist in the main dining. On 8/08/2024 at 12: 50 p.m., Staff A, CNA and Staff B, CNA stated having a CNA pulled to the main dining area during mealtime placed a great deal of stress on the CNA left in the hallways. Staff C and Staff D stated there were two residents that required assistance with feeding in their hallway and when a CNA was pulled to the main dining there was a delay in feeding those residents. On 8/08/2024 at 4:45 p.m., an interview was conducted with the Staff J, CNA /Staffing Coordinator and Central Supply in her office. Staff J stated staffing assignments were based on the census but acuity was considered as well. Staff J stated sick calls were covered by their own staff and the facility did not use agency nurses. Staff J stated telephone calls were made or group texts were posted for coverage requests. Staff J stated Staff C was just suspended a few hours ago as well as Staff F from this morning. Staff J stated Staff C's CNA assignment was covered by Staff I, CNA. Staff J stated this was Staff I's third day of orientation but I was watching and assisting her all day. Staff J stated the Activities Director, Medical Records Director and herself were CNAs. They would cover assignments if there was a last-minute sick call until they could be replaced to then return to their job duties. Staff J stated she was currently covering a CNA who had overslept but would be in later today. A request for policies were requested for ADL care and/or incontinence care but the facility did not have such policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accommodate the needs for one resident (#85) related to placing the call light within the resident's reach out of six residents sampled for environmental concerns. Findings included: On 4/29/2024 at 9:58 AM Resident #85 was observed in the bed, facing the ceiling, arms crossed at the waist. The call light was around the bed rail on the left side near the head of the bed. Resident #85 was on an air mattress with a perimeter cover, in front of the bed rail. Resident #85 was not able to reach the call light when requested. An interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 4/29/2024 at 10:00 AM. Staff S, LPN confirmed Resident #85 uses the call light and call lights should be within the resident's reach. Staff S, LPN confirmed Resident #85's call light was not within reach. Staff S, LPN assisted resident and placed the call light within the resident's reach. On 4/29/2024 at 3:15 PM Resident #85 was observed in the bed facing the door, arms crossed at the waist. The call light was underneath Resident #85's left shoulder. Resident #85 was not able to reach the call light when requested. An interview was conducted with Staff R, CNA on 4/29/2024 at 3:17 PM. Staff R, CNA confirmed Resident #85 uses the call light and call lights should always be within the resident's reach. Staff R, CNA observed the call light and stated, [Resident #85] would not be able to utilize the call in that position. Staff R, CNA moved the call light into the resident's reach. On 4/30/2024 at 9:15 AM Resident #85 was observed in the bed, facing the ceiling, arms crossed at the waist. The call light was underneath Resident #85's left shoulder. Resident #85 was not able to reach the call light when requested. Resident #85 stated, Happens all of the time. On 4/30/2024 at 10:00 AM Resident #85 was calling out for assistance. Resident #85 was observed lying in bed, facing the ceiling, arms crossed at the waist. The call light was underneath Resident #85's left shoulder. Resident #85 was not able to reach the call light when requested. Staff S, LPN was informed Resident #85 was calling out for assistance. Staff S, LPN confirmed the call light was not within Resident #85's reach. Review of Resident #85's admission Record revealed she was re-admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses encephalopathy, abnormalities of gait and mobility, lack of coordination, reduced mobility, and muscle wasting and atrophy. During an interview on 5/1/2024 at 3:40 PM the Director of Nursing (DON) stated Resident #85 was able to use her call light, and residents should be able to access the call light when needed. During an interview on 5/1/2024 at 4:00 PM the Nursing Home Administrator (NHA) stated the facility does not have a policy and procedure for call lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 04/29/2024 at 10:30 a.m. Resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During an observation on 04/30/24 10:00 a.m. Resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During the observation she was yelling out. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/01/2024 at 11:00 a.m. Resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed hair was noted to have been brushed and resident was clean looking in appearance. Resident was happy in demeanor. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/02/2024 at 9:45 a.m. Resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed to be disheveled in appearance with her hair knotted. Resident was not observed to be engaged in any activities throughout the observation. Review of Resident #13's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of reduced mobility, need for assistance with personal care, other chronic pancreatitis, adjustment disorders with anxiety, major depressive disorder, and anxiety disorder. Review of Resident #13's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Section GG revealed Resident #13 was dependent for Toileting hygiene, and Shower/bathe care. Resident requires substantial/maximal assistance for Oral hygiene, upper body dressing and lower body dressing. During an interview on 05/01/2024 at 10:30 a.m. with Staff N, Certified Nursing Assistant (CNA), she stated she is typically assigned to another part of the building and used to be on this hall. She stated Resident #13 is a fully dependent resident who requires full assistance with all of her care. She stated she helps with oral care, dressing for the day, bathing and with meals daily. She stated Resident #13 prefers to have a bath over a shower so she is sure to give her a bed bath daily. She stated Activities of Daily Life (ADL) care are supposed to be completed every shift and she cannot speak for other shifts or staff but when she is working, she ensures the Resident #13 gets her ADL care. She repositions the resident every 2 hours and uses a pillow to keep her comfortable, since the resident prefers to stay in bed most of the time. She stated the resident prefers to do activities in her room and she had brought her an audio book to listen to during the day before and she really enjoyed it. During an interview on 05/02/2024 at 10:30 a.m. with Staff O, CNA she stated she is supposed to provide ADL care to the residents daily. ADL care consists of oral care, daily bathing, and dressing for the day. She also assists the residents out of bed if they wish. Staff O, CNA stated Resident #13 prefers to stay in bed most days and often refuses her help with ADL care. She stated she does not force the resident to let her help them with care or out of bed. If the resident refuses, she takes no as the answer and does not encourage the resident any longer. She stated she does not provide any activities for the residents to do in their rooms because the facility has an activities director who goes to residents rooms and offers them things to do like coloring or a word search puzzle. Staff O, CNA stated she does not document when residents refuse showers, or not wanting to get out of bed or the behavior of the residents because she does not have access to do so. Staff O, CNA stated she reports to the nurse on duty when residents do not want to get out of bed or refuse their showers. During an interview on 05/02/2024 at 11:15 a.m. with the DON she stated they have residents who refuse care and when residents continue to refuse care, they update the care plan. CNA's do not have access to documents when residents refuse care. DON reviewed Resident #13's care plan, dated 03/03/2024, and noted the resident was not care planned to refuse ADL care. Her expectation for activities for residents who are dependent is for the activities director to visit the rooms of those residents and provide them with activities. The facility was asked to provide a policy regarding their ADL care and stated they do not have a Policy for ADL Care. Based on observations, record reviews, and interviews, the facility failed to ensure two dependent residents (#81 and #13), were provided with Activity of Daily Living(ADL) assistance related to hair and fingernail care out of forty one sampled residents. Finding Included: 1. During an observation on 04/29/2024 at 11:00 a.m., Resident # 81 was observed laying down in bed dressed in his nightgown with his call light within reach. Resident # 81 fingernails were observed long and dirty and he had thick facial hair. Resident # 81 stated he has asked staff to cut his hair and his fingernails, but they will not assist him. During an observation on 04/30 /24 at 02:24 PM Resident #81 was observed laying down in bed with his call light in reach, dressed in his nightgown. Resident # 81 said he has asked his aide to cut his facial hair and his fingernail, but she did not assist him with his care. Review of an admission Record, dated 05/02/2024, showed Resident #81 was admitted initially on 06/17/2023 and readmitted on [DATE] with diagnoses to include but not limited to non-Pressure chronic ulcer of unspecified part of left lower leg with unspecified severity, adjustment disorder with anxiety, and Pressure Ulcer of Sacral Region, Stage 4. Review of a Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status, (BIMS) score of 14 to indicated Resident #81 was cognitively intact. Further review of the MDS showed in section GG, for Functional Abilities and Goals, Resident #81 was dependent for his personal hygiene. Review of a care plan focusing on ADL's showed: Resident #81 has an ADL self-care performance deficit related to paraplegia status post Motor Vehicle Accident. Date initiated: 01/03/2024 and revised on 01/03/2024. Interventions: Dependent for personal hygiene. Date initiated 09/06/2023 and revised on 01/03/2024. During an interview on 05/01/2024 at 12:00 p.m., with Staff Q, a Certified Nursing Assistant, CNA, she stated she provides all of Resident #81's ADL care because he is a total dependent resident. She said the first thing she does is empty his colostomy and catheter bag in the morning. She said Resident #81 asked her to shave him yesterday, but she was not able to do it because she was too busy. During an interview on 05/01/2024 at 12:15 p.m., with Staff E, a Registered Nurse, RN, He said his expectation is if staff are having problems with completing their ADL task, they should report it to him and document the reason why they could not complete the task. For example, if resident refuses care the aide needs to report the situation to their nurse and document the concern. His expectation are staff should follow out the residents ADL's according to the resident's plan of care. During an interview on 05/01/2024 at 1:00 p.m., with the Director of Nurses, DON, the DON said her expectation was that every resident should be provided with ADL care. If for some reason they are not able to complete the task, then they should report the issue to their nurse and they should follow up with documentation regarding the resident's refusal of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 04/29/2024 at 10:30a resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During an observation on 04/30/24 10:00 AM resident #13 was observed lying in bed dressed in a gown. Resident #13 was observed to be disheveled in appearance with her hair knotted and overgrown fingernails. During the observation she was yelling out. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/01/2024 at 11:00 am resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed hair was noted to have been brushed and resident was clean looking in appearance. Resident was happy in demeanor. Resident was not observed to be engaged in any activities throughout the observation. During an observation on 05/02/2024 at 9:45 am resident #13 was observed lying in bed dressed in a pink sweater. Resident #13 was observed to be disheveled in appearance with her hair knotted. Resident was not observed to be engaged in any activities throughout the observation. Review of Resident #13's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of reduced mobility, need for assistance with personal care, other chronic pancreatitis, adjustment disorders with anxiety, major depressive disorder, and anxiety disorder. Review of Resident #13's Quarterly Minimum Data Set (MDS) dated [DATE] Section C, Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 10 out of 15. Section GG revealed Resident #13 is dependent for Toileting hygiene, and Shower/bathe care. Resident requires substantial/maximal assistance for Oral hygiene, upper body dressing and lower body dressing. According to the Self-Care Coding dependent means helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Substantial/maximal means helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort. During an interview on 05/01/2024 at 10:30a with Staff N, Certified Nursing Assistant (CNA), she stated she is typically assigned to another part of the building and used to be on this hall. She stated resident #13 is a fully dependent resident who requires full assistance with all of her care. She stated that she helps with oral care, dressing for the day, bathing and with meals daily. She stated resident #13 prefers to have a bath over a shower so she is sure to give her a bed bath daily. She stated ADL care is supposed to be completed every shift and she cannot speak for other shifts or staff but when she is working, she ensures the resident #13 gets her ADL care. She repositions the resident every 2 hours and uses a pillow to keep her comfortable, since the resident prefers to stay in bed most of the time. She stated the resident prefers to do activities in her room and that she has brought her an audio book to listen to during the day before and she really enjoyed it. During an interview on 05/02/2024 at 10:30 am with Staff O, CNA she stated that she is supposed to provide ADL care to the residents daily. ADL care consists of oral care, daily bathing, and dressing for the day. She also assists the residents out of bed if they wish. Staff O, CNA stated that resident #13 prefers to stay in bed most days and often refuses her help with ADL care. She stated that she does not force the resident to let her help them with care or out of bed. If the resident refuses, she takes no as the answer and does not encourage the resident any longer. She stated that she does not provide any activities for the residents to do in their rooms because the facility has an activities director who goes to residents rooms and offers them things to do like coloring or a word search puzzle. Staff O, CNA stated that she does not document when residents refuse showers, or not wanting to get out of bed or the behavior of the residents because she does not have access to do so. Staff O, CNA stated she reports to the nurse on duty when residents do not want to get out of bed or refuse their showers. During an interview on 05/02/2024 at 11:15 am, with the DON she stated they have residents who refuse care and when residents continue to refuse care, they update the care plan. CNA's do not have access to documents when residents refuse care. DON reviewed resident #13's care plan dated 03/03/2024 and noted that the resident was not care planned to refuse ADL care. Her expectation for activities for residents who are dependent is for the activities director to visit the rooms of those residents and provide them with activities. During an interview on 05/02/2024 at 11:30 am, with Staff P, Activities director, she stated she is responsible for activities for the entire resident population. She visits residents who are dependent on Mondays, Wednesdays, and Fridays. She offers the residents word searches, coloring pages, and sits with the resident to provide companionship. She stated that she has not been able to visit the dependent residents recently because she has been busy with her other tasks. She stated this is a frequent occurrence because of everything she does with in the facility she is not able to do her one on one with all the residents because she is the only one who does activities. The facility was asked to provide their activities policy and the facility did not provide this policy. Based on observations, record reviews, and interviews the failed to ensure two residents (# 68, 13) residing on the same hall were provided with activities out of eight residents sampled. Finding Include: 1.During an observation made on 04/29/2024 at 10:00 a.m., 11:30 a.m., and again at 3:00p.m., Resident# 68 was observed in bed, leaning off the side of her bed. Resident # 68 was dressed in her nightgown, with her call light out of her reach. During an observation made on 04/30/24 at 9:00 a.m. and 11:30 a.m., Resident # 68 was observed in bed, dressed in a nightgown with her call light out of reach. Resident # 68 was observed leaning to the side. Review of an admission Record dated 05/02/2024 showed Resident # 68 was admitted on [DATE] with diagnoses to include but not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Cognitive Communication Deficit, Need for assistance with Personal Care Review of a Minimum Data Set, MDS dated [DATE] showed a Brief Interview for Mental Status, BIMS showed a score of 05 to indicated Resident # 68 is severely impaired. Review of a care plan focusing on Activities showed Resident # 68 requires staff assistance with involvement of activities related to cognitive deficits. Date initiated 04/04/2023.Further review of the care plan interventions showed to encourage Resident # 68 to participate with activities of choice. Date initiated: 04/04/2023. During an interview on 05/02/2024 at 2: 00 p.m., with Staff P, the Activities Director. She stated she conducts room visits for dependent residents. She asked the residents in their rooms if they would like to do a word search, or color. She said she even does nail care as an activity for some residents in their rooms. She was not able to conduct activities this week for the dependent residents residing on the 100 halls because she was too busy. During an interview on 05/02/2024 at 2:30 p.m., with the Director of Nursing. She stated her expectation is that residents have activities according to their plan of care.

Based on observations, record reviews, and interviews the facility failed to assess and obtain physician orders for the wounds of two (#60 and #45) out of three residents sampled for skin conditions. Findings included: 1. On 4/30/24 at 9:51 a.m., Resident #60 was observed lying in bed and a tan-colored foam dressing was observed covering the left below the knee amputation (LBKA), the dressing was dated 4/28 11-7 and initialed, EC, with a pencil eraser-sized discoloration. Photographic evidence was obtained. On 5/1/24 at 2:22 p.m., Resident #60 was observed sitting in wheelchair and stated the dressing (to LBKA) had not been changed. The resident reported yesterday's nurse stated the 11 p.m. - 7 a.m. (11-7) shift nurse was going to change it. The dressing was observed and continued to be dated 4/28 11-7 EC with a pencil eraser-sized discoloration. Photographic evidence was obtained. Review of Resident #60's evaluations did not show a Change of Condition or Wound evaluation had been completed on 4/28 in regards to the skin condition covered by the dressing covering the LBKA. Review of Resident #60's April Medication and Treatment Administration Records (MAR/TAR), printed on 5/2/24 at 3:50 p.m., did not reveal a physician order for the dressing applied to the resident's LBKA, which was dated 4/28. Review of the facility provided list of wounds revealed Resident #60 was included with others with pressure, surgical, venous, arterial, diabetic, and moisture-associated skin damaged condition. An interview was conducted with Staff G, Registered Nurse/Unit Manager (RN/UM) on 5/1/24 at 2:26 p.m., the staff member reported the resident had redness to the perineal area, reviewed Resident #60's record, and confirmed there was no order for a LBKA dressing. An unsuccessful attempt was made with Staff G to observe the resident's dressing. The photo evidence of the resident's LBKA dressing was reviewed with the staff member, who stated oh no and confirmed there should have been a change in condition and assessment done for the area. The staff member asked writer if knowing what was under the dressing. On 5/1/24 at 2:47 p.m., the Director of Nursing (DON) was informed by the staff member of Resident #60's unassessed and unordered dressing. Review of Resident #60's care plan revealed the following: - Wound Risk: The resident is at risk of developing a wound related to (r/t)decreased mobility and multiple co-morbidities. The interventions instructed staff to observe for any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; report to nurse if noted, Nurse will report to MD if noted. - Preference/Choice: Resident has indicated the following preferences and/or has made the following choice regarding their health care: Resident chooses to decline recommended or ordered health care interventions of: Resident may decline to be weighed at times; to attend scheduled medical appointments. The interventions should staff were to encourage resident involvement in plan of care. - Behavioral: The resident is noted with the following behaviors: intermittently confabulates information regarding staff and/or other residents; occasionally buys sodas or snacks for other residents (without them requesting such) and will later charge them for the soda and/or snack; will, at times, ask assistance from another resident and/or staff member to look for something she is missing and then report the item missing or taken. 2. On 4/30/24 at 5:17 p.m., an observation was made with Staff J, Registered Nurse (RN) of Resident #45's bilateral lower extremities. The observation revealed no open areas to the resident's lower extremities. The staff member stated the area heals then reoccurs, and right now the staff are just putting cream on it. On 5/1/24 at 12:49 p.m., an observation was made of Resident #45 raising the head of bed as a meal tray was on the over-bed table in front of the resident. Review of Resident #45's admission Record revealed an admission date of 1/13/21 and diagnoses not limited to not elsewhere classified senile degeneration of brain, contracture of left knee, contracture of left ankle, and muscle wasting and atrophy not elsewhere classified unspecified site. Review of Resident #45's Skin Check Weekly and as needed (PRN), dated 1/26/24 revealed No New Areas of Skin Impairment. The document revealed staff also had New Areas of Skin Impairment Found, See Skin Grid (paper version or PCC Skin & Wound Module), See Skin/wound Note, Care Plan Reviewed & Current, and Resident Refused Skin Evaluation available to document any findings. Review of Resident #45's Skin Check Weekly and PRN, dated 2/2/24, revealed No New Areas Of Skin Improvements. Review of Resident #45's progress notes, dated 12/31/23 to 1/30/24, did not reveal the staff had documented any skin condition or change in condition for the resident. Review of Resident #45's progress notes revealed a note, dated 2/5/24, Resident noted with skin impairment to anterior bilateral lower extremities. MD notified with orders and Healthcare Proxy (HCP) called. Review of Resident #45's progress notes revealed the resident was seen by the facility wound care provider on 2/6/24 and an order for a vascular consult was obtained with the primary physician and Power of Attorney updated. Review of Resident #45's Infection Note, dated 2/7/24 showed the resident continued on oral antibiotic for cellulitis. The note on 2/15/24 revealed the resident continued on doxycycline for cellulitis to bilateral lower extremities. Review of Resident #45's January Medication and Treatment Records (MAR/TAR) did not reveal any order for a dressing change or an order for an antibiotic related to any infection. Review of Resident #45's February MAR/TAR's revealed the resident was ordered: - Doxycycline Hyclate Oral Tablet 100 milligram (mg) - Give 1 tablet by mouth two times a day for cellulitis to right (rt) leg for 10 days. The MAR showed the antibiotic was administered on 2/5-2/10, evening shift on 2/13, both times on 2/14 and not administered on morning shift of 2/15/24. - Cleanse area to left anterior lower leg with normal saline (NS), skin preop wound edges, apply Xeroform, and cover with dry dressing daily and PRN every day shift, ordered 2/6 and discontinued on 2/13/24. - Cleanse area to right posterior knee with NS, skin prep wound edges, apply Xeroform, and cover with dry dressing daily and PRN every day shift, ordered 2/6 and discontinued 2/13/24. - Cleanse area to right upper shin with NS, skin prep wound edges, apply Xeroform and cover with dry dressing, and daily and PRN every day shift, ordered 2/6 and discontinued 2/13/24. An interview was conducted on 5/1/24 at 5:31 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding an incident of a CNA reporting a 7-day old dressing that the facility reported to the state agency. The NHA reported a Certified Nursing Assistant (CNA) had reported on 2/5/24 at 8:15 a.m. of observing a dressing to Resident #45's right lower extremity dated 1/27/24. The DON reported the resident has skin alterations of dry and crusty patches and one of the flakes had probably popped off. The NHA reported the investigation into the issue revealed a Registered Nurse (RN) had applied a dressing to the anterior right leg on 1/27/24 however did not follow wound protocol - did not put order in and did not document if an assessment had been done on the wound. The NHA stated the CNA had informed the nurse on 2/5/24 (different than the one on 1/27/24) and the nurse had not looked for a physician order but had just put the same type of dressing (dated 1/27/24) on the wound. The NHA reported Doppler studies were done on the lower extremity of Resident #45 and showed significant stenosis of the right popliteal artery. The wound provider diagnoses the resident with venous insufficiency and cellulitis and the antibiotic Doxycycline was started. At the time of the incident on 2/5/24, the DON assessed the wound and reported it hadn't changed in status and reported currently the resident had crusty scaly areas on legs. The NHA stated on 2/5/24 a physician order was obtained, a dressing was applied and the NHA started a Quality Assurance Performance Improvement plan. The NHA reported the roster of nurses who care from Resident #45 during the period of time were interviewed. The DON stated there was a piece of scale that was there, hadn't come off but did have some drainage. The NHA stated the root cause of the incident was that the nurse on 1/27/24 did not follow the facility's wound protocol. The NHA reported the incident was not substantiated because the wound had not worsened. The NHA stated the facility had completed audits of wound care dressings and labeling and the facility was no longer auditing due to the issue was resolved. The DON confirmed Resident #45's dressing (1/27-2/5/24) had been in place for 7 days, stating some dressings could be left on for 7 days. The facility education on 2/5/24 presented by the previous Assistant Director of Nursing (ADON) instructed staff when a new skin issue was found, a risk management assessment needs to be completed, a change of condition completed, report to the physician, get treatment orders, and notify the responsible party and DON. Review of Resident #45's care plan revealed the resident was at risk for developing a wound related to (r/t) decreased mobility and incontinent of bowel and bladder and multiple co-morbidities. The goal was to minimize wounds from developing. The interventions included Observe for any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; report to nurse if noted, Nurse will report to MD if noted. The facility failed to provide any skin/wound notes for January 2023, any evaluation for 1/26, 1/27, and 1/28/23. Review of the facility policy - Wound Prevention & Treatment Overview, effective October 2021, revealed The facility strives to ensure that a Resident/Patient entering the facility without Ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. A resident with ulcers will receive continued preventative interventions & necessary treatment & services to promote healing & prevent infection. Wound characteristics will be documented by measuring length, width & depth in centimeters. Additional documentation shall also include: - Color of drainage - Wound Bed Color - Odor - Amount of Drainage - Wound Bed Tissue Type - Tunneling/undermining with depth if applicable. Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition.

