**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedure, record review and staff interviews, the facility failed to treat 1 (Resident #46) of 22 residents observed on the memory care unit with respect and dignity during medication administration. The findings included: The facility Policy Quality of Life - Dignity documented Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Residents shall be treated with dignity and respect at all times . the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . The facility policy IIBI: Administration Procedures For All Medications documented To administer medications in a safe and effective manner . Provide privacy for resident during administration of medications . Review of the clinical record revealed Resident #46 had an admission date of 8/1/23 with diagnoses including dementia with behavioral disturbance and seizures. Review of the Brief Interview for Mental Status dated 1/31/25 revealed Resident #46 score of 03 on the evaluation, indicating severe cognitive impairment. On 2/3/25 at 12:38 p.m., Registered Nurse (RN) Staff G was observed administering medications to residents in the dining room. Multiple residents were sitting at tables waiting for their lunch meal. Resident #46 was observed seating at a dining room table with her head down. RN Staff G instructed Resident #46 to lift her head to take her medications. The resident kept her head down. RN Staff G placed two capsules in some pudding. He placed a hand on Resident #46's head and lifted her head. While holding the resident's head, RN Staff G placed one of the capsules in the resident's mouth with some pudding. Resident #46 pushed the capsule out of her mouth onto her lower lip. RN Staff G scraped the capsule and pudding from the resident's mouth with the spoon and placed it back in her mouth. RN Staff G continued to hold Resident #46's head with one hand and placed the second capsule into the resident's mouth with some pudding. Resident #46 spit the capsule out three times. Each time RN Staff G used the spoon to scrape the pudding from the resident's lips and chin and place it back in the resident's mouth with the capsule. Staff G continued to hold the resident's head until she swallowed the medications. On 2/3/25 at 12:45 p.m., in an interview RN Staff G verified he held the resident's head, scraped the pudding and medications several times and placed them back into the resident's mouth. RN Staff G replied ok and walked away when asked about the concern of treating Resident #46 with dignity. On 2/4/25 at 10:15 a.m., Licensed Practical Nurse (LPN) Staff D was observed administering medications in the dining room of the [NAME] memory care unit during an activity program. Resident #46 was observed sitting at a table. On 2/4/25 at 10: 20 a.m., LPN Staff D approached Resident #46 and instructed her to open her mouth to take her medication. LPN Staff D placed the medications in the resident's mouth and told her to swallow them. The instructions were clearly audible to the other resident sitting at the table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to provide Physical and Occupational therapy to 1 (Resident #130) of 2 residents reviewed for specialized rehabilitative services. The findings included: Review of the clinical record for Resident #130 revealed an admission date of 1/24/25. Diagnoses included Multiple Sclerosis, Urinary Tract Infection, Depression, Anxiety Disorder, and a history of falling. Review of the five-day Minimum Data Set, dated [DATE] revealed Resident #130 scored 10 on the Brief Interview for Mental Status, indicative of moderate cognitive impairment. On 2/3/25 at 11:00 a.m., in an interview Resident #130 said she felt like her husband had dumped her at the facility. She stated staff were not doing anything for her since her admission and she had not received any rehabilitative services. Review of the physician's order revealed an order dated 1/24/25 to admit Resident #130 to the facility for Rehabilitation services. A physician's order dated 1/24/25 read, PT [Physical Therapy] evaluation and treatment as indicated. A physician's order dated 1/24/25 read, OT [Occupational Therapy] evaluation and treatment as indicated. On 2/6/25 at 9:20 a.m., in an interview Resident #130 said she had not received any therapy. She stated no one was telling her what she was doing here. She said she felt like she had been dumped at the facility. On 2/6/25 9:30 a.m., in an interview the Regional Physical Therapy Consultant verified Resident #130 had physician's orders dated 1/24/25 for Physical and Occupational therapy but had not been evaluated by Physical Therapy or Occupational Therapy as ordered.

Based on observation, review of the clinical record, review of facility policy and procedures, and staff interviews, the facility failed to develop a care plan that described the resident's medical, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences for 4 (Resident #46, # 54, #42 and #55) of 4 residents residing on the memory care unit. The failure to complete an individualized care plan has the potential to impact the resident's quality of life and quality of care. The findings included: The facility policy Baseline Care Plan and Summary documented the facility will develop and implement a care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident. 1. Review of the clinical record revealed Resident #42 had a readmission date of 2/23/24. Diagnoses included severe dementia with behavioral disturbance, depression, degenerative disease of the nervous system, and anxiety. The clinical record documented a brief interview for mental status (BIMS) could not be conducted as Resident #42's cognition was severely impaired. The care plan initiated on 3/5/24 indicated Resident #42 Prefers not to participate in group activities but will sit in on group activities. The goal for the resident specified, Will participate in independent leisure activities of choice daily such as walking in the halls and listening to music. The interventions included Respect choice in regard to limited/ no activity participation. Responses within recreational programs or activity visits are limited related to physical impairments and impaired cognitive functioning. The care plan also identified Resident #42 had behaviors symptoms related to anxiety including, refusing to wear safety helmet for preventing falls related to traumatic brain injury, picking up items from the floor and putting it in her mouth, Resident removes the signs from the walls, wiping/taking out things from the wall, yelling screaming bumping into things below waist. Observations on 2/3/25 from 10:00 a.m., to 12:30 p.m., 2/4/25 at 11:32 a.m., 2/3/25 at 2:00 p.m., and 2/5/25 at 9:52 a.m., Resident #42 was observed wandering the hallway of the memory care unit. Resident #42 was observed going in and out of other residents rooms. She was wiping walls and doors with her hands. Staff did not redirect the resident. Review of the clinical record revealed Resident #46 had an admission date of 8/1/23 with diagnoses including dementia with behavioral disturbance and seizures. Review of a Brief Interview for Mental Status (BIMS) dated 1/31/25 revealed Resident #46 scored 03, indicating severe cognitive impairment. The care plan initiated 8/7/23 identified Resident #46 Prefers not to attend group activities/limited group activities. However: Enjoys/Enjoyed activities such as watching television and listening to music. The goal for Resident #46 specified, Will participate in independent leisure activities of choice daily. The interventions included, Provide supplies/materials for leisure activities as needed/requested. On 2/5/25 at 1:12 p.m., in an interview the Activity Director said Resident #46 does not participate and yells out. She had a baby doll that she would carry around but it is lost and a new one was ordered. The Activity Director said Resident #46's care plan identified the resident liked to hold a doll. When asked about the care plan goal for the resident was to participate in independent leisure activities of choice daily, when she had a BIMS score of 03, the Activity Director confirmed Resident #46 was not able make that choice. She said, I would never put that on a care plan for her. Further review of the care plan failed show documentation Resident #46's had the desire to hold a baby doll. 3. Review of the clinical record for Resident #54 revealed a readmission date of 7/11/23. Diagnoses included Alzheimer's disease, anxiety disorder, adjustment disorder, dementia and major depressive disorder. Review of the BIMS dated 1/18/25 showed Resident #54 scored 00, indicating severe cognitive impairment. The care plan revised on 7/25/23 documented Resident #54, Prefers not to attend group activities/limited group activities. However: Enjoys/Enjoyed activities such as listening to music, socializing, being outdoors. The goal for Resident #54 specified, Will participate in independent leisure activities of choice daily such as socializing The interventions included, Familiarize with center environment and activity programs on regular basis. Provide supplies/materials for leisure activities as needed/requested. Responses within recreational programs or activity visits are limited related to physical impairments and impaired cognitive functioning. On 2/3/25 at 10:21 a.m., 2/4/25 at 10:13 a.m., 2/5/25 at 9:18 a.m., and 2/5/25 at 9:48 a.m., Resident #54 was observed seating at a table in the dining room with magazines in front of her. Resident #54 kept her head down. Resident #54 was not engaged in any activity and often calling out loudly. 