Based on observations, interviews and record review, the facility failed to provide dialysis care and services to meet the needs of one resident (#53) out of eight residents related to timely assessment and vital signs post dialysis. Findings included: A record review of Resident #53's admission Record has an original admit date of 05/24/2021 with a readmission date of 03/16/2024. Resident #53 has a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Secondary diagnoses include but are not limited to end stage renal disease requiring dialysis, Type 1 diabetes mellitus with diabetic autoimmune polyneuropathy and personal history of other venous thrombosis and embolism. A review of physician orders for Resident #53 include resident to have dialysis on days: Monday, Wednesday, Friday dialysis center, document vital signs upon resident returning from dialysis every Monday, Wednesday and Friday, monitor for signs and symptoms of bleeding, notify MD (physician) of bleeding, monitor for bruit and thrill AV (Arteriovenous) shunt located at left lower extremity (upper leg) and may remove compression dressing post dialysis per MD orders instructions one time a day every Monday, Wednesday and Friday for treatment follow physician instructions when to remove dressing. On 4/30/24 at 11:00 a.m., a review of Resident #53's dialysis communication binder had one day of communication between the facility and the dialysis center, dated 4/29/24. Post vital signs and assessment of AV fistula were not entered from the facility upon return to the facility post dialysis. There was no post dialysis report from the dialysis center either on the communication sheet or on a separate report. An interview was conducted with Staff A, Registered Nurse/Unit Manager (RN/UM) who stated the reports may be faxed over later today but if there was a concern the facility would notify us via telephone conversation. A request was made for Resident #53's dialysis communication tools for the month of April 2024. Later that afternoon on 4/30/24, the facility provided copies of the resident's dialysis communication tools for the month of April with the following dates: 4/05, 4/09,4/10, 4/12, 4/13, 4/15, 4/17, 4/19, 4/22, 4/24, and 4/26. Upon further review, three of the communication tools had vital signs and post assessment of the AV fistula documented. All the communication tools for the month of April lacked timely communication from the dialysis center either in writing or fax. On 5/01/24 at 08:30 a.m., an interview was conducted with Resident #53. Resident #53 was in the main lobby sitting in his wheelchair waiting for transport to take him to his dialysis center. Resident had a binder in the back of his wheelchair with his name on it and the word dialysis. A packed lunch was made for the resident and packed in an insulated lunch bag. Resident #53 confirmed the location of his AV fistula was in his left upper thigh, stating he has had AV fistulas before in his arms but they did not do well due to small vessels. On 5/01/24 at 5:43 p.m., an observation and interview were conducted with Resident #53 post dialysis. In the 300 hallways at the nurse's station, Staff A, RN/UM confirmed Resident #53 was back from dialysis. Resident #53 was in his wheelchair in his room. Resident #53 stated he got back about forty-five minutes ago. He stated he had issues today at the dialysis center when they removed his needle from his AV fistula. Resident #53 stated he bled more than usual from his fistula and required longer direct pressure time to stop the bleeding at the dialysis center. The resident stated blood was all over the place and seeped into his shorts. Resident #53 stated the nursing staff have not come into his room to take vital signs or assess his AV fistula site, stating, they never come and check on it. He stated he did not eat his lunch today because he did not feel good. A request was made for Resident #53's dialysis communication binder from Staff A, RN/UM. Staff A, RN/UM stated she did not have the communication binder and sent a certified nurse assistant to locate the binder. Resident #53's dialysis communication binder was with the resident behind his wheelchair. The CNA gave the binder to a nurse staff member in the process of medication administration. Staff A, RN/UM stated no changes in dialysis were reported to her from the dialysis center. Review of the facility's policy entitled, Dialysis Management (Hemodialysis) dated October 2021 With the following guidelines: 1. Obtain A physician's order to include but not limited to: Name and address of the dialysis center Scheduled days and times of dialysis treatment Fluid management /restrictions -fluids will be coordinated and provided by nursing and dietary Lab values Medication administration terms on dialysis days Blood pressure or blood draw in arm with the shunt or access (error) Site signs and symptoms to monitor such as pain infection or bleeding period . 8. Complete the dialysis communication tool before and after dialysis and following up on any special instructions from the dialysis center. . 10. Evaluate for and manage post dialysis complication which may include, but are not limited to, the following: confusion fever pruritus anaphylaxis seizures hypertension muscle cramps cardiac arrhythmia restlessness air embolus insomnia hemorrhage

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to obtain blood pressures for one (#60) out of 5 residents sampled for unnecessary medications related to the physician ordered vasodilator, Hydralazine. Findings included: On 05/1/24 at 8:06 AM, Resident #60 was observed lying in bed with eyes closed. Review of Resident #60's admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to essential (primary) hypertension and unspecified sequelae of cerebral infarction. Review of Resident #60's March Medication Administration Record (MAR) revealed the following physician orders related to the resident's diagnosis of hypertension: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23. - BP and pulse weekly every evening shift every Sunday (Sun) for preventative measure. - Hydrochlorothiazide 25 mg - give one tablet by mouth one time a day for HTN. - Metoprolol Tartrate 25 mg - Give 1 tablet by mouth two times a day for HTN. Review of Resident #60's March MAR revealed the staff had obtained a blood pressure and pulse one time a week, on Sunday. The MAR did not reveal a blood pressure had been taken every 8 hours to ensure the resident's ordered Hydralazine was not required. The MAR showed a blood pressure was not ordered to be obtained prior to administering the resident's Hydrochlorothiazide and Metoprolol. Review of Resident #60's Blood Pressure Summary report revealed documented blood pressures on 3/3, 3/10 (twice), 3/17, 3/24, and 3/31/24. Review of Resident #60's April MAR revealed the following physician orders related to the resident's diagnosis of hypertension: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23. - BP and pulse weekly every evening shift every Sunday (Sun) for preventative measure. - Hydrochlorothiazide 25 mg - give 1 tablet by mouth one time a day for HTN. - Metoprolol Tartrate 25 mg - Give 1 tablet by mouth two times a day for HTN. Review of Resident #60's April MAR revealed the staff had obtained a blood pressure and pulse one time a week, on Sunday. The MAR did not reveal a blood pressure had been taken every 8 hours to ensure the resident's ordered Hydralazine was not required. The MAR showed a blood pressure was not ordered to be obtained prior to administering the resident's Hydrochlorothiazide and Metoprolol. Review of Resident #60's Blood Pressure Summary report revealed documented blood pressures one time daily on 4/7, 4/14, 4/21, and 4/28/24. Review of Resident #60's care plan showed the resident had a cardiovascular problem related to (r/t) hypertension (HTN), A-fib, (and) history (hx) of cardiovascular accident (CVA). The goal was for the resident to be free from complications of cardiac problems through the review date. The interventions r/t this focus included Vital signs ordered and Administer medications as ordered. An interview was conducted with Staff G, Registered Nurse/Unit Manager (RN/UM), on 5/1/24 at 2:47 p.m., the staff member stated if the resident (#60) had an as needed (PRN) blood pressure medication with parameters and scheduled for every 8 hours (PRN), (the resident) should have blood pressures taken every 8 hours. The staff member reviewed Resident #60's Hydralazine order and stated yes staff should be taking blood pressures every 8 hours. Review of Resident #60's May MAR revealed the following order: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23 and discontinued on 5/1/24 at 4:01 p.m. Review of the policy - Physician Orders, effective October 2021, revealed At the time each resident is admitted , the facility will have physician orders for their immediate care. physician orders will be dated and signed at next physician visit. The policy instructed staff to Confirm the accuracy of orders. Review orders daily in the Clinical meeting to confirm accuracy in transcription and identify errors of omission. The Regional Nurse Consultant reported the facility did not have a policy related to nursing documentation.

Based on observations, record reviews, and interviews the facility failed to ensure medications were stored in a safe and secure manner and failed to ensure medications were discarded after manufacturer expiration date and failed to label medications with shortened shelf lifes with open dates. Findings included: On 4/29/24 at 11:45 a.m., Resident #29 was observed with a bottle of eye drops, for the relief of redness of the eye due to minor eye irritant, on the over-bed table next to the resident's bed and on the bedside dresser was a bottle of nasal spray with a large green top. The resident stated the nasal spray did not work. Review of Resident #29's physician orders revealed an order for Fluticasone Propionate Nasal Suspension 50 microgram (mcg/act) - 1 spray in both nostrils one time a day for allergic rhinitis. The review did not reveal an order for any eye drops. Photographic evidence was obtained. On 4/30/24 at 9:51 a.m., Resident #60 was observed and interviewed in the resident room. The observation revealed on top of the bedside dresser was a large jar of 1% Silver Sulfadiazine cream with a medication on top of it containing a white cream. The Silver Sulfadiazine was labeled Prescription (RX) only. The resident reported not being able to say if (they) put the cream on rash by self. Review of Resident #60's April Medication Administration Record (MAR) revealed an order for Silvadene External Cream 1% - Apply to perineal area topically every shift for rash until resolved, ordered 4/6/24 and discontinued 4/26/24. Review of Resident #60's April Treatment Administration Record (TAR) revealed an order for Silvadene External Cream 1% - Apply to bilateral buttocks topically every shift for redness bilateral buttocks, ordered 12/12/22. The TAR showed Silvadene was applied to the resident's buttocks three times a day during April. On 5/2/24 at 10:02 a.m., the 200-hall medication cart was observed with Staff G, Registered Nurse/Unit Manager. The observation revealed the following: - One round white tablet and one round pink tablet lying on the bottom of a drawer with boxes of eye drops. - Bottle of undated Latanoprost (Xalatan) 0.005% eye drops. The bottle has label to document open date. (According to https://medlineplus.gov/druginfo/meds/a697003.html#storage-conditions, accessed on 5/7/24 at 8:01 p.m., once opened Xalatan can be kept at room temperature for 6 weeks). - A container of disinfecting wipes stored in the same compartment of the bottom drawer as a bottle of Sodium Bicarbonate tablets which was sitting on top of a box of topical pain patches. - A Insulin Lispro Kwikpen labeled with no open date. - Novolog insulin pen labeled with no open date. - Levemir vial, not labeled with an open date. Pharmacy label showed the vial should be discarded in 42 days. Staff G observed the findings. On 5/2/24 at 10:38 a.m., the 400-hall medication cart was observed with Staff K, Licensed Practical Nurse. The observation revealed the following: - An undated open bottle of Liquid Protein. The label showed the bottle was to discarded 3 months after opening. - A vial of Novolog insulin, opened on 3/16/24. The pharmacy label instructed Discard after 28 days. Review of calendar revealed the vial should have been discarded 4/13/24, 19 days prior to the observation. - A vial of Insulin Glargine, opened on 3/21/24. The pharmacy label instructed Discard after 28 days. Review of calendar revealed the vial should have been discarded 4/18/24, 14 days prior to the observation. - An undated open vial of Lantus insulin. The pharmacy label instructed Discard after 28 days. Staff K confirmed the findings. Photographic evidence was obtained of the medication carts and resident findings. The policy - Medication Storage, effective 09/18, revealed Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel ,or staff members lawfully authorized to administer medications. 4. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin file may be stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperature. Do not freeze insulin. If insulin has been frozen, do not use. 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according two procedures for medication disposal and reordered from the pharmacy, if a current order exists. 16. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a safe, clean, and homelike environment for resident rooms and bathrooms, during four days (4/29, 4/30, 5/01, and 5/02/24) of four days observed, in three of four hallways observed. Findings included: 1) On 4/29/2024 at 9:53 AM the nightstand of the occupied room [ROOM NUMBER] B was observed to have three drawers. The front of the middle drawer was not attached to the base on the right side, leaving the drawer lopsided and resting on the bottom drawer. (Photographic Evidence Obtained). On 4/29/2024 at 10:00 AM the door to the bathroom in the occupied room [ROOM NUMBER] was observed with a cylindrical metal piece protruding from where the doorknob should be. No doorknob was found. (Photographic Evidence Obtained). On 4/29/2024 at 10:08 AM the wall behind the occupied bed of 415 A was observed with a deep gouge in the drywall, leaving a hole in the wall behind the bed. The head of the bed was resting on the wall and floor, not attached to the bed. (Photographic Evidence Obtained). On 4/29/2024 at 10:11 AM the nightstand of the occupied room [ROOM NUMBER] B was observed to have three drawers. The front of the top drawer was not attached to the base on the right side, leaving the drawer lopsided and resting on the middle drawer. (Photographic Evidence Obtained). On 4/29/2024 at 10:12 AM the wall behind the occupied bed of 415 C was observed with a gouge in the drywall, behind the bed. (Photographic Evidence Obtained). On 4/30/2024 at 10:11 AM and 10:13 AM the sinks in the occupied resident rooms of 415 and 413 respectively, were observed with cracks in the base of the sinks around the drains. The cracks traveled up the sink base to approximately the middle of the bowl. The cracks were visible with brownish/black substance in the cracks. (Photographic Evidence Obtained). An interview was conducted with the Maintenance Director on 5/2/2024 at 3:52 PM. The Maintenance Director observed the vent cover in room [ROOM NUMBER] and stated, Oh Goodness, that is not acceptable, the vent absolutely needs to be cleaned. The Maintenance Director continued to tour the facility and confirmed the areas were not acceptable and needed repair and painting. The Maintenance Director stated, The entire building needs to be audited and repaired. An interview was conducted with the Nursing Home Administrator (NHA) on 5/2/2024 at 3:50 PM. The NHA reviewed the photographic evidence and confirmed the environment needs repair/replacement/cleaning. 3) During an observation made on 04/29/2024 at 12:00 p.m., rooms [ROOM NUMBERS] had paint missing off the doors. room [ROOM NUMBER]'s sink inside the room was observed with a black like substance stuck inside the sink. room [ROOM NUMBER] was observed with a dirty privacy curtain hanging up in the room. (Photographic evidence obtained). Review of the facility policy titled, Physical Environment, Effective date January 1, 2020, revealed the following: Policy: A safe, clean, comfortable, and home -life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition throughout the facility's Preventative Maintenance Program. 4. Assure resident/patient care equipment is clean, properly stored, and identified. 5. Assure an applicable working system is in place and within reach for the resident/patient to summon assistance, including, but not limited to: Typical call light with cord, Manual call bell, Specialty call bell as needed. 2) On 4/29/24 at 11:11 a.m., an observation was made of the bathroom in room [ROOM NUMBER]. The bathroom did have a shower in the room which had eleven tile transition tiles missing, the floor of the shower and the shower wall grout was discolored black, the shower floor tiles were discolored with a black substance, the caulking around the toilet base was discolored black, and the white shower curtain had black spots of biogrowth. (Photographic evidence was obtained). On 4/30/24 at 8:54 a.m., an observation was made of the bathroom in room [ROOM NUMBER]. The shower curtain in the bathroom was discolored with an unknown black substance and along the bottom edge was tan-colored. The observation revealed the vinyl cove base was pulled away from the wall leaving a gap between the base and tile of a few inches. (Photographic evidence was obtained). On 5/2/24 at 8:47 a.m., an observation of room [ROOM NUMBER]'s bathroom revealed the shower curtain had black spots of unknown substance attached to it and the vinyl cove base was pulled away from the tiled wall next to the toilet. On 5/2/24 at 8:50 a.m., an observation of room [ROOM NUMBER]'s bathroom revealed the shower curtain had black spots of an unknown substance, the showers wall grout and floor tile was discolored with a black unknown substance, and the two safety handles beside and behind the toilet was rusty, therefore uncleanable. On 5/2/24 at 10:20 a.m., observations of room [ROOM NUMBER] and 206's bathrooms were conducted with the Housekeeping Manager and the Environmental District Manager (EDM). The EDM stated they could take money out of petty cash to replace the shower curtain in room [ROOM NUMBER] and the resident reported seeing palmetto bugs/roaches coming out of the cove base about every other day. The EDM stated the floor in room [ROOM NUMBER]'s shower could be cleaned and the shower curtain should have been changed. The EDM stated the handrails were not cleanable and the Housekeeping manager stated the safety handles are cleaned then a hour later the rust was back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/29/2024 at 10:08 AM Resident #1 was observed sitting on the edge of the bed, feet on the floor, bed in the low position. Resident #1 was observed leaning forward reaching for the floor, then sitting up and laying back on the bed, rolling back and forth. On 4/29/2024 at 11:30 AM Resident #1 was observed on the floor outside of room [ROOM NUMBER], wheelchair nearby, and staff attending. Resident #1 was returned to the wheelchair by the staff. Review of Resident #1's admission Record showed a readmission date of 4/15/24 and original admission date of 6/25/2021 with diagnoses including but not limited to: cerebral infarction, abnormalities of gait and mobility, reduced mobility, muscle wasting and atrophy, spinal stenosis, lack of coordination, pulmonary edema, heart failure, anxiety disorder, and schizophrenia. Review of Resident #1's care plan revealed the following: Focus: Fall: Resident #1 is at risk for falls or fall related injury related to unsteady gait, history of falls, decreased safety awareness secondary to impaired cognition and psychotropic and narcotic medication use. Resident #1 is very impulsive, difficult to redirect, also very independent minded, no awareness of abilities or lack thereof - date initiated: 6/28/2021, revision date on 4/15/2024. Goal: Will minimize the risk of injury - date initiated: 1/26/2023, revised on 3/8/2024. Will have no untreated fall related injury - date initiated 3/8/2024. Interventions/tasks: Encourage and try to assist resident with toileting before meals and at bedtime - date initiated 9/20/2023. 4/23 prompted toileting, before and after meals, and at bedtime -date initiated 4/30/2024. Focus: Incontinence: Resident #1 is incontinent of bladder/bowel related to severely impaired cognition with impaired awareness of need to void an unpredictable pattern - date Initiated: 7/16/2021, revised on 10/6/2023. Goal: Will maintain dignity - date initiated 7/16/2021 revised on 10/11/2023. Will minimize the risk of infection - date initiated 7/16/2021 revised on 10/11/2023. Will minimize the risk of skin breakdown - date initiated 7/16/2021 revised on 10/11/2023. Interventions/Tasks: check for incontinence frequently and provide incontinence care is indicated - date initiated 7/16/2021, revised on 1/26/2023. Provide perineal care and apply barrier cream after incontinent episodes as needed - date initiated 7/16/2021. Utilizing continent products as needed to provide dignity - date initiated 7/16/2021. Observe condition of skin with each incontinent episode - date initiated 1/26/2023. Observe for foul smelling, cloudy urine, change in urinary output, mental status change, changes in bowel pattern and report as needed - date initiated 1/26/2023. An interview was conducted with Staff L, CRD on 5/1/24 at 3:18 PM. Staff L, CRD reviewed Resident #1's care plan and confirmed the care plan interventions under the Fall Care Plan were redundant in regards to the encourage toileting. Staff L, CRD stated the resident's entire care plan should have been reviewed and an intervention placed after the root cause for the fall ascertained. Staff L, CRD continued to state the toileting intervention was not appropriate if the Incontinence Care Plan was accurate. On 4/29/2024 at 10:13 AM Resident #47 was observed sitting upright in bed. Resident #47 had an enteral tube feeding hanging on a pole next to the bed. The enteral feeding was dated 4/28/2024 not timed and half of the bottle was gone. The pump was not on and the tubing was not connected to Resident #47. On 4/30/2024 at 9:11 AM Resident #47 was observed sitting upright in bed, an over the bed table next to the bed with a carton of milk. Review of Resident #47's admission Record showed a readmission date of 3/19/2024 and original admission date of 10/11/2023 with diagnoses including but not limited to: encephalopathy, vascular dementia, abnormalities of gait and mobility, dysphagia, acute kidney failure, a transient cerebral schematic attack (TIA), depressive disorder, hypertensive heart disease, and anxiety. Review of Resident #47's Physician Order Summary Report showed: Regular Diet Mechanical soft/soft and bite sized SB6 texture, Regular (Thin) consistency for diet, with an order date of 4/23/2024. Urinary Catheter for obstructive uropathy with urinary catheter size #16FR with 10cc balloon. Observe every shift with an order start date of 3/29/2024. Review of Resident #47's care plan revealed: Focus: Nutritional: the resident has a nutritional problem or potential nutritional problem related to advanced age, depression, hypertension, Benign prostatic hyperplasia (BPH), anxiety, Depression, hyperlipidemia, dementia and muscle wasting . date initiated: 10/11/23 and revised on 11/29/2023. Goal: Maintain nutritional and hydration status via by mouth (PO) intake to avoid significant weight changes, while honoring resident's food preferences - date initiated 10/11/23 and revised on 10/24/23. Interventions/Tasks: Resident is nothing by mouth (NPO)- do not provide food or fluids by mouth. See nurse. - date initiated: 3/1/2024. Focus: activities of daily living (ADL): the resident has an ADL self-care performance deficit related to recent hospitalization, dementia, history of TIA. date initiated: 1/5/2024 and revised on 3/20/2024. Interventions/Tasks: Resolved: Eating: Independent - resolved 3/1/2024. Eat nothing by mouth - date initiated 3/1/2024. Bladder: Incontinent - date initiated 3/1/2024. Focus: Behavioral: the resident is noted with the following behaviors: urinating on the floor - date initiated 11/17/2023. Goal: risk for complications related to behavior will be minimized through review date - date initiated 11/28/2023. Interventions/Tasks: administer psychotropic medications as ordered. Report missed or refused medications to physician - date initiated: 11/28/2023. Medications as ordered, report missed or refused meds to physician, discuss possible alternatives with MD and resident - date initiated 11/28/2023. Praise the resident will behavior is appropriate - date initiated 11/28/2023. Observe for changes in behavior and report to physician for example insomnia, nervousness, loss of interest, decreased ability to concentrate, repetitive movements etc. - date initiated 11/28/2023. Do not Corner if agitated. Provides space, remove other residents, remain calm and call for assistance - date initiated 11/28/2023. Psychiatry services as needed - date initiated 11/28/2023. Psychological services as needed - date initiated 11/28/2023. During an interview on 5/2/2024 at 9:15 AM Staff L, CRD reviewed Resident #47's care plan with focus areas of Nutritional, Tube Feeding and ADLs. Staff L, CRD stated Resident #47's care plan is not updated. Staff L, CRD stated when the order was received for the catheter the behavior and ADL care plan should have been updated to reflect resident's current status. Staff L, CRD continued to state, The same should have been done with the diet order. If the Care Plan is not updated the CNAs, [NAME] does not get updated. The [NAME] is what tells the CNAs what care to provide for the residents. On 4/29/2024 at 9:58 AM and 4/30/2024 at 9:15 AM Resident #85 was observed in bed, with arms crossed at the waste and hands bent with fingers touching both palms. Resident #85 was not able to open fingers or extend either arm out from the elbow. Review of Resident #85's admission Record showed a readmission date of 3/24/2024 and original admission date of 9/8/2023 with diagnoses including but not limited to: encephalopathy, abnormalities of gait and mobility, dysphagia, depressive disorder, hypertensive, anxiety, and paranoid schizophrenia. Review of Resident #85's care plan revealed the ADL care plan had been resolved on 3/25/2024. During an interview on 5/2/2024 at 10:15 AM Staff L, CRD reviewed Resident #85's care plan and stated an ADL care plan should be in place. During an interview on 05/2/2024 at 12:40 PM the Director of Nursing (DON) stated the expectation is to update the residents care plans as changes occur. Review of the facility's policy and procedure topic, Care Plan - Interdisciplinary (IDT) Plan of Care from Interim to Meeting, dated effective February 2024 showed: Policy The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring residents condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situations, coordination with Hospice plan of care). Managing risk factors to the extent possible or indicating the limits of such interventions. a. Addressing ways to try to preserve and build upon a residence's strengths, needs, personal, and cultural preferences. b. Applying current standards of practice in the care planning process. c. Evaluating treatment of measurable objectives, timetables, and outcomes of care. d. Respecting the residents right to choose to decline treatment, request treatment, or discontinue treatment. e. Offering alternative treatments, as applicable. 