4. Record review for Resident #55 revealed an admission date of 10/25/23. Diagnoses included dementia with behavioral disturbance, cognitive communication deficit, sexual dysfunction not due to a substance or known physiological condition, and major depressive disorder. Review of the clinical record revealed Resident #55 was Spanish speaking with a BIMS score of 03, indicating severe cognitive impairment. The care plan initiated 11/1/23 identified Resident #55 Prefers not to attend group activities/limited group activities. However: Enjoys/Enjoyed activities such as watching action/war movies, socializing, and people watching Spanish television. The goal for Resident #55 specified, Will participate in independent leisure activities of choice daily such as watching movies and television. The care plan interventions included, Provide supplies/materials for leisure activities as needed/requested. On 2/3/25 from 10:00 a.m., until 12:30 p.m., 2/4/25 at 9:52 a.m., 2/4/25 at 12:59 p.m., 2/5/25 at 9:36 a.m., and 2/5/24 at 10:02 a.m., Resident #55 was observed seating at a table in the dining room. The resident was observed continually attempting to stand up from the wheelchair or with his head down and appeared to be sleeping. On 2/6/25 at 8:37 a.m., in an interview the Activity Director said the Regional Director of Client Relations and herself identified that there were no activity preference assessments completed for Residents #46, #54, #42 and #55. The Activity Director said the care plans were individualized for each resident on the memory care unit. The care plans for Residents #55, #54, #46 and #42 were reviewed with the Activity Director. She confirmed Residents #55, #54, #46 and #42 had severe cognitive impairment and were not able to choose individualized activities. She said there were issues with the care plans. On 2/6/25 at 8:57 a.m., in an interview Unit Manager Registered Nurse Staff H said she was also the Care Plan Coordinator but did not write the activity care plans. She said the activity department wrote their own care plans. Unit Manager Staff H said the care plans should be reviewed and updated with any changes in the residents condition and before scheduled care plan meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 2/3/25, observations of Resident #5 at 9:30 a.m., 10:16 a.m., 11:43 a.m., and 1:35 p.m. revealed the resident was in her room, in bed wearing a hospital gown. During the observations neither the television nor the radio where on, and Resident #5 was not observed in an in-room or an out of room facility activity program during the day. On 2/04/25, observations of Resident #5 at 11:00 a.m., 12:03 a.m., and 2:35 p.m. revealed Resident #5 was in a wheelchair next to her bed. During the observations neither the television nor the radio where on, and Resident #5 was not observed in an in-room or an out of room facility activity program during the day. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] with diagnoses of pneumonitis, atrial fibrillation, hypothyroidism, dementia without behavioral disturbance, mood disorder, depression, and anxiety disorder. Further review of Resident #5's medical record revealed the Activity admission Assessment, and an interim activity care plan had not been initiated. Review of the Director of Activities (DOA) job description stated they were required to delegate the development and delivery of therapeutic recreational services to promote the residents' opportunities for engaging in normal life enhancement pursuits and to increase and/or maintain functioning levels. They DOA was to encourage resident participation in group and individual activities and ensure each resident's participation in facility and individual daily activity programs were documented in their medical record. On 2/05/25 at 1:18 p.m., during an interview with the DOA, she said she had worked at the facility for about 5 years. The DOA said part of her responsibility was to ensure all the residents in the facility received the activity of their choice on a routine basis. The DOA said as part of her job duties she was required to develop completed the Activity admission Assessment tool within 7 days of the resident admission to the facility. She said the Activity admission Assessment form was used to develop an individual activity program for each resident to promote opportunities for the resident to engage in activities which would provide normal life enhancement to increase and/or maintain the resident's highest functional levels. The DOA reviewed Resident #5's medical record. The DOA confirmed Resident #5 was admitted to the facility on [DATE] with diagnoses of pneumonitis, atrial fibrillation, hypothyroidism, dementia without behavioral disturbance, mood disorder, depression, and anxiety disorder. The DOA said she was unable to find documentation she had completed Resident #5's Activity admission Assessment and/or documentation Resident #5 had participated in any facility activities and/or activities of Resident #5's choice since her admission to the facility as required. Based on observation, review of the clinical record, review of facility policy and procedures, and staff interviews, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident's physical, mental, and psychosocial well-being for 5 (Resident #46, #54, #42, #55 and #5) reviewed for involvement in activity programs. The findings included: Review of the facility policy 2.8 Activity Programs revealed, Activity programs designed to meet the needs of each resident are available on a daily basis . are designed to encourage maximum individual participation and are geared to meet the individual needs . Review of the clinical record revealed Resident #42 had a readmission date of 2/23/24. Diagnoses included severe dementia with behavioral disturbance, depression, degenerative disease of the nervous system, and anxiety. The care plan initiated on 3/5/24 indicated Resident #42, Prefers not to participate in group activities but will sit in on group activities. The goal for the resident specified, Will participate in independent leisure activities of choice daily such as walking in the halls and listening to music. The interventions included, Respect choice in regard to limited/ no activity participation. Responses within recreational programs or activity visits are limited related to physical impairments and impaired cognitive functioning. The care plan noted Resident #42 had behaviors symptoms related to anxiety including refusing to wear safety helmet for preventing falls related to traumatic brain injury, picking up items from the floor and putting it in her mouth, Resident removes the signs from the walls, wiping/taking out things from the wall, yelling screaming bumping into things below waist. The clinical record documented a brief interview for mental status (BIMS) could not be conducted as Resident #42 was rarely understood. Observations on 2/3/25 from 10:00 a.m., to 12:30 p.m., 2/4/25 at 11:32 a.m., 2/3/25 at 2:00 p.m., and 2/5/25 at 9:52 a.m., Resident #42 was observed wandering the hallway of the memory care unit. Resident #42 was observed going in and out of other residents rooms. She was wiping walls and doors with her hands. Staff did not redirect the resident. No activities were offered to the resident. On 2/6/25 at 8:37 a.m., in an interview the Activity Director was asked about individualized activity interventions to decrease Resident #42's wandering behavior. The Activity Director replied Resident #42, will attend activities at times but does not stay because it's her choice to walk, we can't make her sit. Review of the clinical record revealed Resident #46's diagnoses included dementia with behavioral disturbance and seizures. Review of a Brief Interview for Mental Status (BIMS) dated 1/31/25 revealed Resident #46 scored 03 indicating severe cognitive impairment. The care plan initiated on 8/7/23 noted Resident #46, Prefers not to attend group activities/limited group activities. However: Enjoys/Enjoyed activities such as watching television and listening to music. The goal for Resident #46 specified, Will participate in independent leisure activities of choice daily. The interventions included, Provide supplies/materials for leisure activities as needed/requested. The care plan noted Resident #46 had Behavior symptoms as evidenced by resident being tearful and referring her body is covered with wires. The goal was to reduce the behavior. On 2/3/25 from 10:00 a.m., to 12:30 p.m., Resident #46 was observed seating at a back table in the corner of the dining room with a coloring book and pencils in front of her. Resident #46 had her head down, appeared to be sleeping. Resident #46 would randomly lift her head and yell out. Activity Assistant Staff B was tossing a balloon with six residents in a circle while music was playing. She did not attempt to engage Resident #46 in the activity. On 2/4/25 at 10:05 a.m., Activity Assistant Staff B, the Activity Director and the Regional Director of Client Relations had a circle of 10 residents in the center of the dining room. They were tossing a balloon and dancing with the residents. Resident #46 was observed sitting at a table in the back of the dining room. Certified nursing assistant (CNA) staff C was seated next to the Resident. She offered her a snack and soft squeeze balls from a bin. Resident #46 did not respond and was randomly yelling out loudly. On 2/5/25 at 9:20 a.m., in an interview Activity Assistant Staff B said at this time she was the only activity assistant for the facility. She said, I do the activities in the building, there is no one else but me. The Activity Director helps out and the CNA's will help when they can, but they have their own work to do. Right now, I go back and forth to all the units for the activities. For residents like Resident #46 I do aroma therapy, sensory stimulation like massage or sensory lap blankets. On 2/5/25 at 9:38 a.m., Resident #46 was observed seating at a table in the back of the dining room. A group activity of balloon toss and music with 8 residents in the circle was observed. There was a magazine placed in front of Resident #46, but she did not look at it or touch it. Resident #46 had her head down and eyes closed. Activity Assistant Staff B came to the table, took the magazine and placed a busy book in front