2. Using appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. a. Involving the resident to have a role in care planning even if a judged incompetent, and the resident's family and/or other resident representatives as appropriate to participate in the development and implementation of his or her person-centered plan of care. b. Assessing and planning for care to meet the residents medical, nursing, mental, and psychosocial needs. c. Involving the direct care staff with the care planning process relating to the resident's expected outcomes. d. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. Procedure 2. Update to Care Plans - a. Ongoing updates to care plans are added by a member of the IDT, as needed. 3. Dates and Documentation on the Care Plan a. New, revised, or discontinued problems, goals, or interventions are dated for the date the documentation was made. b. Problems and goals have IDT approaches and interventions to assist the resident in their goal attainment. 5. Comprehensive Plan of Care a. The comprehensive care plan is developed by members of the IDT and the resident, resident's family, or representative, as appropriate, in conjunction with the completion of the Admission, Annual, Significant Change in Assessment or other comprehensive assessment, and associated Care Area Assessments. b. The comprehensive care plan describes or includes: i. The services that are to be furnished and goals that reflect the resident's wishes, choices, and exercise of rights. ii. Any services that would normally be provided but are not provided due to the residents exercise of rights, include the right to refuse treatment, or any alternative means or options to address the problem. iii. The needs, strengths, and preferences identified in the comprehensive resident assessment. iv. Prevention of avoidable declines in functioning or functional levels v. Standards of current professional practice vi. Adequate information provided to make informed choices regarding treatment. c. The comprehensive care plan is completed within regulated time frames. 6. Quarterly Update of the Plan of Care a. The comprehensive care plan is reviewed and revised by members of the IDT and the resident, resident's family, or representative, as appropriate, in consultation with completion of the Quarterly Assessment. b. The IDT members make a quarterly care plan review note within the designated discipline's progress notes which include: i. If goals are met or unmet ii. If care plan will remain in effect for resident 7. Care Plan Meeting Invitation a. The facility assists residents or their representatives to participate in and understand the assessment and care planning process, when feasible, holding care planning meetings at the time of day when a resident is functioning best, planning enough time for information exchange and decision making; Encouraging a residence representative to attend (e.g., family member, friend), if desired by the resident, and/or Hospice representative. b. The clinical reimbursement director (CRD) and/or clinical reimbursement specialist (CRS) facilitate the care plan schedules and letters to be delivered to the resident or their representative prior to the care plan meeting. i. A copy of the letter is retained by the facility and is filled into the medical record upon completion of the care plan meeting. Ii. When feasible, CRD, CRS, or designee calls or visits resident or their representative prior to meeting if no response has been received for confirmation of attendance. Call or visit is recorded on copy of letter. 8. Care Plan Meeting a. All team members are to report promptly at time indicated on weekly schedule. b. Care plan meetings are held in an uncluttered, confidential setting with all team members able to sit as well as resident and/or representative. c. All care plan updates, revisions, and evaluations are completed prior to the meeting. d. IDT Meats regardless of resident and/or resident representative ability to attend. e. Care plans are discussed allowed, to include discussion goals, interventions, and evaluations. f. CRD, CRS, unit manager (UM) or other designee in absence of, facilitates and explains the purpose and length of the meeting: i. Purpose: to communicate the medical, psychosocial, recreational and nutritional condition and discuss the approaches being taken to attain goals. ii. Time time allotted for meeting: 15 minutes per resident or private meeting after with appropriate department team members. iii. Introduction to team members and their titles. g. Nursing i. Review current diagnosis, tests, or procedures, treatments (wounds, rashes, etc.), discuss current interventions and risk of further breakdown, if applicable, recent, or pending referrals, physician consults, restorative, medications, pain management plan, behavioral management plan, special needs, risks of falls and current interventions, and recent falls or other issues (informed consents, isolation, etc.) ii. Clinical representative will be UM we're charged nurse familiar with the care of the resident. Assigned CNA also attends or provides input to IDT regarding care provided and resident response. Absence of UM or charge nurse should be by exception. h. Dietary/nutritional status i. Current weight, loss or gain, appetite, supplements, food likes/dislikes, and confirm history of allergies. i. Social Services i. Review any changes needed to face sheet information, advanced directive status, review code status to include do not resuscitate (DNR) and presence of state required documents. Discuss living will, ethical concerns, competency/capacity (surrogate, DPOA, guardian status), ancillary, services/pending referrals - dental, Podiatry, vision, hearing, mental health, recent changes in cognition, behaviors, and socialization and approaches, any discharge planning or any needed assistance with Medicaid application process or grievances that may need to be addressed. j. Recreation i. Update on customers participation in, and response to, activities. k. Therapy i. Physical, occupational, and/or speech therapy goals and progress. l. Position i. New orders, disease progression, discharge planning or advanced care planning needs may be addressed, as examples. m. CRD, CRS, UM, or designee to review/summarize any action steps or follow up needed. n. Questions o. Adjournment 9. Care plan meeting participation record a. The copy of the care plan meeting invitation letter is also the participation record. Attendee sign names, indicate relationship, or title and date of attendance at care plan meeting. b. If the resident or resident representative cannot participate in the care plan meeting, the reason is documented on the copy of the letter in the indicated section. c. The completed care plan meeting invitation/participation record is then maintained in the medical record under the 'Care Plan' tab. Based on observations, record reviews, and interviews, the facility 1) failed to revise and review one resident (#60) care plan with the appropriate staff/professionals and resident out of forty-one sampled residents, 2) failed to review and revise the care plan for four residents (#55, #1, #47, and #85) related to psychotropic medications, falls, activities of daily living (ADL), and range of motion (ROM) out of forty-one sampled residents. Findings included: 1. Review of Resident #60's admission Record revealed the resident was initially admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus, unspecified peripheral vascular disease, and unspecified sequelae of cerebral infarction. During an interview on 4/30/24 at 9:46 a.m., Resident #60 reported no participation in care planning meetings and stated, They're supposed to do all that?, then began chuckling and clapping hands. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's Brief Interview of Mental Status (BIMS) score was 13 out of 15, indicating an intact cognition. Review of Resident #60's care plan revealed the goals for the resident's focuses had been revised on 1/15/24 with a target date of 6/20/24. A focus regarding the resident being a smoker had been initiated 4/11/24. Review of Resident #60's progress notes revealed there was no progress note on 4/11/24 regarding a care plan meeting. Review of the resident's progress notes from 12/30/23 to 1/29/24 did not reveal a care plan meeting had been held. An interview was conducted on 5/1/24 at 9:29 a.m. with Staff G, Registered Nurse/Unit Manager (RN/UM). The staff member reported being unaware of the location of Resident #60's care plan. An interview was conducted on 5/1/24 at 9:45 a.m., with Staff L, Senior Clinical Reimbursement Director. The staff member stated the CRD was in charge of scheduling and notifying residents and representatives of care plan meetings. The staff member reported doing an electronic progress note and at minimum the note contained what was discussed. Staff L reported the invitation (to resident) was used to record the attendees at the time of the care plan meeting. An interview was conducted on 5/1/24 at 11:11 a.m., with Staff L, the staff member reported finding one progress note for Resident #60 regarding a care plan meeting, dated 4/14/23, revealing a meeting was scheduled for 1 p.m. on 4/19/23. The staff member confirmed there was no note revealing what was discussed and being unable to locate a care plan invitation for the period between December 2023 and January 2024. Staff L confirmed the invitation for the care plan meeting on 4/11/24 at 1:45 p.m. for Resident #60 was blank. An interview was conducted on 5/2/24 at 9:58 a.m. with the Social Service Director (SSD), the SSD stated the attendees at the care plan meetings were a Certified Nursing Assistant, Activities, the Unit Manager or nurse or the MDS Coordinator has already spoken with the nurse regarding meds, (and/or) therapy. Review of Resident #60's care plan meeting invitations for 7/12/23 and 9/21/23 revealed the attendees were the resident, the CRD and the SSD. 2. On 4/30/24 at 8:16 a.m., Resident #55 was observed sitting in wheelchair, appropriately dressed, and the resident's bed was made. On 5/1/24 at 12:48 p.m., Resident #55 was observed lying in bed, eyes closed, with audible rhythmic breathing. Review of Resident #55's admission Record showed an admission date of 4/3/23 and diagnoses including but not limited to other encephalopathy, unspecified depression, and unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #55's care plan revealed Psychotropic Med: The resident uses psychotropic medications related to (r/t) antidepressant to manage: depression, initiated and revised 4/4/23. The goals initiated 4/4/23, revealed Resident will be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum functional ability both mentally and physically through the next review and Will have no side effects of psychotropic medications. The goals were initiated on 4/4/23, revised on 4/22/24, and had a target date of 7/6/24. Review of Resident #55's active physician orders did not reveal the resident was to receive either a scheduled or as needed psychotropic medication. Review of Resident #55's current and discontinued medications revealed the resident did not have a current order for any psychotropic medication and the discontinued medications showed the last psychotropic order was Trazodone 50 milligram - Give 1 tablet via gastrostomy (G-tube) at bedtime for insomnia. The resident's order for Trazodone was started on 4/3/23 and discontinued on 10/30/23. An interview was conducted with Staff L, Clinical Reimbursement Director (CRD) on 5/2/24 at 3:44 p.m., the CRD reviewed Resident #55's care plan and confirmed it revealed the resident was receiving antidepressant medications. The CRD reviewed the current and discontinued medications, revealing the resident had not been receiving any psychotropic medications since Trazodone, confirming the care plan should have been resolved when the resident's antidepressant, Trazodone had been discontinued in October 2023. The facility did not provide any other discontinued psychotropic orders from the time frame of October 2023 to May 2, 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to provide restorative therapy related to applying splints for Resident #30 and did not prevent the further decrease in range of motion for Resident #85 out of twelve residents. Findings included: On 04/29/24 at 10:25 a.m., an observation was made of Resident #30 in his room with his eyes closed. Resident #30 had a blanket covering his body from chest to feet with his arms on top of the blanket. Resident #30's hands were in a curled loose fist bilaterally on top of his chest. Record review of Resident #30's admission Record had an original admission date of 6/30/2018 with a readmission date of 04/15/2024. Resident #30 has a primary diagnosis of Multiple Sclerosis (MS) with secondary diagnoses to include but not limited to aphasia and dysphagia following nontraumatic subarachnoid hemorrhage, major depression, and contracture of muscle multiple sites. A record review of Resident #30 physician orders shows orders for Physical/Occupational and Speech Therapy to evaluate and treat as needed and Restorative Nursing as needed with a revision date of 4/15/2024. A review of Resident #30 care plan has a focus area of Range of Motion (ROM) actual limitations in range of motion, and remains at risk related to diagnosis of MS as evidence by contracture bilateral lower extremities initiated on 02/16/2023 and revised 02/11/2024. The goal for this focus area will be to maintain range of motion and remain free of injuries or complications related to limitations of range of motion with a target date of 05/17/2024. Interventions for this focus area include: to encourage/assist the resident to change position for comfort and to observe and report decline in range of motion. On 5/01/24 at 12:10 p.m., an interview was conducted with the Program Manager for the therapy department. The facility's restorative therapy program is formally called Functional Maintenance program and it is nurse driven. The therapy department will determine if a resident is appropriate for the Functional Maintenance program after the initial acute therapy regimen is completed or if the resident has reached their goals and /or not progressing. The therapy department will design the program which includes but not limited to donning and doffing splints, active and/or passive range of motion, and eating assistance or devices for eating. The therapy department will train the nursing staff to the designed therapy specifically made for a resident in this program. The Program Manager will hand a paper form to the unit managers for each hallway which consists of the therapy designed for the resident, actual pictures of the splint and how it looks on a resident and an education sign in sheet of the staff in-service. The Program Manager stated the nursing staff will have to place this into the electronic medical records as well so it will show up as a task for the certified nursing assistants (CNAs) to implement. The Program Manager was unaware of a new order for Resident #30 for PT/OT/Speech therapy to evaluate and treat dated 4/15/24. On 5/01/24 at 12:35 p.m., an interview was conducted with the facility's two-unit managers (UM), Staff A, Registered Nurse and Staff G, Registered Nurse (RN). Both agreed there is a notebook which contains the information for restorative therapy but where not sure of its location. On 5/01/24 at 1:05 p.m., the Program Manager was observed in Resident #30's room doffing isolation personal protective equipment (PPE) stating the evaluation was completed. On 5/01/24 at 1:15 p.m., an interview was conducted with Staff C, CNA and Staff D, CNA. Both staff members stated they are familiar with Resident #30 and they have seen him in splints but stated they do not see any splints in his room currently. Both staff members agreed the restorative therapy is done by the smoking aid CNA when she comes in at 11:00 a.m., in between the smoking periods, she will take care of the residents in the program. Both staff members, added Staff B, CNA will assist with the restorative therapy program as well. Neither staff member knew of the formal name for the restorative therapy as the Functional Maintenance program. On 5/01/24 at 1:38 p.m., incontinence care was observed for Resident #30 with Staff C, CNA and Staff D, CNA. Resident #30 had bilateral feet and toes in a stiff pointing position. Both staff members stated he has splints for his feet and hands but were unable to locate in the resident's drawers or closet. On 5/01/24 at 1:44 p.m., an interview was conducted with Staff B, CNA regarding her role in the restorative therapy program. Staff B, CNA stated she oversaw all the residents assigned to restorative therapy and stated most of her job duties included donning and sometimes doffing of splints, range of motion either Active or Passive. She would get the instructions from the physical therapy team but the nurses would put the plan into the electronic chart so the tasks could be viewed and charted by the CNAs. She would also assist in the dining area for residents in need of assistance or for queuing and/or observation while eating and assist with weighing residents as ordered. Ever since Covid she no longer oversees the restorative program and stated, I miss it quite a lot. Staff B, CNA recalled Resident #30 wearing splints at some point in the past but is rarely assigned to his area. Currently, Staff B, CNA did not know anything about the smoking CNA assisting in restorative therapy. On 5/01/24 at 2:20 p.m., the Program Manager showed the process of a current resident getting ready to complete her acute therapy program and transition to the Functional Maintenance program (restorative therapy). In the packet was the written plan of therapy, pictures of the splint to be placed in various stages of donning and a blank sign in sheet for the CNAs to sign once they have been educated. On 5/01/24 at 3:30 p.m., two unlabeled notebooks were provided of the current residents for their Functional Maintenance program (Restorative Therapy). Upon review, Resident #30 had programs in both notebooks {photographic evidence}. A list of residents for splints/braces was provided by the facility for a total of four residents. Upon further investigation of these two notebooks, other residents were listed as well as residents no longer in the facility. On 5/02/24 at 11:20 a.m., an interview was conducted with Staff C, CNA, Staff N, CNA and Staff R, CNA. All three agreed to not be part of the restorative therapy program. All three stated they do not place splints/braces on residents and the smoking aid/CNA oversees the splints/braces when she arrives at 11:00 a.m. On 5/02/24 at 11:50 a.m., an interview was conducted with Staff I, CNA. Staff I, CNA stated if she sees on her task list a resident for splints, she will follow the task and place it on the resident and complete it in her task. Staff I, CNA stated physical therapy is good for educating the nursing staff but if she had a question, she knows therapy would assist her with her concerns. A review of Resident #30's Task Description for CNAs has under Nursing Rehab: Assistance with splint bilateral lower ankle foot orthotics (AFOs) for up to six hours as tolerated , may remove to check skin integrity and for hygiene care. On 5/02/24 at 12:29 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The newly hired ADON stated she is aware of the lack of ownership for the restorative therapy program and stated this will be addressed from the bottom up stating this is a nursing issue and all need to take responsibility for this project. The ADON was not aware of the smoking CNA responsible for the restorative therapy and stated it was inappropriate. On 5/02/24 at 12:29 p.m., an interview was conducted with Staff T, CNA. Staff T, CNA was feeding a resident in his room. Staff T, CNA stated she will do the restorative therapy in between smoking times, feeding residents, answering the phone in the front when the receptionist takes a break and whatever activities I need to do, I just go where they tell me. On 4/29/2024 at 9:58 AM and 4/30/2024 at 9:15 AM Resident #85 was observed in bed, with arms crossed at the waste and hands bent with fingers touching both palms. Resident #85 was not able to open fingers or extend either arm out from the elbow. Review of Resident #85's admission Record showed a readmission date of 3/24/2024 and original admission date of 9/8/2023 with diagnoses including but not limited to: encephalopathy, abnormalities of gait and mobility, dysphagia, depressive disorder, hypertensive, anxiety, and paranoid schizophrenia. Review of Resident #85's Minimum Data Set (MDS) dated [DATE] revealed Section GG - Functional Abilities and Goals no upper or lower extremity impairments. Review of Resident #85's care plan revealed the Activity of Daily Living (ADL) care plan had been resolved on 3/25/2024. During an interview on 5/2/2024 at 10:15 AM Staff L, Clinical Reimbursement Director (CRD) reviewed Resident #85's care plan and stated an ADL care plan should be in place. An interview was conducted with Staff D, Certified Nursing Assistant (CNA) on 4/30/2024 at 10:01 AM stated I only provide care, not Range of Motion (ROM). ROM is provided by someone else but I don't know who. Staff D, CNA continued to state noticing some tightness in the Resident's upper and lower extremities when trying to dress Resident #85. An interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 4/30/2024 at 10:05 AM. Staff S, LPN stated she was unaware of who provided ROM to the residents. Staff S, LPN continued to state noticing Resident #85's fingers and elbows beginning to tighten, but did not think much of it. An interview was conducted with the Director of Rehabilitation (DOR) on 5/2/2024 at 10:56 AM. The DOR stated residents are screened based on referrals from nursing and the therapist are knowledgeable of the residents. The DOR went on to say screens might also be completed on a resident when readmitted from the hospital or if the resident has a functional decline. On 5/2/2024 at 11:05 AM an observation and interview were conducted with Resident #85 and the DOR. Resident #85 was lying face up in bed, arms were crossed at the waist and fingers were touching the palms. Resident #85 was not able to open her fingers on either hand when requested by the DOR. Nor was she able to extend her arms. The DOR asked Resident #85 if she could massage her hands. Resident #85 granted permission. The DOR massaged the Resident's hands for a few minutes then tried to open the palm of the hand (one hand at a time) the Resident grimaced and pulled away, bilaterally. The DOR stated the resident is in need of an evaluation and would request an order from the physician. During an interview on 05/2/2024 at 12:40 PM the Director of Nursing (DON) stated the expectation is for all CNAs to complete ROM and a referral to therapy be made if a staff member notices a decrease in any flexibility of a resident. Review of the facility's Restorative Nursing Programs dated revision October 2017 showed: Topic Restorative Nursing Programs and Guidelines Overview The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning. The interdisciplinary team (IDT), resident and, or family identify the needs of the resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The programs include: *Contracture Management and Prevention- This program includes the provision of active and/ or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity. * Mobility- This program improves or maintains self-performance in bed mobility, transfers, wheelchair mobility and walking. * Activities of daily Living-This program involves improvement or maintenance of the resident's self-performance in dressing (including prosthetic care), grooming and bathing. * Bowel and Bladder Continence- This program involves facilitating a resident in regaining or preserving continence to their maximal functional potential. * Restorative Dining- This program improves or maintains the resident's self-performance and self-feeding which may involve compensatory/adaptive strategies, positioning, and assistance/cues. * Communication- This program involves activities to improve or maintain the resident's self-performance and expressive and receptive communication. This may involve adaptive techniques, compensatory strategies, and adaptive devices. These programs can be combined based on the person-centered goals of each resident. The varied combinations can promote the highest functional level of each resident as well as enhance the restorative process. Refer to the following potential combinations that may be beneficial to the resident's needs. Combinations to consider that may enhance the restorative nursing process: *Passive Range of Motion (PROM) + Splint/Brace Assist *PROM/AROM (Active Range of Motion) + Splint/Brace Assist *AROM plus dressing/grooming *Bed Mobility + Transfer *Eating/Swallowing + Splint/Brace Assist *Bed Mobility/Walking + Transfer *Amputation/Prosthesis Care + Dressing/Grooming *Transfer + Amputation/Prosthesis Care *Transfer + Walking + Bowel/Bladder *Transfer + Walking *Communication + Dining + Walking *Communication + ADL (grooming/dressing) + Transfers