of the resident. Staff B instructed the resident to touch the book and walked away. Resident #46 touched the busy book for less than a minute and began to grab the table and rotate it as she loudly yelled out. No staff member intervened to offer redirection or support. On 2/5/25 at 9:59 a.m., Resident #46 was observed yelling out as she sat at the table. CNA Staff L offered the resident graham crackers and water. On 2/5/25 at 10:00 a.m., in an interview the regional Director of Client Relations said Resident #46 gets upset after meals and she will start yelling. She is occasionally able to say a few words but mostly she just calls out. On 2/5/25 at 10:22 a.m., Resident #46 remained at the table in the back of the dining room frequently yelling out. The resident was not offered staff interventions including aroma therapy, sensory stimulation like massage or sensory lap blankets. On 2/5/25 at 1:12 p.m., the Activity Director said, for Resident #46 who does not participate and yells out, she had a baby doll that she would carry around but it is lost and a new one was ordered. The Activity Director said Resident #46's care plan identified the resident liked to hold a doll. On 2/5/25 at 1:21 p.m., Resident #46 was observed seating at the back of the dining room at the same table and was frequently yelling out. On 2/5/25 at 1:23 p.m., Activity Assistant Staff B entered the dining room carrying a doll. Staff B approached Resident #46 and said, I have your baby. Staff B tried to place the doll in the resident's arms twice. Resident #46 would not hold the doll. Staff B placed the doll on the table in front of the resident and left the room. Review of the clinical record revealed Resident #54 had a readmission date of 7/11/23. Diagnoses included Alzheimer's disease, anxiety disorder, adjustment disorder, dementia and major depressive disorder. Review of a BIMS dated 1/18/25 revealed Resident #54 scored 00 indicating severe cognitive impairment. The care plan revised 7/25/23 documented Resident #54 Prefers not to attend group activities/limited group activities. However: Enjoys/Enjoyed activities such as listening to music, socializing, being outdoors. The goal for Resident #54 specified, Will participate in independent leisure activities of choice daily such as socializing The interventions included, Familiarize with center environment and activity programs on regular basis. Provide supplies/materials for leisure activities as needed/requested. Responses within recreational programs or activity visits are limited related to physical impairments and impaired cognitive functioning. On 2/3/25 at 10:21 a.m., Resident #54 was observed seated at a table in the dining room with magazines in front of her. 80's music was playing in the background while Activity Assistant Staff B was tossing a balloon to 6 residents seated in a circle. The resident had her head down and was not participating in the activity. On 2/4/25 at 10:13 a.m., Resident #54 was observed seated in a group circle listening to 80's music while the Activity Director, Activity Assistant Staff B and the Regional Director of Client Relations assisted the residents to dance. Resident #54 had her head down and was not engaged in the activity. On 2/5/25 at 9:18 a.m., and 2/5/25 at 9:48 a.m., Resident #54 was observed seated at the table in the dining room. The resident was agitated and yelling out. There was no staff intervention or activity offered to the resident to address the agitation and yelling. There was a group circle of eight residents participating in music and balloon toss. Six other residents were observed sitting at tables with magazines, blocks or a sensory book on the tables in front of them, who received no staff intervention. Record review for Resident #55 revealed an admission date of 10/25/23. Diagnoses included dementia with behavioral disturbance, cognitive communication deficit, and major depressive disorder. Review of the clinical record revealed Resident #55 was Spanish speaking with a BIMS score of 03, indicating severe cognitive impairment. The care plan initiated 11/1/23 identified Resident #55 Prefers not to attend group activities/limited group activities. However: Enjoys/Enjoyed activities such as watching action/war movies, socializing, and people watching Spanish television. The goal for Resident #55 specified Will participate in independent leisure activities of choice daily such as watching movies and television. The care plan interventions included, Provide supplies/materials for leisure activities as needed/requested. On 2/3/25 Resident #55 was observed seated in the dining room at a table from 10:00 a.m., until 12:30 p.m. There were magazines (English language) on the table in front of him, but he showed no interest. He sat with his head down, occasionally attempting to stand from the wheelchair (w/c) and was instructed by staff members to sit down. On 2/4/25 at 9:52 a.m., Resident #55 was observed seated at the same table in the dining room with his head down, alternating sleeping, yelling out or attempting to stand. There was a busy book in front of him but he did not touch it. There was a group activity in progress, but staff did not ask him if he wished to participate. On 2/4/25 at 12:59 p.m., Resident #55 was observed at the same table in the dining room having just completed the noon meal. He was observed continually standing up from the w/c, and staff call out for him to sit back down. There was no intervention of Spanish television, or war movies offered to him. Observations on 2/5/25 at 9:36 a.m., and 10:02 a.m., revealed Resident #55 sitting at the same location at a table in the back of the dining room in a w/c. He had his head down, alternating sleeping, calling out and attempting to stand. On 2/5/25 at 10:15 a.m., Resident #55 was observed calling out and attempting to stand from the w/c. A magazine (English language) was on the table in front of him. A Spanish Speaking Staff member approached Resident #55 asked him his name and gave her name. The conversation in the residents language lasted approximately two minutes. Resident #55 remained in the same location but the magazine was removed and he continued to stand and was told to sit back in the w/c. During observations on 2/5/25 at 1:21 p.m., 2/6/25 at 8:30 a.m., Resident #55 was observed in the same position at the table, calling out and attempting to stand, then sits and repeats the behavior. On 2/6/25 at 8:33 a.m., in an interview the Activity Director confirmed Resident #55 was not able to self-initiate activities. She said we will do Spanish Puzzles, and word search for Resident #55 and said the resident will attend group activities when he wants to. On 2/6/25 at 8:37 a.m., in an interview the Activity Director said the Regional Director of Client Relations and herself identified that there were no activity preference assessments completed for Residents #46, #54, #42 and #55. The Activity Director said the care plans were individualized for each resident on the memory care unit. The care plans for Residents #46, #54, #42 and #55 were reviewed with the Activity Director who confirmed the residents were not able to choose and self-initiate activities. Review of the February 2025 [NAME] Memory Care Unit Activity Calendar revealed the following activities were scheduled: 2/3/25- 9:00 a.m., daily chronicles. 9:30 a.m., Move and Grove, 10:00 Reminiscing, 11:00 a.m., what's that sound, 2:00 p.m., snacks and hydration, 3:00 Touch therapy-textures. 2/4/25 at 9:00 Daily Chronicles, 9:30 arts and crafts-abstract art, 10:00 Coordination games- catch, 11:00 a.m., move and groove, 2 :00 p.m., snacks and hydration, 3:00 Music Therapy- sing along to the 60's Reminiscing. 2/5/25 At 9:00 a.m., daily chronicles, 9:30 Move and groove, , 11:00 Aroma Therapy - calming scents, 2:00 p.m., snacks and hydration, 3:00 Reminiscing- Childhood. 2/6/25 9:00 a.m., Daily Chronicles, 9:30 a.m., Catholic church services, 10:00 matching games-color, 11:00 move and groove, 2:00 p.m., snacks and hydration, 3:00 Dancing in the 70's. On 2/5/25 at 1:12 p.m., in an interview the Activity Director said when Activity Assistant Staff B is not on the memory care unit doing activities, she covers for her. She said they do not always follow the activity calendar because it all depends on the residents moods and what they want to do.

Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to report allegation of resident to resident abuse involving 1 (Resident #8) of 3 sampled residents reviewed. The findings included: The facility Patient Protection Guidelines dated 10/2021 stated, The center supports and protects patients, family members and staff from harm during an investigation for abuse. Patient protection actions include: immediately removing the patient form contact with the alleged abuser . Reporting the actual or suspicious event to the Abuse Prevention Coordinator and Administrator, Reporting allegations of abuse to other agencies or law enforcement. Review of the clinical record for Resident #8 revealed a progress note dated 3/26/23 at 10:51 p.m., which noted, Resident was found lying on the floor in her room, she stated that her roommate (Resident #9) pulled her out of bed on to the floor because she was coughing. Resident was assessed vitals, neurological observations, pain, and skin assessment completed and charted; a tiny skin tear was noticed on resident left arm was cleanse [sic] with saline and STERIS [sic] trip applied. Resident denied pain. MD (physician) and resident's niece informed. Records reviewed showed Residents #8 and #9 resided in the secured memory care unit. On 5/10/2023 at 4:20 p.m., the Director of Nursing (DON) said the facility did not submit a Federal Day 1 to the State Survey Agency as required. She said, We separated them and (Resident #9) who pulled her (Resident #8) out of the bed now does not have any roommates, but we did not report it. We talked about it as a group but did not think to report. But looking at the nursing note, I see we should have reported it. During the interview, the Administrator walked into the DON's office, reviewed the nursing progress note and agreed the incident should have been reported.