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure medication was administered in a clean manner, ensure staff doffed PPE (personal protective equipment) appropriately, and residents were offered hand hygiene prior to meals. Findings included: On 4/30/24 at 11:00 a.m., an observation was made of the main dining area prior to lunch service of residents self-propelling with their arms to dining tables. Staff were present waiting for lunch tray delivery and/or bringing residents to the dining area. Residents were not offered hand hygiene prior to the delivery of lunch. The Activities Director was witnessed washing a resident's hands with a wet paper towel and then sitting next to this resident to assist with feeding. On 5/01/23 at 1:38 p.m., an observation was made during incontinence care of two Certified Nursing Assistants (CNAs) and a resident on Enhanced Precaution Isolation. Both CNAs were wearing appropriate personal protective equipment (PPE) during the care provided to the resident. The resident was turned to his left side with the assistance of Staff C, CNA while Staff D, CNA was in the process of cleaning the resident and changing the linen. Staff D, CNA with the same PPE still on rummaged through the resident's closet stating she was looking for a sheet. Unable to locate what she was looking for, Staff D, CNA walked out of the room with the same gloves and gown used while providing care and walked across the hallway to the locked linen closet pressing numbers on the code box to obtain access into the closet. Numerous attempts were made at accessing the linen closet via the locked keypad system. Unable to access the closest, Staff D, CNA returned to the resident's room. Staff C, CNA rolled the resident to his back, removed the PPE appropriately and gathered the sheet in the linen closest. Staff C, CNA donned new PPE and returned to assist Staff D, CNA to complete the care provided to the resident. Staff D, CNA removed the PPE she was wearing and left the room with dirty linen in a bag. Staff A, Registered Nurse/Unit Manager was notified of the incident and stated, She knows better than that, I will talk to her. Staff A, RN/UM was seen cleaning the keypad to the linen closest. On 5/01/24 at 9:30 a.m., an observation was made of Staff E, RN during medication administration. Staff E, RN was observed pulling medication administration cards for the resident but did not punch the tablet into a medicine cup but instead popped the medication in his hand to then dropped the pill into the cup. When questioned regarding the cleanliness of this process, Staff E, RN stated he uses the alcohol based hand rub (ABHR ) in between each medication. This process was not witnessed consistently and Staff E, RN was witnessed opening and closing medication drawers as well as touching medication cards. On 5/02/24 at 8:18 a.m., an observation was made of Staff F, RN during medication administration. Staff F, RN was observed dropping a pill onto the medication cart and placed it back into the medicine cup. During medication administration of a resident, Staff F, RN attempted to give all eleven pills at once to a resident. Resident was unable to take all at once and pills were witnessed dropping down the side to the resident onto her side by her hip in the bed. Staff F, RN rummaged through the bed, picked up loose pills with his ungloved hand and placed them in the resident's mouth to complete the medication administration for this resident. On 5/02/24 at 10:30 a.m., the Director of Nursing was aware of the infection control during medication administration. A review of the facility's policy titled: Medication Administration General Guidelines, Section 7.1 dated 09/18 shows their policy as: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. . 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, optic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: soap and water should always be used after contact with residents with Clostridium difficile (C. Diff) as antimicrobial sanitizer does not kill the spores produced by C. Diff., which may result in the spread of the infection. An observation was conducted of meal service on 5/1/24 at 8:12 a.m., with Staff H and Staff I, Certified Nursing Assistant's (CNAs). The observation revealed the breakfast meal cart was delivered on 5/1/24 at 8:16 a.m. to hallway. The following was observed: - 8:16 a.m., the breakfast cart arrived to the unit. - Staff H delivered a tray to room [ROOM NUMBER] A-bed without offering hand hygiene; - Staff H delivered a tray to room [ROOM NUMBER] A-bed, leaving the room without offering hand hygiene; - 8:22 a.m., Staff I delivered tray to Resident #60, who opened eyes and stretched, the staff member encouraged the resident to open eyes and not close eyes, leaving the room without offering hand hygiene. During an interview with Resident #60 on 4/30/24 at 9:47 a.m., the resident stated the facility did not ask residents to wash hands before meals. Resident #60 was observed during the survey period eating meals in room and in the main Dining Room. Review of the facility's policy and procedure titled with the Topic Hand Hygiene dated Effective February 2021 showed: Policy The facility considers hand hygiene the primary means to prevent the spread of infections Procedure: . 2. Personal shall follow the handwashing/hand hygiene guidelines to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. No other policy and procedure were received from the facility in regards to resident hand hygiene.

Based on observations, interviews and policy review the facility failed to ensure a clean and sanitary kitchen on three of three observations regarding areas that were not clean or were in disrepair. Finding included During an observation on 4/29/2024 at 11:00 a.m. showed on an initial tour in the kitchen a dirty trash can next to the hand washing station. Food trays were observed piled up on kitchen sink, next to the hand washing station during meal preparation. Dirt and food particles were observed on the walk-in refrigerator floor. During a follow-up kitchen visit on 04/31/2024 at 11:00 a.m., showed the kitchen stove dirty with grease stuck on the side of the stove and missing stove knobs covers. An open garbage can was observed next to cooked food on the stove. The kitchen floor was observed dirty multiple times throughout the survey. During an interview on 5/3/2024 at 2:00 p.m., with the Certified Dietary Manager, CDM. She stated that there are areas in the kitchen that need to be cleaned up. She has tried to clean the walk-in refrigerator floor, but it is very hard to clean that type of floor. She agrees that the stove should be cleaner than what it looks like right now. During an interview on 5/3/2024 at 2:00 p.m., with the Nursing Home Administrator. She stated she has spoken with CDM multiple times about the cleanliness of the kitchen. The way the kitchen was presented is not acceptable and her expectations are that her kitchen remains clean. Review of the facility policy titled, Cleaning and Sanitation Effective date September 2012, showed the facility promotes a clean and sanitary environment for its employees, residents, and visitors. The entire Food and Nutrition Service team maintains clean and sanitary kitchen facilities and equipment walls, floors, ceiling, equipment, and utensils are clean, sanitized and in good working order. 7. Follow appropriate procedures for washing and sanitizing kitchen equipment. 12. Cover trash cans with lids while in the kitchen and/or when taken out to dumpster. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide monitoring and care according to professional standards of practice related to urinary catheter care for one resident (#1) out of 3 residents sampled for catheter care. Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a hospitalization. Resident #1 diagnoses include but are not limited to, Bacteremia, Stage 3 Chronic Kidney Disease, candidiasis, need for assistance with personal care, obstructive and reflux uropathy, dementia without behavioral disturbances, and dysphagia. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed in Section H: Bladder and Bowel, Resident #1 had a urinary catheter. Section C: Cognitive Patterns, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. A review of Resident #1's Certified Nursing Assistant (CNA) documentation from 7/3/23-7/12/23 revealed documentation that identified Resident #1 as having an indwelling urinary catheter. An observation was conducted of Resident #1 on 7/12/23 at 3:00 p.m. The resident was observed to be in bed sitting upright with the head of the bed elevated, watching television. A urinary catheter bag was observed to be hanging on her bed frame, empty and off of the floor. A review of Resident #1's Physician orders did not reveal any orders related to Resident #1 having a urinary catheter, care of a urinary catheter, or monitoring of a urinary catheter. A review of Resident #1's July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal any documentation a urinary catheter was being monitored or cared for by nursing. A further MAR and TAR review from June 2023, revealed Resident #1 had not had a urinary catheter monitored or cared for by nursing since June 12th, 2023. An interview was conducted on 7/12/23 at 2:00 p.m. with the facility's Director of Nursing (DON). She confirmed there were no urinary catheter orders in place for Resident #1 and she stated, The resident has been in and out of the hospital so the orders must not have been reordered when she came back. On 7/12/23 at 2:35 p.m. The DON stated the facility does not have a urinary catheter policy for review, they only have a catheter competency list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/01/2022 at 1:58 p.m. a phone interview was conducted with Resident #3 family member, who confirmed she felt like someone was taking her mother's money. She said staff were probably changing her mother money to get things for her. She stated, how else would $10.00 be gone in 2 days? The family member said she had told a staff member about the missing money. She indicated she could not recall the staff member name. Review of the facility provided Grievance Log did not reveal an entry for Resident #3 related to missing money. On 11/03/2022 at 11:35 a.m. interview was conducted with the SSD, who said he was not aware of any missing money for Resident #3. 4. On 11/02/2022 at 9:25 a.m. Resident #4 was observed in his bed and when approached he was receptive to an interview. He appeared comfortable and answered questions appropriately. Resident #4 said he was missing a [sports team] T-shirt and it was blue in color. He stated, it was brand new, and I had only worn it one time. He further stated, I told the social worker about it. He said it was a couple of months ago, and denied the social worker followed-up with him. Review of the facility provided Grievance Log did not reveal an entry for Resident #4 for the prior five months. On 11/03/2022 at 10:30 a.m. an interview was conducted with the Nursing Home Administrator (NHA), who stated, I am unaware he had a missing [sports team] T-[NAME].t The NHA confirmed if a resident had a concern with a missing item, there should be an entry in the grievance log. On 11/03/2022 at 10:19 a.m. an interview was conducted with the SSD, who confirmed he knew Resident #4. When asked about his concern related to a missing [sports team] T-shirt, he stated I remember him telling me about it. I don't recall when it was. I can't recall if it was last month, I really can't recall how long it had been. The SSD said when a resident is missing something he would normally write it down in the Grievance Log. He reviewed the log that was provided by the facility and confirmed that the log did not reflect a grievance for the missing shirt for Resident #4. Based on observation, record review and interviews, the facility failed to comprehensively implement the facility Grievance policy and procedures for four (#8, #2, #3, and #4) of fifteen sampled residents. Findings include: A review of the facility policy and procedure, Grievance/ Concern Management, effective February 2021, documented the policy: Residents/representatives have the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing and the reporter may request to remain anonymous . These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. The Procedure included: .4. The NHA is responsible for oversight of the concern process. 5. The Social Services Representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion. 6. The department involved will document the concern and record the resident/resident representative's satisfaction with the resolution to the concern . 10. Concerns are tracked, trended, and reported in monthly QAPI Committee Meeting. 1. On 11/02/2022 at 9:35 a.m., Resident #8 was observed in her bed in her room. She agreed to an interview, and stated, the staff member with the orange jacket, who was working today, her language is not appropriate, and she followed with explicative comments, which she reported the staff member used. Resident #8 said she had told someone two days ago. Resident #8 stated, they put a stop to it. Now she does not say anything at all. She is rough. She throws my legs out of the bed. I cannot lift them because they are so filled with fluid. It is painful when she cares for me. She roughs me up. Some people are really nice, and they take care to be sensitive and move you gently. Not her. The Certified Nursing Assistant (CNA) with the orange jacket was observed in the hallway outside of Resident #8's room, and she was identified to be Staff C. A review of the facility grievance log for the date of 05/01/2022 through the date of survey, 11/02/2022 reflected no grievances from Resident #8. An interview was conducted on 11/02/2022 at 10:00 a.m. with the Social Service Director (SSD). He stated Resident #8 had not complained or filed a grievance. An interview was conducted on 11/02/2022 at 4:40 p.m. with the Payroll Specialist. She confirmed she had access to the personnel files and reported there were no reports or disciplinary action for Staff C, for use of inappropriate language that she was aware of. She said, if so, it should have gone to social services. On 11/03/2022 at 9:57 a.m., during an interview with the Nursing Home Administrator (NHA), she stated she had gone and talked to Resident #8 yesterday after the Payroll Specialist had told her about the surveyor asking if there were any disciplinary or counseling for Staff C, CNA. The NHA stated she had suspended Staff C yesterday, and she file a reportable event form. 2. A review of Resident #2's clinical chart, the face sheet, reflected an admission of 03/02/2022, and a subsequent discharge of 07/08/2022. A phone interview was conducted on 11/03/2022 at 11:25 a.m. with Resident #2's family member. The family member stated, she had visited her mother in July, and she mentioned to her she was missing $95.00. The family member reported she had given her the $95.00 with her identification at admission. The daughter stated, they said they would look for it. Never heard anything else. A review of the facility Grievance log reflected no grievances for missing money for Resident #2. On 11/03/2022 at 11:35 a.m., the SSD was interviewed. He stated he was not aware of $95.00 missing for Resident #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure it implemented the facility Abuse Prevention Program related to the absence of Abuse and Neglect training for one (Staff B, Certified Nursing Assistant) of five direct care staff members reviewed. Findings include: On 11/02/2022 at 2:20 p.m. the Nursing Home Administrator (NHA) was asked to provide Level II background screenings, most recent Abuse & Neglect training, and license information for five direct care staff members, which included Staff B, Certified Nursing Assistant (CNA). A review of Staff B's Certified Nursing Assistant (CNA) personnel file reflected a hire date of 10/10/2022. The facility did not provide evidence Staff B, CNA had received Abuse and Neglect training. Further review of Staff B's personnel file reflected she had formerly terminated employment from the facility on the date of 04/28/2022. An interview was conducted on 11/03/2022 at 11:47 a.m. with the NHA. She confirmed Staff B, CNA, had been hired on 10/10/2022 and Staff B, CNA was a rehired employee. The NHA reported Staff B had received a copy of the employee handbook, which she stated the employee had signed receipt of, and in that handbook on page 34, she said the handbook covered Abuse and Neglect training. A review of the handbook reflected a risk management paragraph, and under this paragraph, the handbook briefly outlined abuse reporting. On 11/03/2022 at 12;07 p.m. an interview was conducted with the Staff Educator, Registered Nurse (SERN). She confirmed she normally would provide education to employees. She stated Staff B, CNA was a rehire, so, she only signed the employee handbook. The SERN said, Staff B did not have the Abuse and Neglect training with the new hired employees, because she was a rehire. On 11/03/2022 at 12:54 p.m., an interview was conducted with the Regional Nurse Consultant (RNC). She provided the facility Day 1 Agenda Checklist New Employee Orientation summary list which listed the orientation curriculum. Included in the curriculum was a 1-hour long session, which included Risk Management and Events Reporting; Abuse/Neglect/ Exploitation/Mistreatment and Misappropriation-Immediate Reporting; Compliance Hotline; Leave of Absence/Elopement/Missing Residents; Quality Assurance; Smoking and Designated Areas; and Elder Justice Act. The RNC reported the Risk Designee was to provide the training. The RNC further reported that at this time, the Risk Designee was the NHA. The facility did not provide any documentation that would indicate Staff B, CNA, had received the facility orientation. On 11/03/2022 at 1:35 p.m., the NHA provided a Post Test Abuse, Neglect and Exploitation document, dated 10/12/2021 (over one year old), that had Staff B's name printed on the cover. A review of the second page, the line that the employee would sign, was blank. A review of the facility's Abuse Prevention program policy and procedures, effective date January 2012, last reviewed October 2022, documented the policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. Included in procedures: Training: Facility orientation program & ongoing training programs will include, but may not be limited to: 483.95 (c): Freedom from abuse, neglect, & exploitation requirements in 483.13. 483.95 (c): Activities that constitute abuse, neglect, exploitation, & misappropriation of resident property as set forth in 483.12. 483.95 (c): procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. 483.95 (c): Dementia management & resident abuse prevention. Elder Justice Act. Identification of abuse, neglect, mistreatment, exploitation, and misappropriation. Utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff, aggressive &/or catastrophic reactions of residents. Refer to Behavior Management program and Code CAT process for further information. How staff should report their knowledge related to allegations without fear of reprisal. How to provide protection for residents. Components of a complete and through investigation. Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques. Refer to HR Manual for identifying and managing staff burnout, and [NAME] (Employee Assistance Program) availability. Staff training will be documented and maintained with facility education records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy on medication administration, the facility failed to ensure sufficient nursing staff to meet the needs of residents as evidenced by 1.) Untimely medication administration for eight (#1, #9, #10, #11, #12, #13, #14, #15) of fifteen residents; and 2.) Untimely Speech Therapy Evaluation for one (#3) of fifteen sampled residents. Findings Include: 1. On 11/02/2022 at 10:10 a.m. an interview was conducted with Resident #1. The resident stated, I'm not getting my medications on time. Their late every day. I won't take them after 11:00 a.m. I have things I have to do, and it doesn't make any sense why I have to wait so long. On 11/02/2022 at 10:15 a.m. Staff Member A, Licensed Practical Nurse (LPN) was observed on the 200 unit in a resident bedroom administering medications. She confirmed she was administering medication to the 200 unit and part of the 400 unit. The LPN said she would start administering medications on the 400 unit in approximately half an hour. Staff A said her normal routine was to start on the 200 unit but today a certified nursing assistant (CNA) did not show up for work and that had left the residents on the unit with one nursing assistant. Staff A said she had assisted the residents which caused the medication pass to be delayed. She then added even if she had started the medication pass on time (8:00 a.m.) she was not unable to administer 31 resident's medications timely. When asked if she had informed anyone about her concern about not having sufficient time allowed to provide the necessary medications she stated, I told the Unit Manager, the Director of Nursing, and the Nursing Home Administrator. On 11/02/2022 at 10:50 a.m. Staff Member A confirmed she finished the 200 unit and was preparing medication for Resident #1. The following medications were prepared and administered at 10:56 a.m.: -magnesium oxide oral tablet 400 milligrams (mg) -loratadine 10 mg -keppra 500 mg give one two times a day -furosemide tablet 40 mg one time a day -metoprolol tartrate tablet 25 mg two times a day -potassium tablet 10 milliequivalents (meq) one time a day. Review of Resident #1 Medication Admin Audit Report revealed her medications were due at 9:00 a.m., indicating the medications were delayed by one hour and fifty-six minutes. Further review of the audit reflected on 11/01/2022 the resident's medications were administered at 10:20a.m., and on 10/31/2022 at 10:28a.m. At 11:00 Staff A, LPN confirmed Residents #9, #10, #11, #12, #13, #14, and #15 had not received their medications, which were due at 9:00a.m. Review of Resident #9 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. medications listed: -amlodipine 10 mg -hydralazine HCI 50 mg tablet three times a day -aspirin 81 tablet one time a day -lexapro 10 mg tablet one time a day -baclofen 0.5 mg tablet three times a day -pantoprazole 40 mg tablet one time a day. The audit did not reflect an administration time for the day. Review of resident #10 Medication Admin Audit Report revealed his scheduled 9:00 a.m. medications listed: -folic acid 800 micrograms (mcg) give one tablet time a day -vitamin B-12 1000 MCG one tablet one time a day -atenolol 100 mg one time a day -hydrochlorothiazide 12.5 mg tablet give one two times a day -fluphenazine HCL tablet give 2.5 mg two times a day -simbrinza suspension 1-0.2% instill one drop in both eye three times a day. The audit reflected the administered time at 11:17 a.m. Further review of the audit reflected on 11/01/2022 the 9:00 a.m. scheduled medications were administered at 10:34 a.m., on 10/31/2022 at 10:50 a.m., and on 10/30/2022 at 10:25 a.m. Review of resident #11 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. medications listed: -amlodipine 5 mg one time a day -levetiracetam 500 mg tablet two times a day -metoprolol 25 mg two times a day -venlafaxine HCL 225 mg one time a day -aspirin 81 mg one time a day -cephalexin 500 mg give two times a day -famotidine 20 mg two times a day. The audit did not reflect an administration time for the day. Further review of the audit reflected on 11/01/2022 scheduled 9:00 a.m. medications were administered at 10:36 a.m. and on 10/28/2022 at 12:34 p.m. Review of resident #12 Medication Admin Audit Report revealed his scheduled 9:00 a.m. medications listed: -fluoxetine NCL 20 mg one time a day -ferrous sulfate 325 mg one time a day -divalproex sodium 500 mg one tablet three times a day -spironolactone 12.5 mg tablet two times a day -lactulose 30 gram three times a day -metformin HCL 1000 mg two times a day -clopidogrel 75 mg one time a day -lisinopril 10 mg one time a day The audit reflected the administered time at 11:11 a.m. Further review of the audit reflected on 11/01/2022 the scheduled 9:00 a.m. medications were administered at 10:48 a.m. Review of resident #13 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. medications listed: -gabapentin 100 mg give 2 capsules two times a day -apixaban 5 mg two times a day -clopidogrel bisulfate 75 mg one time a day -Tylenol extra strength 500 mg two tablets two times a day. The audit did not reflect an administration time for the day. Further review of the audit reflected on 11/01/2022 the 9:00 a.m. medications were administered at 10:43 a.m., on 10/31/2022 at 11:15 a.m., and on 10/30/2022 at 10:31 a.m. Review of resident #14 Medication Admin Audit Report revealed she had medications scheduled 8:00 a.m. and 9:00 a.m. The 8:00a.m. medications listed: -omeprazole delayed release 40 mg every morning and at bedtime -fish oil 1000 mg every morning and at bedtime -levetiracetam one every morning and at bedtime -furosemide 40 mg one every morning and at bedtime. The 9:00 a.m. scheduled medications listed: -potassium 20 [NAME] one a day -cyanocobalamin 1000 mcg one time a day -multivitamin one time a day -carvedilol 6.25 mg two times a day -folic acid 1 mg one time a day -albuterol sulfate two puffs two times a day -fluconazole 200 mg one time a day -budesonide -formoterol two puffs two times a day -canagliflozin 100 mg one time a day. The audit reflected on 11/02/2022 the 8:00a.m. and 9:00a.m. medications were administered at 11:08 a.m. Further review of the audit reflected on 11/01/2022 the morning medications were administered at 10:24 a.m., on 10/31/2022 at 10:32 a.m., and on 10/29/2022 at 1:08 p.m. (13:08). Review of resident #15 Medication Admin Audit Report dated November 2,2022 at 11:30 a.m. revealed his scheduled 9:00 a.m. listed: -memantine HCL 5 mg one time a day -metoprolol tartrate 25 mg one tablet two times a day -procardia XL 25 mg give one two times a day -lexapro 10 mg one time a day -aspirin 81 mg one time a day donepezil 10 mg one time a day metformin HCL ER give one tablet two times a day. The audit did not reflect an administration time for the day. Further review of the audit revealed on 11/01/2022 the morning medication were administered at 10:31 a.m., on 10/31/2022 at 10:51 a.m., and on 10/30/2022 at 10:33 a.m. On 11/02/2022 at 1:09 p.m. during an interview with the NHA, she stated, we started an ad hoc training on medications given on time, lacking organization skills, and less distractions. It is being provided by the Staff Development Coordinator at this time. She said we have unit managers (UM) that help the nurses during the day and perform treatments. The NHA confirmed it is her expectation the staff would deliver the residents with their medications timely. On 11/02/2022 at 1:18 p.m. an interview was conducted with the Director of Nursing (DON) related to the residents on the 400 unit not being provided their medications in a timely manner. She stated, will call the Physician and inform them. She said normally I would have two-unit managers on the units. One is out today and the second one is working a unit. She said she was unaware a nursing assistant did not show up today. Review of the policy titled Medication Administration dated 2007. General Guidelines Policy Medications are administered as prescribed in accordance with manufactures specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. PROCEDURES Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered in according to the established medication administered schedule for the nursing center. 2. Review of Resident #3 admission Record form revealed the resident had resided at the facility for over a year. Diagnosis information listed primary hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, aphasia, dysphagia, dysarthria, gastrostomy status and gastroesophageal disorder. (Dysarthria - difficulty speaking caused by brain damage, which results in an inability to control the muscles used in speech. Dysphagia - difficulty swallowing, which can be a symptom of dysarthria). A review of progress notes dated on 09/27/2022 at 10:28 a.m. reflected a Therapy Referral was made for Speech (ST) consult for evaluation (eval) and treatment (tx) for dysphagia and increased difficulty swallowing. At 1:43 p.m. (13:43) Therapy referral received. Signed by the Speech Therapist. A continued review of progress notes dated 10/06/2022 at 1:01 p.m. (13:01) revealed a Therapy Referral The following were noted: Difficulty feeding self. While: not eating Referral was made to speech (SP) Further review of progress notes dated 10/12/2022 08:33 revealed Therapy Referral Received. Signed by the Director of Therapy Services. At 10:34 a.m. resident reports difficulty with eating utensils. She is requiring increased assistance with meals. Therapy referral noted. On 11/02/2022 at 3:55 p.m. an interview was conducted with the Speech Therapist (ST). She said she knew Resident #4 and had worked with her in the past. The ST said Resident #4 was able to understand when she was spoken to. She had dysarthria and mild cognitive impairments but not significant. Her primarily goals were dysphagia and speech. She was cooperative and receptive to the therapy. She said she additionally had worked with the resident the day (10/13/2022) prior to being discharged to the hospital. The ST said her first treatment was 10/05/2022. The ST confirmed there had been an eight-day delay. She stated, sometimes when the nursing referral goes into [name of the computer system] there is a breakdown in communication. On 11/02/2022 at 4:10 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated, The Therapy Department is responsible for running their daily reports. On 11/03/2022 at 10:10 p.m. an interview was conducted with the Rehabilitation Director and the NHA. The Director said she had received a speech evaluation recommendation for Resident #4 on 09/27/2022. She confirmed the resident was not seen until 10/05/2022. The Director said she has one speech therapist. She continued, saying, if necessary, a sister facility therapist can come over and help. The Director stated, the Speech therapist was off on 09/30, (Friday), 10/01, 10/02, and returned on 10/03/2022. She further said she was off on 10/02/2022. The Director said when she returned on 10/03/2022, she went through the box of paperwork and assigned the evaluation to start on 10/05/2022. She added, that was the soonest it could be done. When asked if she had asked for assistance to get the evaluation (speech) done, she said she had not. The Director said normally evaluations are completed within three days of the referral. She confirmed the evaluation took nine days to implement care after receiving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure a change in condition was identified and addressed in a timely manner for one resident (#83) of fifty sampled residents. Findings include: During a facility tour on 02/14/22 at 9: 53 a.m., Resident #83 was observed in his room laying on the bed. His roommates were observed eating their breakfast meal. Resident #83's breakfast tray was noted untouched. Resident #83 did not eat anything from his tray, and staff assistance, supervision or cueing was not observed. On 02/14/22 at 10:05 a.m., Resident #83 was observed from the doorway, noted to be throwing up. Emesis was observed on his gown and bed linens. Staff O, Certified Nursing Assistant (CNA) and Staff P, Registered Nurse (RN) were notified. An immediate interview was conducted on 02/14/22 at 10:08 a.m. with Staff O, after responding to Resident #83. Staff O stated, He makes himself throw up and then hides it. Staff O said this had been going on since the resident was admitted to the facility. Review of an admission Record for Resident #83 showed an admission date of 01/20/22, and diagnoses to include, muscle wasting and atrophy, Schizophrenia, hypothyroidism, adult failure to thrive, unspecified protein calorie malnutrition, difficulty walking, need for assistance with personal care, respiratory care, iron deficiency and underweight. An admission Minimum Data Set (MDS) dated [DATE] showed under Section C Cognitive Patterns that Resident #83's Brief Interview for Mental Status (BIMS) could not be assessed, indicating severe mental impairment. Section D related to mood, showed the total severity score was not assessed. Section G Functional Status showed Resident #83 required supervision for eating with one-person physical assist. Section K indicated no swallowing disorders and no complaints of loss of fluids, holding food in the mouth, no coughing or choking and no complaints of pain when swallowing. Section K also showed Resident #83 was admitted with a weight of 123 pounds and had no indication of weight loss or weight gain. Review of the electronic medical record (EMR) showed Resident #83 had a current weight of 119.4 pounds, indicating current weight loss. Review of a lunch meal ticket for Resident #83 dated 02/14/22 showed the resident was on a regular diet, thin liquids and an SB6 mechanical diet, meaning Resident #83 should be receiving a soft, tender, and moist diet. Under preferences, the ticket showed to add fortified food, magic cup, and whole milk. A care plan for Resident #83 showed a Nutritional focus initiated on 01/31/22 indicating Resident #83 had a potential nutritional problem due to schizophrenia diagnosis, underweight body mass index (BMI) category. The goal indicated Resident #83 will maintain CBW (current body weight) without weight loss and maintain nutritional intake through the next review. The interventions included to receive fortified foods with meals, weights as indicated, allow adequate time to eat, diet as ordered, fluids as ordered, offer substitute if refusal, obtain and review labs, observe and document meal consumption, amount assistance needed with meal, tolerance to diet / fluids, administer meds as ordered and to notify physician as needed. Resident #83 was further observed as follows: -On 02/14/22 at 1:23 p.m., Resident #83 was observed in his room during lunch, his tray was noted untouched as his roommates were finishing their meal. -On 02/14/22 at 1:44 p.m., Staff O was observed removing the tray from the room. Staff O said the resident refuses to eat, and stated, He never asks for anything. I will offer him yogurt or something. -On 02/15/22 at 8:53 a.m., Resident #83 was observed with his breakfast tray and did not eat his breakfast meal. -On 02/16/22 at 8:38 a.m., Resident #83 was observed in his room without a tray. Resident #83's roommates were observed eating their breakfast. A follow -up interview was conducted with Staff Q, CNA on 02/16/22 at 8:59 a.m Staff Q confirmed Resident #83 did not eat his meal. Staff Q said, He never eats. He drank a little juice and spit it out. An interview was conducted on 02/16/22 at 8:59 a.m. with Staff P, RN. Staff P said, Everyone knows he [Resident #83] does not eat. Staff P stated they had notified the doctor. On 02/16/22 at 1:29 p.m. Resident #83 was observed in his room with his lunch tray noted untouched. Resident #83 was observed spitting out a pink colored liquid. Review of physician orders for Resident #83 printed on 02/17/22 showed: -Diet orders dated 01/21/22, regular texture diet, regular thin consistency, fortified foods with meals and a health shake BID (twice daily) with lunch and dinner. -Medpass (nutritional supplement) three times a day for poor intake give 240 ml (milliliters), dated 02/16/22 -Speech Therapy, Resident to be seen 5 times per week for dysphagia management for dysphagia management, dated 02/10/22. -Mirtazapine daily for appetite, dated 01/21/22. -Send to ED (emergency department) for evaluation dated 02/16/22. Review of Resident #83's Medication Administration Record (MAR) dated 02/01/22 to 02/28/22, printed on 02/17/22, showed Resident #83 had been refusing his medications for 6 days (02/11/22 to 02/16/22). The MAR showed an order for KUB (Kidney, Ureter and Bladder) X-ray was ordered STAT (immediately) on 02/15/22. Review of Resident #83's progress notes did not show any documented reports related to on-going refusal to eat, reports of daily emesis and on-going medication refusals. Request for IDT (inter-disciplinary team) meeting notes presented by the facility showed the facility did not identify concerns of refusal to eat, daily emesis and medication refusals. The notes showed unrelated documented concerns of weights and showers. On 02/16/22 at 4:03 p.m., an interview was conducted with Staff R, CNA. Staff R stated Resident #83 has been refusing food from day one. Staff R said, He should be checked out. He does not eat or drink. Review of the CNA Task Log dated 01/21/22 to 02/16/22 showed Resident #83 ate less than 25% of his meal or refused entire meal consistently for the entire 30-day period reviewed. An interview was conducted on 02/16/22 at 1:33 p.m. with the Certified Dietary Manager (CDM) and the Registered Dietician (RD). The RD stated Resident #83 was admitted with a diagnosis of schizophrenia and did not express any food preferences, nor eating concerns on admission. The RD stated Resident #83 answered yes and no questions and did not express himself. The RD said Resident #83 was eating about 50% when he came in and fortified foods were included in his diet, and she had just added a high nutrient treat twice a day. The RD and CDM confirmed they did not know Resident #83 was not eating and was throwing up his meals. The RD said, I was not notified that he was eating any differently; the nurses should have notified me that he was spitting out his drinks. An interview was conducted with the Director of Nursing (DON) on 02/16/22 at 1:58 p.m The DON said, I was notified yesterday that he was not eating and is spitting out fluids. The DON stated she called the doctor and ordered a KUB (abdominal x-ray). The DON confirmed she had just become aware of the concern with not eating, emesis and refusing medications. The DON said, They [nurses] should have notified me and the doctor. A follow-up interview was conducted with the DON on 02/16/22 at 4:00 p.m The DON stated Resident #83 had some GI (gastrointestinal) issues and that was why she had called the doctor. The DON stated Resident #83 had refused the KUB x-ray and she had let the doctor know, and was sending him out to the ED (emergency department). The DON confirmed notification should not wait 2-3 weeks, and stated, If a resident has GI issues, nurses should call the doctor right away. On 02/17/22 at 1:45 p.m. Resident #83 was observed in his room with Staff S, Speech Therapist and the CDM. The CDM reported Resident #83 did not eat lunch, and stated, He threw up the med pass, we are attempting to give him water. An interview was conducted on 02/17/22 at 1:12 p.m. with Staff L, RN Unit Manager. Staff L said she did not do anything about the medication refusals because she thought the doctor knew about it. Staff L stated she had contacted the family today and was updated on his meal preferences. Staff L confirmed she did not know Resident #83 had any concerns prior to this week. An interview was conducted with Resident #83's doctor on 02/17/22 at 10:31 a.m The physician stated he had been notified Resident #83 refused his medication but could not recall when he was notified. The physician stated he comes to the facility on Thursdays, and he would follow-up. Review of the facility's policy titled, Physician Notification, dated October 2021, showed that Licensed Nurses will ensure physicians are notified of changes or diagnostic results that occur between visits. Changes may include but are not limited to: -A change in condition, mental or physical. -Resident's refusal to take medication. Review of the facility's policy titled, Notification of Resident / Patient Change in Condition, dated October 2021, showed: (1.) Notify the physician/resident representative and case management when indicated, if there is a significant change in condition, regardless of the time of the day. (2.) Document the nurses' notes, the time notification was made and the names of the person(s) to whom you spoke to. Review of an undated facility policy titled, Medication Administration, showed under page 6 of 6: (2.) If a dose of regularly scheduled medication is refused, an explanation note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to identify and develop a care plan with problem areas, goals, and interventions to include the use of an antibiotic and diagnosis of a Urinary Tract Infection (UTI), timely, for one (#62) of fifty sampled residents. Findings include: On 2/15/2022 at 1:45 p.m. Resident #62 was observed in his room. The side of the bed was observed with a properly placed urinary catheter drain bag, and catheter tubing. In a subsequent interview, Resident #62 revealed he currently had a Urinary Tract Infection and was receiving antibiotics; he could not remember how long he had been on antibiotics. On 2/15/2022 at 2:00 p.m. an interview with Staff I, Unit Nurse confirmed Resident #62 was recently readmitted from the hospital and is being treated with an antibiotic for a UTI. On 2/16/2022 at 10:00 a.m. an interview with the Staff T, 300/400-Unit Manager also confirmed Resident #62 had a UTI and is receiving antibiotics. Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the current Minimum Data Set (MDS) admission assessment, dated 1/10/2022, revealed: Cognition/Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating he had intact cognition; Under Active Diagnosis, UTI was not checked. Review of the current Physician's Order Sheet dated for the month 2/2022 revealed: - Cipro 500 mg (milligrams) 1 PO (orally) BID (twice daily) for 7 days (original order date 2/12/2022 and end date 2/19/2022) for a UTI. - Schedule transport for Urology appt. (appointment) on 2/22 at 1:45 p.m. Review of the progress notes/assessments revealed: -2/11/2022 - Reviewed labs and indication of UTI. -2/12/2022 - Orders to start Cipro for UTI. -2/14/2022 - Continues Antibiotic for UTI. -2/16/2022 - Antibiotic/UTI continues PO fluids encouraged and accepted this shift. On 2/16/2022 at 1:00 p.m. and again on 2/17/2022 at 10:00 a.m., review of the current care plans with next review date 5/2/2022 revealed: -Use of catheter with history of infection and or complication with interventions in place. The care plan did not indicate problem areas, goals and interventions related to a UTI, nor use of an antibiotic. On 2/16/2022 at 1:35 p.m. and 2/17/2022 at 10:00 a.m., an interview with the Care Plan Coordinator revealed the resident was receiving an antibiotic for a UTI. She confirmed this problem area should have been care planned with goals and interventions. She indicated Resident #62 had been utilizing the antibiotic since 2/12/2022 (five days) and confirmed a change in condition such as UTI or use of an antibiotic should be reflective in the care plan as soon as possible, and not to exceed two days. Review of a facility-provided policy titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated March 2017 showed: -The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The facility shall assess and address care issues that are relevant to individual resident, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. -The overall care plan should be oriented towards: 2. Preventing avoidable declines in function or functional levels or otherwise clarifying why another goal takes precedence. 3. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. 4. Applying current standard of practice in the care planning process. 5. Evaluating treatments of measurable objectives, timetables, and outcomes of care. 6. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. The procedure section of the policy, revealed: #2. Daily Updates to Care Plan (a) Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to update and revise a care plan to reflect non-use of an antidepressant for one (#81) of fifty sampled residents. Findings include: On 2/16/2022 at 7:30 a.m. Resident #81 was observed in her room. She did not present with any behaviors, pain, or discomfort. Resident #81 was pleasant to speak with and had no immediate concerns. Review of Resident #81's medical record revealed she was admitted to the facility on [DATE], with diagnoses to include but not limited to: Adult Failure to Thrive, Need for assistance with personal care, Abnormality of gait, Depression, Insomnia. Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 1/21/2022 revealed: -Cognition/Brief Interview for Mental Status (BIMS) score - 15 of 15, indicating intact cognition, -Behaviors - None exhibited, -Mood - None exhibited, ADL (activities of daily living) - Extensive to total care with most to all ADLs to include Toilet use Total dependence with one person assist, Personal Hygiene Total dependence with one person assist, Bathing with total dependence, -Active Diagnosis - Depression. Review of the current care plan revealed: 7. Psychotropic med - The resident uses psychotropic meds related to antidepressant and to manage depression with interventions to include: Administer medications as ordered/document for side effects and effectiveness; Anti-Depressant: Observe/document for potential side effects may include dizziness, drowsiness, diarrhea, dry mouth, urinary retention, suicidal ideation, orthostatic hypotension; Psychological services per order and PRN [as needed]; Use of psychotropic medications will be reviewed at least quarterly with the IDT/MD to review continued need for the medication and ensure lowest dose. The care plan was developed and initiated on 4/26/2021. Review of the current Physician Order Summary for the month of 2/2022 revealed no active orders for antidepressant use. Review of the 2/2022 Medication Administration Record (MAR), and Treatment Administration Record (TAR) did not indicate use of an antidepressant, or any psychotropic medications. On 2/16/2022 at 1:10 p.m. an interview with Staff T, 300/400-unit manager confirmed Resident #81 does not receive any psychotropic medications to include any antidepressants. The unit manager provided the following information: 1. Original order date 9/15/2021; Remeron 15 mg (milligrams) 1 PO (orally) QD (daily) for appetite supplement and under the category of Antidepressant use. 2. Discontinue order date 1/17/2022; Remeron 7.5 mg 1 PO QD for appetite supplement and under the category of Antidepressant. The unit manager confirmed as of 1/17/2022, the antidepressant was discontinued, and the care plan should have been revised to reflect current non-use of this medication. On 2/16/2022 at 1:33 p.m. an interview with the MDS/Care Plan Coordinator revealed Resident #81 was no longer ordered for an antidepressant. She confirmed the care plan should have been revised and updated to reflect the discontinued use of the medication. Review of a facility-provided policy titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated March 2017 showed: -The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The facility shall assess and address care issues that are relevant to individual resident, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. -The overall care plan should be oriented towards: 2. Preventing avoidable declines in function or functional levels or otherwise clarifying why another goal takes precedence. 3. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. 4. Applying current standard of practice in the care planning process. 5. Evaluating treatments of measurable objectives, timetables, and outcomes of care. 6. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. The procedure section of the policy, revealed: #2. Daily Updates to Care Plan (a) Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and medical record review, the facility failed to ensure nail care was provided for one resident (#87) of five sampled residents reviewed for assistance with activities of daily living (ADLs). Findings include: On 2/14/2022 at 9:55 a.m., and 1:00 p.m. Resident #87 was in his room in bed and all fingernails, on both his left and right hands, were observed to be elongated approximately three quarters of an inch to one inch in length past the tips of the fingers. Further observation revealed built up brown matter beneath all ten of the fingernails and some of the nails appeared cracked, peeling, and with sharp edges. Resident #87 explained he could pretty much do everything on his own to include showering, dressing, moving out of bed, eating, and personal hygiene. However, when asked about his fingernails, he explained, I would cut them myself but they won't give me scissors to cut my hair and won't give me clippers to cut my nails because they think I will hurt myself. He confirmed he did not like them long and he wanted them cut. He further explained he spoke to his nurse and various aides in the past week or so, but they never came back to cut his nails. The resident's left thumbnail was observed to be longer than all the others and was cracked and peeling. Resident #87 took his right hand and peeled the fingernail off to the fingertip. He confirmed his fingernails were too long for him. On 2/14/2022 at 11:00 a.m. both Staff G, Certified Nursing Assistant (CNA) and Staff N, Licensed Practical Nurse (LPN) confirmed Resident #87 was able to complete most of his activities of daily living (ADLs) tasks on his own with supervision, and was not able to do fingernail care on his own. They both indicated they would follow up with him and did not at this time offer that he refuses nail care. On 2/16/2022 at 10:05 a.m. Resident #87's was noted in bed and lying on his side, with the covers only covering his lower half of his body. Further observations revealed both his hands were visible and only his left thumbnail was observed trimmed/peeled to the fingertip. All others were still observed elongated, not clipped and with brown matter beneath the fingernail beds. On 2/17/2022 at 8:20 a.m. Staff G, CNA revealed Resident #87 routinely refuses nail clipping care and she had reported this to the nurses. Staff G also revealed she documented in the CNA daily progress notes when and what Resident #87 refuses, to include refusing nail care. On 2/17/2022 at 8:30 a.m. Resident #87 was observed lying in bed holding a cup of coffee with his left hand. His hand was observed with four of the five fingernails elongated approximately three quarters of an inch to one inch long from the tips of the fingers. Further observation revealed brown matter stuck under the nails. Resident #87 explained, Nobody has still offered to cut my fingernails, and they were supposed to come and clip my nails last night (2/16/2022). He said they (staff) know about his nails and told him they would provide him with nail care but never showed up back to his room after his initial conversation with two aides (names unknown). He again explained he was constantly told he was not allowed to clip his own fingernails, and that he does not like his nails long and dirty. He stated again, I have asked repetitively for clippers so I can clip the nails on my own but keep being told that I can't have clippers and do nail care on my own because they think I will hurt myself. On 2/17/2022 at 9:35 a.m. Staff G, CNA noted, I was able to complete nail care and clip all the fingernails for [Resident #87]. She further noted he did not refuse the nail care and did not present with any behaviors. She revealed he was thankful. On 2/17/22 at 9:50 a.m. all of Resident #87's fingernails were observed to be clipped and well groomed. He exclaimed, It's about time and my hands feel a lot better. Review of the admission Record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include cerebral infarction, dementia, bipolar, depression, adult failure to thrive, and cognitive functions nontraumatic. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status score of 8 indicating moderate impairment. Section G - Functional Status revealed ADLs Personal Hygiene with Supervision and with one person physical assist. Review of the nurse progress notes dating from his recent admission 1/17/2022 to 2/17/2022, did not indicate any documentation of Resident #87 refusing fingernail care, nor presenting with any behaviors with relation to personal hygiene. Review of the current care plans with the next review date 5/3/2022, revealed the following areas: 14. Activities of Daily Living (ADL) - [Resident #87] has an ADL self care performance deficit as evidence by weakness, impaired cognition, with interventions in place to include but not limited to: Personal hygiene - independent; Bathing - Check all nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. (This care plan area was originally dated 7/27/2020). 15. Behaviors - [Resident #87] noted with the following behaviors may be angry outbursts at times: confabulation, may mix past and present at times, may call 911 thinking a truck was stolen or other items and he has not had one here since admission or other things mixing up when he lived in an apartment years ago, may prefer not to ask staff for assistance and or use the call light, may become confused to time and place, may become forgetful about when his last meal was, does not have a wallet in facility, may refuse care, labs, showers, meals, supplements, and clothing changes, prefers to wear shoes in bed. Prefers not to shave his beard, may throw items may prefer to not have supplement drink, may remove call light from bed and clip to the curtain, with interventions in place. Review of the current care plan problem area did not reflect Resident #87 had any behaviors of refusal specific to assistance with fingernail care, nor did it specify Resident #87 presented with any type of behaviors related to fingernail care. On 2/16/2022 at 1:33 p.m. the Care Plan Coordinator revealed she was fairly new to the MDS and Care Planning position and was not fully aware of the resident and his nail care. She revealed that he was able to perform most of his ADLs with supervision and does not know if there was any concerns with him clipping his fingernails on his own. She reviewed his care plans and nurse progress notes and confirmed there was no documentation to support the resident was not able to conduct clipping his fingernails on his own. She further confirmed there was no assessment or documentation that would indicate he specifically refused or has a history of refusing nail care. On 2/17/2022 at 9:07 a.m. an interview with Staff T, RN revealed she was aware of Resident #87 actively and historically refusing bathing, personal hygiene care and nail care. She revealed, with his cognition level, they will not allow for him to have his own scissors and clippers. She revealed he continues to ask for them but they offer him assistance instead; and he refuses. Review of the CNA ADL daily flow sheets for the months 1/2022 and 2/2022 included documentation that personal hygiene was completed and nail care as a PRN (as needed) task for the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. The flow sheet for February 2022 did not show Resident #87 refused nail care. It showed: -Dates of 2/1, 2/2, 2/9, 2/12, 2/14, 2/15 and 2/16 NN was documented during the 7:00 a.m. to 3:00 p.m. and 2/5 and 2/7 for the 3:00 p.m. to 11:00 p.m.; indicating Resident Not Available. -Dates of 2/4 NA: was documented during the 3:00 p.m. to 11:00 p.m. indicating Not Applicable. -Dates of 2/3, 2/6, 2/8, 2/10, 2/11, and 2/13 there was no documentation of nail care. The CNA ADL daily flow sheet for January 2022 showed a RR for the dates of 1/1, 1/22 an 1/29 during the 7:00 a.m. - 3:00 p.m. shift, indicating the resident refused nail care. The other dates indicated the following: - Dates of 1/3-1/10, 1/18-1/19, 1/26-1/28, and 1/30 NN was documented during the 7:00 a.m. to 3:00 p.m. and 1/1, 1/3-1/8, 1/10-1/11, 1/18-1/22 and 1/29 - 1/30 for the 3:00 p.m. to 11:00 p.m.; indicating Resident Not Available. -Dates of 1/ 2 and 1/27 NA: was documented during the 3:00 p.m. to 11:00 p.m. indicating Not Applicable. Dates of 1/12 and 1/31 were noted with a NC during the 7:00 a.m. - 3:00 p.m. shift indicating Nail Care was completed. Review of the admission Record showed the most recent hospital stay for the resident was 1/12/22 - 1/17/22. -Dates of the remaining 15 opportunities between both shifts either showed an X or no documentation of nail care. On 2/17/2022 at 8:30 a.m. the Director of Nursing revealed the facility did not have a specific policy and procedure related to fingernail care. The Nursing Home Administrator confirmed this at 3:30 p.m.

Based on observation, interview and record review, the facility failed to ensure four (#4, #54, #69 and #93) of fifty sampled residents received comprehensive skin assessments weekly in accordance with professional standards, and facility policy. Findings include: 1. An observation of Resident #4 on 2/15/22 at 11:28 a.m. revealed her left lower leg dry and flaky with multiple scabs observed. An observation of Resident #4 on 2/16/22 at 8:10 a.m. revealed her left lower leg dry and flaky with multiple scabs observed. During an interview and observation of Resident #4 on 2/16/22 at 1:40 p.m. with Staff L, Licensed Practical Nurse (LPN), the LPN stated the resident's leg had a lot of dryness and she had lotion ordered three times a day. The LPN said they document weekly skin checks on her condition. Review of physician orders for Resident #4 revealed: -Lac-Hydrin lotion 12% (ammonium lactate) apply to affected areas topically every shift for dry skin dated 4/23/21. Review of the treatment administration record (TAR) for February 2022, documented the resident receiving the lotion every shift. Review of the care plan for Resident #4 revealed a focus area of skin integrity risk and has potential/actual impairment to skin integrity, initiated 7/2/19. Interventions include observe for signs and symptoms swelling, tenderness, discoloration, or pain dated 7/9/19. Report changes in discoloration area dated 7/9/19. Review of the last four weekly skin checks for Resident #4 revealed: -2/16/22 Skin check weekly and as needed completed and checked as new areas of skin impairment found scabs on left and right front lower legs. -2/7/22 Skin check weekly and as needed completed and checked as no new areas of impairment. -1/31/22 Skin check weekly and as needed completed and checked as no new areas of impairment. -11/17/21 Skin check weekly and as needed completed and checked as no new areas of impairment. During an interview with Staff M, Unit Manager on 2/17/22 at 5:21 p.m. she confirmed skin assessments are completed weekly and on admission for each resident. 2. An observation of Resident #54's feet on 2/14/22 at 11:30 a.m. revealed they were dry and flaky. An observation and interview on 2/16/22 at 10:25 a.m. with the Regional Nurse revealed the resident's feet were dry and flaky. The Regional Nurse confirmed the resident's were dry and flaky and said she would get him some lotion. An observation and interview with Staff L, LPN on 2/16/22 at 1:21 p.m. confirmed the resident's feet were dry and flaky. A review of physician orders for Resident #54 did not reveal any lotions ordered. Review of the care plan for Resident #54 revealed a focus area for risk of developing a wound initiated on 6/10/21. Interventions included observe for any new areas of skin breakdown: redness, blisters, bruises. initiated on 6/10/21. Review of the last four weekly skin checks for Resident #54 revealed: -2/9/22 skin check weekly and as needed completed as no new areas of skin impairment. -2/2/22 skin check weekly and as needed completed as no new areas of skin impairment. -1/4/22 skin check weekly and as needed completed as new area of skin impairment found open area to bilateral buttocks measuring a stage II for each. -10/3/21 skin check weekly and as needed completed as no new areas of skin impairment. During an interview on 2/16/22 at 11:14 a.m. with Staff M, unit manager she confirmed skin checks are weekly and on admission. During an interview with the Director of Nursing (DON) on 2/16/22 at 4:55 p.m. she confirmed skin checks should be completed weekly on all residents. 3. An observation of Resident #69 was conducted on 2/15/22 at 9:01 a.m. The resident was sitting up in bed and eating with assistance. The resident's skin was observed clean and intact. Review of Resident #69's medical record revealed the last three weekly skin checks were completed on: -2/7/22 skin check weekly documented as no new areas of skin impairment. -1/31/22 skin check weekly documented as no new areas of skin impairment. -9/22/21 skin check weekly documented as no new areas of skin impairment. During an interview with the DON on 02/17/22 03:32 p.m., she stated the resident's skin assessments should be completed weekly. 4. An observation of Resident #93 was conducted on 2/14/22 at 12:28 p.m. The resident's hands were observed closed and without palm guards. An observation and interview of Resident #93 was conducted on 2/16/22 at 1:23 p.m. with Staff L, LPN. The LPN revealed the resident wears palm guards and skin assessments are completed weekly. During an interview and observation with the Director of Rehabilitation on 2/17/22 at 3:50 p.m., she confirmed palm guards do not need to be ordered or care planned, but confirmed the skin needs to be assessed. Review of the last four weekly skin checks for Resident #93 showed: -2/3/22 skin check weekly completed and documented as no new areas of skin impairment. -1/3/22 skin check weekly completed and documented as no new areas of skin impairment. -10/5/21 skin check weekly completed and documented as no new areas of skin impairment. -10/3/21 skin check weekly completed and documented as no new areas of skin impairment. Review of the care plan for Resident #93 revealed a focus area of activity of daily living for self-care. Resident does not initiate or follow through due to impaired cognition initiated on 7/31/20. Interventions included, provide assistance as needed to perform activity of daily living functions. During an interview with the DON on 2/16/22 at 4:55 p.m. she confirmed skin checks should be completed weekly on all residents. Review of facility policy titled, Weekly and as needed skin check, from Clinical Programs Manual, effective 10/21, two pages, revealed: -The weekly and as needed skin check is used to document skin condition throughout the Resident's stay in the facility. The nurse will conduct weekly skin check and or as needed skin check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. -Procedure: 1. Once a week and when an area of skin impairment is reported the skin check should be documented on the Weekly and as needed skin check documentation tool. If a new area is identified the appropriate skin grid should be initiated within 8-hours.

Based on observation, interview, and record review, the facility failed to ensure one resident (#67) received services to maintain or promote further range of motion of a contracture related to the application of hand, elbow, knee, and boot splints for four days (02/14/22, 02/15/22, 02/16/22 and 02/17/22) of four days observed of a total sample of 29 residents with contractures. Findings include: On 02/14/22 at 10:31 a.m. Resident #67 was observed in his room, lying in bed. Resident #67's left hand appeared contracted and was positioned on his chest area. Resident #67 was not wearing a splint on his left hand during the observation. Further observation revealed blue, gray and black splints on top of the dresser in Resident #67's room. On 02/14/22 at 11:23 a.m. another observation was made, and the splints were observed again, on top of the dresser. (Photographic Evidence Obtained) On 02/15/22 at 9:38 a.m. Resident #67 was observed in his room, lying in bed. Resident #67 stated the splints had not been applied at any time yesterday. The splints were observed again, on top of the dresser. On 02/16/22 at 9:05 a.m. Resident #67 was observed in his room, lying in bed. Resident #67's splints were observed again, on top of the dresser. (Photographic Evidence Obtained) On 02/16/22 at 9:58 a.m., an interview was conducted with Staff T, Registered Nurse (RN), Unit Manager. She stated Resident #67 received therapy while in bed. She believed there was an order for splint placement and therapy was supposed to apply them. She needed to double check the orders to make sure. On 02/16/22 at 1:32 p.m., an interview was conducted with Staff U, Certified Nursing Assistant (CNA). She stated Resident #67 was seen by therapy, they put his splints on for a few hours and remove them afterwards. The CNAs were not responsible for applying the splints. The facility has a restorative aide, but she was unable to recall her name. On 02/17/22 at 8:38 a.m., Resident #67 was observed in bed, after eating breakfast. Resident #67 stated he had not worn the splints at any time during the week. Resident #67 stated he was not sure exactly who was responsible to place the splints on him. He had previously asked a CNA about the splints and was told that therapy was responsible to put them on him. The splints were observed on top of the dresser. (Photographic Evidence Obtained) Review of Resident #67's medical record revealed an initial admission date of 08/13/18, with diagnoses to include quadriplegia, contractures, and unilateral primary osteoarthritis. Review of the Quarterly Minimum Data Set (MDS) assessment, Section G: Functional Status, dated 01/14/22, revealed Resident #67 required extensive to total care assistance with Activities of Daily Living (ADLs) and was impaired on both sides of the upper and lower extremities. Section C: Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #67 was cognitively intact. Section O for . indicated restorative nursing for splint or brace assistance was not provided. Review of the current physician orders for the month of 02/2022 revealed Resident #67 had orders for: Left hand splint to resting hand splint on in am/pm removed before/after lunch as tolerated. May remove for skin sweep on 7-3. Right wrist stabilizer on in the am/pm removed before/after lunch or other as tolerated. May remove for skin sweep on 7-3. Left elbow splint on in the am/pm removed before/after lunch or other as tolerated. May remove for skin sweep on 7-3. Right knee extension on in am/pm removed before/after lunch or other as tolerated. May remove for skin sweep on 7-3, all ordered 08/20/21. On 02/17/22 at 9:25 a.m., an interview was conducted with Staff V, RN. She stated Resident #67 was seen by therapy very early in the morning. She has had to remove Resident #67's splints because he was too hot. Resident #67 was hot often, she had to remove the blanket from him yesterday because he was hot. She assumed that any staff member could have put the splints on him, as she had done so before. Staff V checked Resident #67's medical record and confirmed the CNAs were responsible to put the splints on him. On 02/17/22 at 9:45 a.m., an interview was conducted Staff W, Certified Occupational Therapy Assistant (COTA). She stated the resident was currently being screened by the Therapy Program Manager. When a resident completed therapy, nursing was provided with recommendations for the resident. From that point, nursing was responsible for the resident's care. She was not sure if there was a Restorative program at the facility because once a resident was removed from their caseload, they were no longer involved. On 02/17/22 at 11:08 a.m., an interview was conducted with the Therapy Program Manager. She stated Resident #67 was discharged from the therapy program on 01/12/22. He was discharged to the nursing staff. CNAs were responsible to apply his lower and upper splints. When a resident with splints was discharged to nursing, the CNAs were trained in how to apply the splints. Since she was informed the resident had not been wearing his splints, she planned to put him back onto the therapy caseload. The goal was to maintain his current level of functioning. On 02/17/22 at 1:18 p.m., an interview was conducted with the Director of Nursing (DON). She stated if Resident #67 had an order to wear splints she would expect staff to follow the order, according to the resident's desires. If the resident was refusing to wear the splint, it should have been documented. She was going to check the resident's medical record to confirm the specifics of the order and follow up with the surveyor. At the completion of the survey, the DON had not returned with any additional information. Review of the Restorative Nursing Progress Notes revealed the most recent notes as: 04/09/21- Resting hand splint donned to left hand and elbow splint donned to left arm. Both remained on for two hours. 04/16/21- Resting hand splint donned and left elbow splint for two hours. No redness or breakdown noted. 04/23/21- Resting hand splint and contracture splint donned to left hand and elbow for two hours. No redness or irritation noted. Review of the current care plan with initiation dates of 11/02/2020 and 04/13/21 revealed, a focus area for Range of Motion (ROM) and splint application related to a risk or actual limitations in ROM. Goals were to minimize the risk of complications related to splint application and maintain range of motion. Interventions included left wrist resting hand splint on after breakfast/off before breakfast, left anti-contracture splint (elbow) on after breakfast/off before lunch for approximately 2-3 hours daily as tolerated, left foot (boot) for approximately 3 hours daily as tolerated on after breakfast/off before lunch, right knee extension splint, apply to right knee for approximately 3 hours daily as tolerated on after breakfast/off before lunch, removed for bathing or personal care activities. Review of the CNA task documentation for splint application revealed not applicable, for the following dates, 02/01-02/15/22. Further review of the medical record revealed no documentation of refusals. Review of the facility's policy titled Restorative Nursing Programs, revised October 2017 revealed: The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental, and psychological functioning. The IDT [interdisciplinary team], resident and, or family identify the needs of resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The program includes- Contracture Management and Prevention- This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (#4) received care and services to prevent a urinary tract infection of three residents sampled. Findings include: An observation of Resident #4's catheter on 2/15/22 at 11:41 a.m. revealed yellow urine draining into a patent catheter. An observation of Resident #4's catheter on 2/16/22 at 8:10 a.m. revealed the catheter draining yellow. An observation of Resident #4's catheter and interview with Staff L, Licensed Practical Nurse (LPN) on 2/16/22 at 1:45 p.m. confirmed the catheter bag and tubing turned deep purple. The urine was amber in color. During an interview and observation with the Director of Nursing (DON) on 2/16/22 at 4:41 p.m. she confirmed they were calling the doctor to get an order for a urinalysis and would change the catheter bag. The DON stated she would have expected documentation about the catheter changing to purple. The DON confirmed her expectation was the documentation would indicate the color of the urine and if the bag was purple and that should have been documented. During an interview with Staff K, Certified Nursing Assistant (CNA) on 2/17/22 at 9:10 a.m. she stated the resident's bag started turning purple and she told the nurses, but they did not do anything, and she has no where to document that. An observation of Resident #4's catheter on 2/17/22 at 9:28 a.m. revealed a newly inserted catheter was observed patent with yellow urine draining. During an observation of Resident #4's catheter on 2/17/22 at 1:28 p.m. the resident was observed sitting in her wheelchair and pulling at her catheter yelling that it hurt. The urine in the catheter was yellow at the bottom, cloudy and then the top of the tube was purple. The traveling DON confirmed on 2/17/22 at 1:29 p.m. the new catheter would come out and get changed again. They would call the doctor to get another order for urine and pain medication until the first urine sample comes back. A review of the admission Record revealed Resident #4 was admitted on [DATE] with a readmission on [DATE] with diagnoses to include neuromuscular dysfunction of bladder. Review of the physician orders as of 2/17/22 revealed: change catheter bag as needed, label with date as needed for urinary retention dated 9/11/20. [Indwelling] catheter care daily and as needed for preventative measure dated 11/2/21. [Indwelling] catheter: change [Indwelling] catheter as needed for leakage/blockage or dislodgement as needed document in resident's record dated 11/3/2020. [Indwelling] catheter to drainage bag for diagnoses of neurogenic bladder. [Indwelling] catheter size #20 with 10 cc (cubic centimeter) balloon. Observe every shift every shift for observation dated 11/3/20, and Urinalysis culture and sensitivity every night shift for 2 days dated 2/16/22. Review of the care plan for Resident #4 revealed a focus area of indwelling catheter: the resident uses the catheter with risk for infection and or complications, related to neurogenic bladder dated 8/29/19. Interventions included: change drainage bag routinely and as needed initiated on 8/29/19; Provide catheter care daily initiated on 8/29/19; Observe/document/report to physician for signs and symptoms of urinary tract infection: pain, burning blood tinged urine, cloudiness, no output, deepening of urine color initiated on 8/29/19; Irrigate catheter as ordered for blockage or sluggish output and notify physician, initiated on 8/29/19. Review of the Treatment Administration Record for February 2022 documented: [Indwelling] catheter care daily and as needed every shift for preventative measures dated 9/11/20; [Indwelling] catheter to observe every shift dated 11/3/20 signed off daily; and [Indwelling] catheter to irrigate [Indwelling] catheter with 30 ml (milliliters) normal saline as needed for blockage/leakage or sluggishness dated 2/7/22. Review of facility policy, Notification of Resident/Patient Change in Condition, effective October 2021, revealed: Nurses will notify the resident/representative, if there is a crucial/significant change in the resident condition. A facility policy related to [Indwelling] catheters was requested on 2/17/22 at 5:00 p.m. and was not provided to the survey team at the time of the exit.

Based on observation, interview and record review, the facility failed to ensure respiratory care was consistent with professional standards of practice for one resident (#9) of three sampled residents. Findings include: An observation of Resident #9 on 2/15/22 at 10:08 a.m. revealed the resident was on 3 liters of oxygen via a nasal cannula. An observation of Resident #9 on 2/15/22 at 4:40 p.m. revealed the resident sitting up in bed with the head of bed at 45 degrees and revealed the resident was on oxygen via a nasal cannula infusing at 3 liters. An observation of Resident #9 on 2/16/22 at 8:49 a.m. revealed the resident using a nasal cannula with foam around the ears, infusing at 2 liters. An observation of Resident #9 on 2/16/22 at 10:37 a.m. revealed the resident was sitting up in bed with a nasal cannula with foam around her ears and infusing 2 liters of oxygen. At this time, Staff K, Certified Nursing Assistant (CNA) confirmed the resident wore the nasal cannula with foam around her ears, an infusing the oxygen all the time. An observation and interview with Staff L, Licensed Practical Nurse (LPN) on 2/16/22 at 1:30 p.m. confirmed Resident #9 was wearing oxygen at 2 liters via a nasal cannula. Staff L, LPN confirmed the resident did not have physician orders for continuous oxygen and does not need the oxygen unless she is below 93% room air. Staff L, LPN confirmed the resident's oxygen was usually between 97% and 98% on room air. Staff L, LPN removed the resident's oxygen at 1:46 p.m. and confirmed her oxygen level was 100% at room air and removed the oxygen tubing, stating she did not need the oxygen with saturation of 100% on room air. A review of the physician orders as of 2/17/22 revealed: -Change oxygen tubing and set up weekly as needed, label tubing with date when changed, dated 2/4/22. -Change oxygen tubing and set up weekly every night shift every Sunday, label tubing with date when changed, dated 2/4/22. -Change oxygen filter weekly every night shift every Sunday for shortness of breath, dated 2/4/22. -Oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath every shift for shortness of breath, dated 2/7/22. A review of the Treatment Administration Record (TAR) for February 2022 revealed the resident was scheduled from 2/4/22 to 2/7/22 to receive oxygen at 3 liters via nasal cannula continuously for shortness of breath. A continued review of the TAR for February 2022 revealed the resident was scheduled from 2/7/22 to current for oxygen at 2 liters via nasal cannula as needed for shortness of breath. Documentation of oxygen levels for February 2022 ranged from 95% to 98%. Lung sounds were documented as clear. A review of the care plan revealed a focus area for oxygen therapy dated 11/22/21. The Interventions included: administering oxygen as ordered, and give the medications as ordered by the physician. During an interview with the Director of Nursing (DON) on 2/16/22 at 4:51 p.m. she confirmed the resident should have oxygen levels checked and documented if on room air or oxygen. The DON confirmed the resident's oxygen levels did not require oxygen continuously and should not have been left on. A review of the facility policy titled, Oxygen Therapy and Devices, revealed: 1. Oxygen is a drug which must be ordered by a physician .7) Apply device to the patient with appropriate liter flow.

Based on interview and record review, the facility failed to ensure medical records were complete and accurate for one resident (#69) related to hospice care of fifty sampled resident records. Findings include: Review of the Order Summary Report as of 2/17/22 revealed Resident #69 had an active physician order for: Resident followed by [Hospice Provider Name] for diagnosis of Adult Failure to Thrive, dated 10/20/21. Review of the care plan focus area initiated on 10/20/21 revealed the resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis: adult failure to thrive. Interventions included: collaborate with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, initiated on 10/20/21; Hospice to provide supplemental services per order/ plan of care. (See hospice documentation for more detail.) initiated on 10/20/21; Notify physician/hospice for change in condition, initiated on 10/20/21. Review of progress notes dated 12/8/21 revealed Resident #69 would be discharged from hospice in two weeks and hospice was requesting family contact information. Review of the medical record for the Hospice Discharge/Transfer Summary showed it was absent at 10:00 a.m. on 2/17/22. The facility requested the Hospice Discharge/Transfer Summary and received it at 12:59 p.m. on 2/17/22. The Hospice Discharge/Transfer Summary, dated 12/23/21, stated the resident was discharged from hospice for no longer being terminally ill. During an interview with Staff L, Licensed Practical Nurse (LPN) on 2/17/22 at 3:22 p.m. he confirmed the resident had been discharged from hospice for several months. During an interview with the Director of Nursing (DON) on 2/17/22 at 3:32 p.m. she stated the resident was not on hospice and confirmed the progress note was from the previous unit manager in December (2021). The DON confirmed the record did not reflect the resident's current medical status. During an interview with the DON on 2/17/22 at 4:22 p.m. she confirmed the resident was discharged from hospice on 12/23/21. A facility policy was requested on 2/17/22 at 5:00 p.m. and was not provided to the survey team at the time of the exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews and record review, the facility failed to treat residents with respect and dignity as evidenced by five staff members (A, B, D, E, F) failing to knock or announce themselves prior to entering occupied resident rooms in two halls (300 and 400) of four halls for four of four days observed (2/14/2022, 2/15/2022, 2/16/2022, and 2/17/2022). Findings include: During the days from 2/14/2022 to 2/17/2022 staff were observed to not consistently knock, announce or identify themselves prior to entering occupied resident rooms. The observations were as follows: - On 2/14/2022 at 10:08 a.m., Staff A, Certified Nursing Assistant (CNA) was observed to walk in resident room [ROOM NUMBER] and did not first knock and or announce herself. There were two residents in the room at the time. - On 2/14/2022 at 10:14 a.m. Staff B, CNA was observed to walk in resident room [ROOM NUMBER] without first knocking or announcing herself. There were two residents in the room at the time. - On 2/14/2022 at 10:16 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident in the room at the time. - On 2/15/2022 at 6:33 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There were two resident in the room at the time. - On 2/15/2022 at 6:37 a.m. Staff D, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident observed in the room at the time. - On 2/15/2022 at 6:42 a.m. Staff E, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There were two residents in the room at the time. - On 2/16/2022 at 7:50 a.m. Staff F, Licensed Practical Nurse (LPN) was observed to carry medications into resident room [ROOM NUMBER] and did not first knock or announce herself prior to entering. There was one resident in the room at the time. - On 2/17/2022 7:34 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] and did not first knock and or announce herself prior to entering. There was one resident in the room at the time. - On 2/17/2022 8:22 a.m. Staff F, LPN was observed to walk into resident room [ROOM NUMBER] and did not knock or announce herself prior to entering. There was one resident in the room at the time. Random resident interviews revealed: On 2/14/2022 at 11:45 a.m. Resident #87 revealed staff always and continually walk into his room at all times of the day and most do not knock or announce themselves. He indicated he does like his privacy and would like for them to knock. He spoke to management before with no resolution. He has stopped complaining because nothing ever gets better. On 2/14/2022 at 2:00 p.m. Resident #53 confirmed staff routinely just walk in the room and don't knock before answering. While interviewing her, an aide was observed to walk in the room and only motioned to knock on the door as she was walking in. The resident indicated this happens at times and she does not like it. She further revealed she does not like confrontation, so she has not verbally complained to anyone about it. On 2/15/2022 at 2:15 p.m. Resident #62 revealed he has had it with staff just walking in the room and they don't say anything or knock before coming in. He has complained in the past but nothing ever gets better. He would like his privacy. On 2/14/2022 at 1:30 p.m. Resident #76 confirmed staff walk in her room all the time and don't say anything or knock. She felt staff should at least announce themselves before coming in the room. Sometimes she does not even know why staff come in her room, and they don't tell her why. She has reported it to management in the past but did not remember when or who she spoke with. On 2/17/2022 at 1:30 p.m. an interview with Staff T, Registered Nurse (RN)/300/400 Unit Manager revealed it is the facility's policy for all staff to either knock or announce themselves prior to going into resident rooms, no matter what. She did not have any documented information to show she audits staff knocking and announcing prior to going in rooms. She was also unaware that residents were not comfortable with staff just walking into the rooms unannounced. On 2/17/2022 at 2:00 p.m. an interview with the Director of Nursing (DON) confirmed staff should always knock and/or announce themselves prior to going into occupied rooms and they (staff) are trained and inserviced on that matter. There was no documented evidence to show staff were trained on this area. A review of the policy and procedure titled, Personnel Policies & Employee Conduct, with an effective date of April 2017, documented the policy as: To provide guidelines and standards pertaining to Environmental Management Services Sanitation Section job-related issues. The Manner section of the policy read: Be alert, courteous, helpful and brief. Employees should report any problems or issues to their immediate supervisor. Avoid showing irritation with residents and staff members. Show job interest and willingness to learn. Take pride in job. Be considerate of residents and the staff responsible for their care. Always knock, Announce, Identify, Duration, Engage, and Thank when entering and working in a Resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure activities were provided for seven dependent residents (#64, #83, #10, #39, #72, #66, and #75) on one hall (Hall 200) of three halls out of a total of twenty one sampled residents. Findings include: On 02/14/22 at 10:19 a.m. and 1:21 p.m., Resident #64 was observed in her room, lying on the bed. Resident #64 was non-verbal and dependent on staff for all activities of daily living (ADLs). Resident #64 was observed not engaged in any activities or receiving interaction from staff. On 02/14/22 at 2:28 p.m. seven dependent residents on Hall 200 (Resident #64, #10, #75, #72, #39, #66 and #83) were observed to be in bed, without staff interaction. Review of the electronic medical records (EMR) for the residents showed the following: An admission Record for Resident #64 showed she was admitted to the facility on [DATE] with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery. The Minimum data set (MDS), 1/10/2022, for Resident #64 showed under Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities was noted as blank, and Section G Functional Status indicated Resident #64 was totally dependent on staff for ADLs. An admission Record for Resident #83 showed he was admitted to the facility on [DATE] with diagnoses to include muscle wasting and atrophy, schizophrenia and adult failure to thrive. The MDS for Resident #83, dated 01/27/22, showed in Section C-Cognitive Patterns a BIMS score of 00, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities was noted as blank, and Section G Functional Status indicated Resident #83 required staff supervision for ADLs and requires a wheelchair for mobility. An admission Record for Resident #10 showed the resident was admitted to the facility on [DATE] with a diagnosis of senile degeneration of brain, not elsewhere specified. A MDS for Resident #10, dated 05/24/21, showed in Section C-Cognitive Patterns a BIMS score of 09, indicating moderate impairment. Section F - Preferences for Customary Routine and Activities participation was somewhat important. Section G Functional Status indicated Resident #10 required extensive assistance from staff for ADLs. An admission Record for Resident #39 showed she was admitted to the facility on [DATE] with diagnoses to include Parkinson's, muscle wasting and atrophy. A MDS for Resident #39, dated 12/22/21, showed in Section C-Cognitive Patterns a BIMS score of 07, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities was noted as blank. Section G - Functional Status indicated Resident #39 required extensive assistance for ADLs. An admission Record for Resident #72 showed she was admitted to the facility on [DATE] with diagnoses to include heart failure, multiple sclerosis, muscle wasting and atrophy and obesity. A MDS for Resident #72, dated 10/14/21, showed in Section C-Cognitive Patterns a BIMS score of 07, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities indicated activity preference was somewhat important. Section G - Functional Status indicated Resident #72 required extensive assistance for ADLs. An admission Record for Resident #66 showed she was admitted to the facility on [DATE] with diagnoses to include muscle wasting and atrophy, unspecified dementia, schizophrenia and morbid obesity. A MDS for Resident #66 showed in Section C-Cognitive Patterns a BIMS score of 09, indicating moderate cognitive impairment. Section F - Preferences for Customary Routine and Activities indicated activity preference was somewhat important. Section G - Functional Status showed Resident #66 required extensive assistance for ADLs. An admission record for Resident #75 showed she was admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance. A MDS for Resident #75, dated 10/19/21, showed in Section C-Cognitive Patterns a BIMS score of 00, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities indicated activity preference was somewhat important. Section G - Functional Status indicated Resident #75 required extensive assistance with ADLs. Review of the activity care plans in the EMRs for Residents #64, #10, #75, #72, #39, #66 and #83 showed each resident's care plan contained the same wording: at risk for psychosocial outcomes due to visitation limitations related to COVID-19. The care plans did not include individual activity preferences. Copies of the Care Plans were requested but not made available. On 02/15/22 at 11:27 a.m. and at 3:23 p.m. an observation was made of dependent residents in Hall 200 staying in beds in their rooms all day. Residents were noted without any activities. (Resident #64, #10, #75, #72, #39, #66 and #83.) An interview was conducted with an independent alert and oriented resident in Hall 200, Resident #79. Resident #79 stated she had not seen activities facilitated for dependent residents. Resident #79 said, There are no activities here for them. They don't have anyone to run the activities. On 02/16/22 at 9:15 a.m., dependent residents in Hall 200 were observed not engaging in any activities. (Resident #64, #10, #75, #72, #39, #66 and #83.) On 02/15/22 at 2:40 p.m., an interview was conducted with the Activities Director (AD). The AD stated she was the activities staff until about a month ago. The AD stated she was now in the role of the staffing coordinator. The AD stated the activities position had not been filled. When asked who was conducting activities, the AD stated she was filling in here and there, between being the receptionist and staffing. On 02/16/22 at 2:30 p.m. a Resident Council meeting was held. The meeting was attended by 16 residents. When asked about activities, the residents reported Staff Y, Certified Nursing Assistant (CNA) was the only one who does Bingo or any activities at least two times a week. The residents confirmed they had not seen activities provided for dependent residents. The residents confirmed earlier they had Bingo in the dining room, which was attended by residents who could ambulate. Review of an activities calendar posted in resident rooms on Hall 200 showed on each Wednesday 3pm One on One. On 02/16/22 at 3:00 p.m. Residents #64, #10, #75, #72, #39, #66 and #83 were each observed to not be receiving the scheduled One on One activity. An interview was conducted on 02/15/22 at 3:00 p.m. with Resident #46 an independent resident in Hall 200. Resident #46 said, They don't do activities. Resident #46 stated independent residents engage themselves but not the dependent ones. On 02/17/22 at 12:50 p.m. on Hall 200 Residents #64, #10, #75, #72, #39, #66 and #83 were observed and they were not engaged in an activity. On 02/17/22 at 9:10 a.m. an interview was conducted with Staff Y and Staff H, CNA. Staff H said, They do not do activities. Staff H said the AD was covering other areas. Staff Y stated independent residents initiate their own activities. An interview was conducted on 02/17/22 at 9:14 a.m., with Staff Q, CNA. Staff Q stated they did not have enough staff to conduct activities. Staff Q stated the AD was now doing staffing. On 02/17/22 at 9:14 a.m., an interview was conducted with Staff P, Registered Nurse (RN). Staff P stated residents who are dependent stay in their rooms, mostly in bed. Staff P confirmed no one was providing activities for dependent residents. Staff P said, I know, it's hard for them [residents] and us. An interview was conducted on 02/17/22 at 9:19 a.m. with Staff O, CNA. Staff O stated sometimes they do activities like Bingo. When asked if they do activities in the resident rooms, Staff O said, I guess it is for those that can ambulate. On 02/17/22 at 9:21 a.m. an interview was conducted with Staff Z, CNA. Staff Z stated there had been no formal activities since the AD started doing staffing. Staff Z said, I know they are short staffed here. Staff Z stated the facility did not have enough staff for care, let alone activities. On 02/17/22 at 9:33 a.m. an interview was conducted with the AD. The AD said, I know we have not been going into the rooms for 1:1. I used to do it when I was in my position. The AD stated she had been pulled in many directions including screening. The AD said, It is not fair to them [dependent residents]. A interview was conducted on 02/17/22 at 9:53 a.m. with the Director of Nursing, (DON), the Nursing Home Administrator (NHA) and Regional Clinical. They were notified that activities were not observed to be provided for dependent residents and the care plans for the residents were not individualized. The Regional Clinical stated they would update the care plans. The NHA stated they are in the process of transitioning a new aide to the position. Review of a job description titled Director of Activities, dated January 2013, showed the Director of Activities is responsible for supervising and providing an activity program appropriate to meet the physical, social, cultural, spiritual, emotional and recreational needs and interests of each patient / resident. Under essential duties and responsibilities, the Director of Activities will assess individual / group resident / patient needs and develops related meaningful morning, afternoon, evening and special programs. The Director of Activities coordinates, directs and / or conducts all planned activities. Review of a facility policy titled, Activities Program, dated November 2013, showed the facility will develop and implement an on-going activities program, including individual and group activities. The procedure showed: 1. At the time of move-in, leisure interest information will be gathered. 2. Scheduled activities shall be planned to include recreational, social and educational opportunities, offering no less than 12 hours weekly of activities, 6 days each week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform representatives of five residents (#34, #9, #54, #93, & #69) of positive cases of COVID-19 in the facility on eight days (1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22) by 5 p.m. the next calendar day, out of five residents sampled for notification of COVID-19 status. Findings include: Review of the facility's listings for COVID-19 positive staff and residents revealed positive COIVD-19 cases documented on 1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22. Review of five resident (#34, #9, #54, #93, & #69) medical records for notification of families or representatives by 5:00 p.m. the next calendar day for January 2022 did not show notification by mail was received by 5:00 p.m. the next day. Review of the medical records for notification of positive COVID-19 cases showed: Resident # 69's family member was notified last on 1/5/22 of a positive COVID-19 case. Resident #34's family member was notified last on 1/5/22 of a positive COVID-19 case. Resident #9's daughter was notified last on 1/5/22 of a positive COVID-19 case. Resident #54's friend was notified last on 1/5/22 of a positive COVID-19 case. Resident #93's responsible party was notified last on 1/4/22 of a positive COVID-19 case. An interview on 2/15/22 at 2:35 p.m. with a representative of one of the above residents, who requested to remain anonymous, confirmed they did not receive a phone call or a letter related to the COVID-19 positive cases following the last phone call received. A review of Resident #69's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 00, indicating severe impairment. A review of Resident #34's Annual MDS assessment, dated 12/11/21, revealed in Section C - Cognitive Patterns a BIMS score of 07, indicating severe impairment. A review of Resident #9's Quarterly MDS assessment, dated 11/12/21, revealed in Section C - Cognitive Patterns a BIMS a score not indicated, however in section C1000 for Cognitive Skills for Daily Decision Making the #3 was checked for severely impaired never/rarely made decisions. A review of Resident #54's 5- Day MDS assessment, dated 1/7/22, revealed in Section C - Cognitive Patterns a BIMS score of 08, indicating moderate impairment. A review of Resident #93's Annual MDS assessment, dated 1/15/22, revealed in Section C - Cognitive Patterns a BIMS score of 00, indicating severe impairment. During an interview with the Social Service Director (SSD) on 2/17/22 at 9:00 a.m. he confirmed he was responsible for calling the families and responsible parties and confirmed he had others assist him with calls. He said the documentation was entered into the electronic medical record each time. The SSD stated he was unsure of the last time he contacted the families and responsible parties. During an interview with the Nursing Home Administrator (NHA) on 2/17/22 at 10:42 a.m. he confirmed the Social Service Director is responsible for notifying the families and representatives after a positive COVID-19 test. The NHA confirmed the facility calls and sends out letters with the updated website information. The NHA confirmed letters were sent out by regular mail, the website is updated daily, and the phone calls are documented in the electronic record by Social Services. The NHA could not provide documentation the families or representatives were notified by 5:00 p.m. the next calendar day. Review of the facility policy titled, COVID-19 - Guidance, effective 11/21, revealed: Letters of notification of COVID-19 initial cases will be mailed or given to the residents on admission and staff will be made aware. Letters are sent out by mail. The website is updated daily and addressed in the letter. The documentation should be in the [electronic medical record].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a dignified existence for two residents (#3 and #39), with impaired cognitive status and communication deficits, of seven residents, related to direct care staff standing over the residents while assisting them with eating for two of two days. Findings included: During an observation on 12/08/20 at 12:27 p.m., Resident #3 and Resident #39 were seen sharing the same room. Staff A, Licensed Nurse Practitioner (LPN) entered [Room Number] and stood beside Resident #3 with a meal tray. Resident #3 was lying in bed under the covers with her bed in a low position. Staff A placed the meal tray onto the side table and adjusted Resident #3's bed into the highest position and lifted the headboard upwards. Staff A prepped Resident #3's tray and began assisting her with eating by bringing the fork to her mouth. Staff A remained standing. Simultaneously, Staff E, Certified Nursing Assistant (CNA) entered the room and asked Resident #39 if she desired the food on her tray. Resident #39 slightly shook her head no (side to side) and Staff E exited the room, walked down the hallway, and then returned with a sandwich. Resident #39 was lying in bed under the covers with both hands over the covers, contracted. Staff E used hand sanitizer, entered the room, stood beside Resident #39's bed and cut the sandwich into bite size pieces. Staff E began assisting Resident #39 with eating by bringing the fork downward into her mouth. Staff E remained standing. Both Staff A, LPN and Staff E, CNA remained standing while assisting the residents with eating throughout the course of their meals. An empty cloth chair was seen in the room beside Resident #3's bed. During an observation on 12/09/20 at 12:50 p.m., Staff C, CNA was seen entering [Room Number] with a meal tray and stood beside Resident #3. Resident #3 was lying in bed under the covers with her bed in a low position. Staff C adjusted Resident #3's headboard into a higher position while the bed remained low. Staff C prepped the Resident's meal tray and began assisting her with eating by bringing the food in a downward angle on a fork into her mouth. Staff C remained standing over the resident during the meal. A review of Resident #3's admission Record revealed an admission date of 8/14/20 with medical diagnoses of epilepsy, muscle wasting, polyneuropathy, Alzheimer's disease with early onset, and unspecified age-related cataract. Resident #3's Minimum Data Set [MDS], dated 11/26/20, Section C: Cognitive Patterns revealed the resident has severely impaired daily decision-making abilities. Section G: Function Status of the MDS revealed the resident requires one-person extensive assistance for eating. A review of Resident #3's care plan, initiated on 8/17/20, revealed, . The Resident has a problem with communication: Rarely or Never Understood- unable to express ideas or want. Rarely/Never understands. A review of Resident #3's Nutritional Evaluation Quarterly, dated 11/21/20, Section D: Meals/Dining revealed a requirement for full assistance with meals inside her room. A review of Resident #39's admission Record, revealed an admission date of 7/22/19 with medical diagnoses of cerebral infraction, unspecified protein-calorie malnutrition, muscle wasting and atrophy, and transient cerebral ischemic attack. Resident #39's MDS, dated [DATE], Section C: Cognitive Patterns revealed the resident has difficulty focusing, and disorganized thinking. Section G: Functional Status of the MDS revealed the resident requires one-person extensive assistance for eating. A review of Resident #39's Care Plan, initiated on 7/23/19, revealed, . The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Moderately Impaired . Short term memory loss. A review of Resident #39's Nutrition Evaluation Quarterly, dated 9/30/20, Section D: Meals/Dining revealed a requirement for full assistance with meals inside her room. An interview conducted on 12/09/20 at 1:34 p.m. with Staff C, CNA revealed the process for assisting residents with eating includes sanitizing hands and making sure the resident is sitting upright. Staff C said, We are supposed to be sitting down when assisting a resident with eating, but I didn't have a chair. I asked the [Social Services Director] for a chair but she said she couldn't find one, so I had no choice but to stand up. An interview conducted on 12/09/20 at 1:39 p.m. with Staff A, LPN revealed she does not normally help with passing meal trays or assisting residents with eating. She stated she is not completely sure about policies [related to assisted eating] and would need to double check what the facility requirements are. Staff A confirmed she assisted Resident #39 with eating on 12/08/20 and remained standing while assisting the resident with eating. She stated normally there are metal chairs inside of the rooms because staff are no longer allowed to use cloth chairs due to infection control issues. She stated that she has not personally received education regarding assisting residents with eating but is unsure if CNAs were provided with education. An interview conducted on 12/09/20 at 1:46 p.m. with the Director of Nursing (DON) revealed the Nursing Home Administrator recently purchased additional metal chairs that are placed throughout the building for staff to use when assisting residents with eating. The DON stated the expectation for staff members when assisting residents with eating is to be seated. She stated there is no specific policy related to staff members and assisted eating procedures, however, it is part of the CNA's competencies that they must complete upon hire. A record review of the Competency Review Certified Nursing Assistant form, undated, revealed required competencies of preparing the resident for dining, properly preparing a tray for residents who can feed themselves, assist with eating and drinking, feeding those residents who require total assistance, providing a dignified environment and privacy, being able to explain resident rights, and ensuring resident dignity, respect, and recognition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure appropriate and timely completion of grievance reporting, documentation, and resolution for three residents (#2, #51, and #63) of three residents related to maintenance, repair, and replacing of electric wheelchairs and missing personalized wheelchair equipment and an assistive walking device. Findings included: 1. An observation on 12/09/20 at 11:04 a.m. revealed two electric wheelchairs in the [Unit Number] hallway with blue tarps covering them. An interview with Staff A, Licensed Practical Nurse (LPN) revealed the wheelchair on the left belonged to a resident who was recently discharged to the hospital. Staff A was unable to identify who the second electric wheelchair belonged to and stated she would need to speak with someone to find out. Staff A walked away and returned a moment later with the Social Services Director (SSD). The SSD stated she knew the electric wheelchair on the left belonged to a resident who was discharged to the hospital but was unsure who the second wheelchair belonged to and she would need to consult with a unit assigned Certified Nursing Assistant (CNA) to determine its owner. The SSD called over Staff B, CNA. Staff B, CNA stated she thinks the second electric wheelchair (one on the right) may belong to [Resident #51]. An interview on 12/09/20 at 11:10 a.m. with Resident #51 revealed the second electric wheelchair in the hallway belonged to him. He stated he has not used the wheelchair for a while since coming back from the hospital. Resident #51 said the wheelchair was . broken and acting weird. He stated he told the SSD during a care plan meeting but could not remember the date of the meeting. He stated the meeting was a while ago and after he reported the wheelchair was not functioning correctly . nothing came of it. A review of Resident #51's admission Record revealed an initial admission date of 10/03/08 with a readmission date of 7/17/20 and with medical diagnoses of paraplegia, immobility syndrome, chronic pain syndrome, and major depressive disorder. His Quarterly Minimum Data Set (MDS) assessment, dated 10/15/20, Section C: Cognitive Patterns revealed Resident #51 had no behaviors of inattention, disorganized thinking, or altered level of consciousness and had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #51 was cognitively intact. Section G: Functional Status revealed Resident #51 requires supervision with one-person assistance for location on and off the unit with a mobility device of a wheelchair. A review of Resident #51's progress notes, dated 10/19/20, revealed . Resident is alert able to make needs know . During an interview on 12/09/20 at 11:23 a.m. the Program Manager of Rehabilitation (PMR) stated Resident #51 does not ambulate and has an electric wheelchair for mobility. She stated that she has not performed the 6-month safety assessment on him (Resident #51) yet. She stated Resident #51 has not been up very much and has not been very motivated to get out of bed, so she has not seen him use his electric wheelchair recently. During an interview on 12/09/20 at 11:50 a.m. the SSD stated Resident #51 has not reported any grievances to her. The SSD went into Resident #51's room and asked him if he needed to speak with her. Resident #51 immediately stated that the only issue he is having is that the front motor on his wheelchair is not working. The SSD stated she would file a grievance on his behalf. Resident #51 stated that he mentioned the problem before in a care plan meeting where . A bunch of people were present. During an interview on 12/09/20 at 11:55 a.m. with the SSD and the MDS Coordinator, the MDS Coordinator stated she documents any complaints during care plan meetings. She stated Resident #51 has never had any complaints. During an interview on 12/09/20 at 1:15 p.m., Staff F, CNA stated Resident #51 does not ambulate by himself and used to have an electric wheelchair. She stated he has not been using it for a while because he said it has not been working. Staff F stated Resident #51 told her about a month ago that the wheelchair was not functioning properly, and he reported it in a care plan meeting which the SSD attends. Staff F stated she did not follow-up regarding the malfunctioning wheelchair because the resident told her he already reported it to the SSD, and she oversees filing and resolving grievances. A review of the medical record revealed a care plan/IDT note dated 10/22/20 at 16::32 (4:32 p.m.) which indicated, The resident's care plan meeting was held for the quarterly review. The resident was invited and attended. The plan of care was reviewed by the IDT and the resident. The current plan of care will continue at this time. 2. During an interview on 12/07/20 at 10:40 a.m., Resident #63 stated he has an electric wheelchair. He stated he returned from the hospital a few months ago and was placed under quarantine for COVID-19. Once he was moved off COVID-19 precautions, the facility told him they lost his wheelchair charger. He spoke with the SSD regarding the issues with his wheelchair. Resident #63 stated he misses being able to move independently to the outside area to, . Feel the sun on my face . I have some memory problems but I'm not a liar. A follow-up interview on 12/09/20 at 12:20 p.m. with Resident #63 revealed he feels that the facility does not follow through on grievances and he really need his electric wheelchair. A review of Resident #63's admission Record revealed an initial admission date of 8/13/18 with medical diagnoses of quadriplegia, personal history of traumatic brain injury, contracture of the left wrist and hand, major depressive disorder, and suicidal ideations. His MDS, dated [DATE], revealed no behaviors of inattention, disorganized thinking, or altered level of consciousness and a BIMS score of 14, which indicated the resident was cognitively intact. Section G: Functional Status revealed Resident #63 requires extensive assistance with two-person assistance for locomotion on the unit, and one-person assistance for location off the unit with a mobility device of a wheelchair. A review of Resident #63's care plan, initiated on 11/07/18, revealed a Focus of . The Resident has an ADL [Activities of Daily Living] Self Care Performance Deficit As Evidence by: Cannot complete ADL tasks independently . This focus included interventions of . LOCOMOTION: Electronic Wheelchair . During an interview on 12/09/20 at 11:23 a.m., the PMR stated Resident #63 does not ambulate and has splints to address his contractures. She stated the resident has an electric wheelchair and the facility has been attempting to replace some of the broken parts. She was told the entire electric wheelchair would need to be replaced, this has been an ongoing process for a couple of months. Resident #63 is not able to self-ambulate and declined a high-back manual wheelchair until his mechanical one is fixed. She stated Resident #63 does have some monetary funds in his account so perhaps they could get him a used electric wheelchair to replace his broken one as it would not be an easy task to get Resident #63 into a manual one. During an interview on 12/09/20 at 11:50 a.m., the SSD stated that she was aware of Resident #63's wheelchair problems, but she did not feel that he reported it as a grievance. During an interview on 12/09/20 at 12:30 p.m., the PMR stated she did not have any written notes about attempting to repair Resident #63's electric wheelchair and she would need to check with maintenance to see if they had any documentation. The PMR returned a few moments later saying that maintenance did not have any documentation related to Resident #63's wheelchair repair attempts. 3. During an interview on 12/08/20 at 9:06 a.m., Resident #2 stated he went to the hospital about four months ago. Before he went to the hospital, he had a personalized wheelchair with a cupholder, that his [family member] gave him, and a brown seat cover that a friend gave him. Resident #2 stated he also had a walker that he used. When he went out to the hospital, the facility staff told him they would store his wheelchair and walker until he returned. When he was re-admitted (8/12/20), he spoke to the Social Services Director (SSD) to get his wheelchair and walker back. He said, But nothing came of it. When Resident #2 followed up about his assistive devices with the SSD, he had the Activities Director with him, and the SSD said they never had the conversation about his assistive devices. Resident #2 said, I have my mind about me. I have some troubles on my left side, but my mind is fine. Resident #2 stated the Activities Director told him to always make sure these types of conversations are documented. During a follow-up interview on 12/09/20 at 12:11 p.m., Resident #2 stated when he returned to the facility after the hospital . I went to social services like I was supposed to if there are problems, and she said she would write up a form. That never happened. So, then I went with the Activities Director to see the SSD and she said we never had that conversation. This really upset me . Resident #2 stated no one has seen him to complete or sign any documentation related to his concern. A review of Resident #2's admission Record revealed an initial admission date of 3/28/19 and a readmission date of 8/12/20 with medical diagnoses of epilepsy, peripheral vascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, and COVID-19. His Minimum Data Set [MDS] assessment, dated 11/18/20, Section C: Cognitive Patterns revealed a BIMS score of 14; indicating an intact cognition with no behaviors of inattention, disorganized thinking, or altered level of consciousness. Section G: Functional Status revealed Resident #2 requires supervision with one-person assistance for locomotion on and off the unit with a mobility device of a wheelchair. A review of Resident #2's progress notes, dated 11/27/20, revealed . Resident is able to make needs known . During an interview on 12/09/20 at 11:23 a.m., with the PMR and Staff K, Restorative CNA, the PMR stated that Rehabilitation (department) screens all residents and determines their needs. She stated that Resident #2 was discharged from therapy services and primarily uses a wheelchair for location. In the past, the restorative program was working with him with a walker for assistance to increase strength. The Restorative CNA stated that prior to Resident #2 going to the hospital with COVID-19, he was on an ambulation program and . was doing really well. The PMR stated upon his readmission to the facility, he was screened. Resident #2 did report to her that his old wheelchair and walker were missing but the facility has been unable to find them. The PMR stated she found out about his missing walker on Friday of last week, 12/04/20. During an interview on 12/09/20 at 11:50 a.m., the SSD stated she is the facility's designated Grievance Officer. She stated that Resident #2 reported his wheelchair missing to the activities department, who then reported it to therapy first. Therapy provided him with another wheelchair until they figured out how to get him another one with his personalized items. She stated it was reported late afternoon on 12/04/20 and she was waiting on the PMR to complete her portion of the grievance form. During an interview on 12/09/20 at 12:16 p.m. with the Activities Director it was revealed Resident #2 reported to her that his wheelchair and walker were missing. She then went to speak with the PMR and the PMR stated she was already aware of the situation. The Activities Director stated the PMR looked for the wheelchair with Resident #2, and Resident #2 did not identify his wheelchair. After this conversation, she stated Resident #2 and herself went to the SSD. At this point, the SSD stated there had never been a conversation about Resident #2's missing assistive devices and a grievance would be filed. The Activities Director stated she has filed grievances on the behalf of residents before. She usually does it immediately and passes the information to the SSD. During an interview on 12/9/20 at 12:30 p.m. with the PMR it was revealed that she assisted Resident #2 with finding his personalized wheelchair sometime during the middle of last week and was unsuccessful but did not find out about the missing walker until 12/4/20. She stated she completed her portion of the grievance form related to Resident #2's missing items today. During an interview on 12/09/20 at 1:46 p.m., the Director of Nursing (DON) stated the process at the facility is to review and talk about grievances as an Interdisciplinary Team during the morning meetings. Usually, the SSD will even call her over the weekend if any issues or concerns arise. The DON reviewed the facility's Grievance/Concern Management policy and stated that a grievance is anything that impedes on the resident's rights. She stated a grievance can also be if a resident feels like they need something and are not getting it. She reminds staff that even if a resident states a problem that seems small, write it on the grievance log and complete the grievance form. The DON stated she educates staff to immediately write up a grievance form. A review of the policy titled, Grievance/Concern Management, dated August 2017, page 1 revealed, Residents/representatives has the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous . These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents . Page 2 of the Grievance/Concern Management revealed, . 3. Residents/resident representative who are unable to complete a written concern will be assisted by staff to prepare and submit the form. 4. The NHA is responsible for oversight of the concern process. 5. The Social Services Representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion.

Based on observations, record review, and interviews, the facility did not ensure that four vials of a Schedule IV medication, Ativan, were stored in a locked, permanently affixed compartment for one medication storage room (300/400 hall) of two medication storage rooms sampled during the performance of the facility task of Medication Storage and Labeling. Findings included: On 12/9/2020 at 3:55 p.m. Staff G, Registered Nurse (RN), and Staff H, RN accommodated the observation of the locked medication storage room located behind the nurse's station between the 300 hall and 400 hall. The refrigerator in the room was not locked and contained a locked plastic box that contained four vials of Ativan 2mg/ml (milligram/milliliter), a Schedule IV medication. (photographic evidence obtained). The plastic box was not permanently affixed and was easily removed from the refrigerator. Staff G, RN, and Staff H, RN were then asked if they were aware that Schedule II-V medications stored in the refrigerator were to be stored in a locked, permanently affixed compartment. Staff G, RN replied that she was aware, but did not realize that the Ativan in the refrigerator was not stored in a locked permanently affixed compartment. Staff H, RN did not reply. On 12/9/2020 at 4:10 p.m. an interview with the Director of Nursing (DON) revealed that she was aware that Schedule II-V medications stored in the refrigerator were to be stored in a locked, permanently affixed compartment. On 12/9/2020 at 4:20 p.m. a telephone interview with the Consulting Pharmacist revealed that she was aware that controlled substances need to be stored in a locked, permanently affixed compartment in the medication storage room and has informed the facility of such in the past. On 12/10/2020 at 4:15 p.m. a review of the facility's policy titled, 4.2 Medication Storage Controlled Medication Storage, page 1 of 3 and dated 11/17, showed in section 4, Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator.

Based on interview and record review the facility failed to ensure that annual influenza vaccine was offered to one (Resident #73) out of five sampled residents. Findings included: Record review of Resident #73's medical record revealed no documentation regarding influenza vaccination. There were no orders or administration record for vaccination, no documentation that the vaccination was offered, and no documentation that the vaccination was declined. The admission Record revealed an admission date of 10/26/20 and a readmission date of 11/5/2020. On 12/10/20 at 10:48 a.m. the facility Director of Nursing (DON) was interviewed about the facility influenza vaccination program. She confirmed that attempts were made to offer the vaccine to all residents starting at the end of September 2020 and the beginning of October 2020. She stated that the corporation had required for all residents to be offered the vaccine by the beginning of November 2020, that the facility had met that goal, and that currently efforts were ongoing to re-offer the vaccine to anyone who had refused it. The DON was requested to produce records that the influenza vaccine had been offered/administered/declined for Resident #73 and she confirmed that there was nothing on record. On 12/10/20 at 2:25 p.m. the DON, facility Administrator, and Corporate Regional Nurse consultant (RNC) were interviewed. They reported that the consent to influenza vaccine form was part of the admission packet for any resident admitted to the facility and agreed that influenza vaccine had not been offered to Resident #73. The RNC described that the process for influenza vaccination for residents was to offer the vaccine and associated consent form, if resident consented then the vaccine was ordered and administered and if a resident declined then they would sign the declination form. She confirmed that the vaccination process started in the facility in September 2020 and included a mass mailing and mass calling to responsible family and resident representatives. She confirmed that the corporate expectation was to offer the influenza vaccine to all residents by November (2020) and that the facility had achieved that goal. She stated that typically the facility infection control nurse would have close follow-up regarding influenza vaccination and that the facility had identified that more help was needed in this area, although no formal quality assurance process had been started. Review of the facility policy and procedure titled, Immunizations - Pneumococcal & Annual Influenza, dated May 2020 revealed the following: The influenza vaccine will be administered during the optimal time for immunization, which is usually October to March, Immunization will be offered from October to March. The Infection Prevention Coordinator/DON will coordinate the influenza and pneumococcal immunizations. The facility will continue to offer vaccine to unvaccinated personal and newly admitted residents all throughout the influenza season as recommended (usually October 1 through March 31). Procedure .1. Screen the resident on admission to determine if they are current on the following adult immunizations: a. Influenza .2. Obtain consent for immunization or immunization declination on the Pneumococcal and Annual Influenza Vaccination Information and Request form. The influenza vaccination will be offered annually, and a new request form will be signed annually.