Based on record review, resident, and staff interview, the facility failed to ensure meals were palatable, and served at a safe, and appetizing temperature, which had the potential to affect all residents who received meals from the kitchen. The census was 94 at the time of the survey. The findings included: The Facility policy titled Food Temperatures During Holding, dated 11/2020 stated, Food temperatures are checked and recorded: upon completing of cooking; prior to the start of meal service; whenever a new pan of food is put into use; if food has remained on the steam table for over two hours; any other time if needed . Food temperature logs are kept for a rolling year for previous 12 months. On 5/10/23 at 11:00 a.m., Resident #3 said, No one likes the food here. The food is terrible, I get Jell-O soup which is supposed to be cold and cold soup when it is supposed to be hot. On 5/10/23 at 11:10 a.m., Resident #6 said, The food is not good. The temperature is hit or miss. On 5/10/23 at 12:10 p.m., the Administrator said he could not provide the documentation for monitoring the temperatures of the food served to residents. He said the food services manager had been on vacation for the past two weeks. The Administrator said the cook for the facility said they take the temperatures but do not keep a log. The Administrator said, I know they are supposed to do the temperatures, log them and keep that information for a year so I will be doing in-services today. I am reaching out to the food services manager even though she is on vacation hoping she has the logs and that it is just the past two weeks that they have been doing the temperature monitoring incorrectly. On 5/10/23 at 12:30 p.m., facility cook Staff A described the process for checking food temperatures as, If we put something in the oven, we use the timer. When cooking food, I can tell by looking at it that it is done. Not everything needs to have temperature done. I take the temperature when I take it out of the pan and then put it on the steam table, again before I start tray line, I retake temperature and if needed put back in steamer to reheat. Staff A said, We write the temperatures on the menu, but then we don't keep them. On 5/10/23 at 2:35 p.m., Resident #7 said the food is, institutional tasting. The resident said, About 50 percent of the time it is the right temp.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and resident record review, the facility failed to treat each resident with respect and dignity for 2 (Residents, #11 and #158) of 2 residents reviewed for dignity. The findings included: 1. Record review revealed Resident #11 was admitted on [DATE]. Review of the Minimum Data Set (MDS) assessments noted Resident #11 was discharged to an acute care hospital on 8/20/22 and returned to the facility on 9/1/22. The quarterly MDS dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. On 9/19/22 at 11:38 a.m., Resident #11 was observed sitting in her wheelchair wearing a hospital gown. Resident was asked if she wanted to be in a hospital gown. Resident #11 said, I don't have my clothes they are in the other room. I would get dressed if I had my clothes. Observation of the resident's closet with her permission showed one light mint colored t-shirt and no other clothes. On 9/20/22 at 9:05 a.m., Resident #11 observed in bed wearing hospital gown. Asked if she wanted to stay in her hospital gown or if she would rather be dressed. Resident #11 replied, I don't have my stuff. Asked if she has asked staff for her items. Resident #11 replied, They know I don't have my stuff. On 9/20/22 at 11:08 a.m., Resident #11 was observed in bed wearing light mint green colored t-shirt and incontinence briefs. Resident #11 said she has been in this current room since she came back from the hospital. Resident #11 said no staff offered to get her clothes or personal items from her previous room, and no staff has told her if she will go back to her original room. On 9/21/22 at 10:00 a.m., Resident #11 was observed in wheelchair wearing a hospital gown over light mint green t-shirt. When asked if she wanted to be in a hospital gown, Resident #11 said, Who cares, but I don't want anyone messing with my stuff. I don't have my clothes or my things. On 9/22/22 at 9:00 a.m., observed Resident #11 in wheelchair in room wearing hospital gown. On 9/22/22 9:09 a.m., Certified Nursing Assistant (CNA), Staff B, assigned to Resident #11 said, She was in the 400 hall and then she came to the 500. She has been here a long time. Usually, residents in 500 hall are temporarily there. Since she is long term, I figured she would go back to her room at some point. CNA, Staff B, confirmed resident had no personal items and only one t-shirt in current room. CNA Staff B confirmed she put resident in mint green t-shirt on 9/20/22, two days ago. CNA, Staff B, confirmed Resident #11 has only worn a hospital gown otherwise since 9/19/22. CNA, Staff B said, I don't know why they didn't bring her stuff from long term. On 9/22/22 at 9:15 a.m., the Assistant Director of Nursing (ADON) confirmed Resident #11 came back to facility on 9/1/22. ADON said Resident #11 was a long-term resident and would be going back to her room, but her roommate had been covid positive, so they did not move her there right away. The ADON said, Plus she was on routine quarantine after being in the hospital. ADON said, I am not sure where the items are. I will check with the CNAs for this hall. On 9/22/22 at 9:17 a.m., with surveyor present, the ADON asked CNA Staff A about Resident #11's clothing and personal items. CNA, Staff A, said she did not know where Resident #11's personal items were. The ADON said, I know that this is a problem. I would want my stuff too. I know it is here and I'll keep looking for them. On 9/22/22 at 10:30 a.m., the Director of Nursing (DON) said, It is unacceptable to have her (Resident #11) in a gown for 4 days and even wearing a t-shirt with only her incontinence briefs. They should know better. I know where her items are. I will address it right now and fix it. Especially our long-term residents they need their things. 2. On 9/19/22 at 12:45 p.m., Resident #158 was observed in her in room with husband at bedside. Resident #158's husband said, I need to show you something in the bathroom. On the floor of the bathroom was a commode bucket filled with formed bowel movement and cloths. Resident #158's husband said, I was here when she had the bowel movement at 8:30 to 8:45 a.m. They left it in there. I told the nurse at 10:00 a.m. and still they haven't cleaned it up. It is upsetting. Husband then walked out of room for a few minutes, came back in and said, I just told the nurse again. On 9/19/22 at 1:00 p.m., Registered Nurse (RN), Staff E confirmed he was told around 10:00 a.m., about the dirty commode pan. RN, Staff E, said he told the CNAs to take care of it. RN, Staff E, said, I should have checked myself. It is bad that it is almost 1:00 p.m. and it was sitting in the bathroom that long. That should not happen. On 9/19/22 at 1:15 p.m., observed CNA, Staff D, assigned to Resident #158 entering room to empty commode pan. On 9/22/22 at 10:30 a.m., the DON said the expectation was for staff to clean the commode right away and put it back in case the resident needed to use it again. The DON said it was unacceptable to leave the dirty commode in the bathroom for hours.

Based on observation, record review, staff, family and resident interview, the facility failed to ensure ordered therapeutic diets were correctly provided for 3 (Residents, #1, #158, and #93) of 6 residents reviewed for food and nutrition. The findings included: 1. On 9/19/22 at 12:24 p.m., Resident #1 observed eating lunch which consisted of vegetables, mashed potatoes and mixed vegetables. No protein, meat or fish was observed on the plate for lunch. Resident #1 said she did not know why she did not get any meat or protein. She said, It would be nice to have some meat. Photographic evidence obtained Resident #1's lunch meal included a nonfat yogurt. Observation of the meal ticket showed the resident was lactose intolerant. Photographic evidence obtained On 9/20/22 clinical record review for Resident #1 revealed an order summary documenting the resident was lactose intolerance. The ordered diet was carbohydrate controlled, no added salt, mechanical soft texture. On 9/21/22 at 12:05 p.m., the Certified Dietary Manager (CDM) confirmed Resident #1 was on soft mechanical diet and was lactose intolerant. The CDM reviewed the photographic evidence and said Resident #1 should have received the tortellini for that meal and did not know why she did not get any. The CDM confirmed Resident #1 did not receive protein or tortellini for the lunch meal of 9/19/22. The CDM also confirmed Resident #1 received yogurt when she was identified as lactose intolerant. The CDM said, That was an error. The CDM said, Dietary is responsible to make sure it goes out correctly and nursing confirms. I don't know why her tray was so wrong on Monday. On 9/21/22 at 12:45 p.m., the Registered Dietician confirmed Resident #1 should not have received yogurt and should have received a full meal. 2. On 9/21/22 at 11:55 a.m., Resident #93's spouse complained about his spouse's lunch meal and said, I just don't understand why they would only give him peas and mushrooms for lunch. Observation of the lunch meal showed the only items served were peas and mushroom. The spouse said, I just told Assistant Director of Nursing (ADON) and he is taking care of it. The ADON and CDM entered room and provided resident with another boxed lunch containing a regular meal with fish, starch, and vegetables. On 9/21/22 at 12:05 p.m., the CDM said, Another resident requested only peas and some cold foods. The dietary staff must have grabbed the wrong box to put on Resident # 93 lunch tray. Asked if the lunch ticket does not show a selection will the resident receive the planned meal on the menu. CDM replied, Yes, we have a select menu for requests otherwise it is a blank ticket with allergies or preferences, and they get the full meal. This was just an error, but I have fixed it. CDM confirmed per resident meal ticket Resident #93 should have received the full meal. On 9/21/22 clinical record revealed an order summary for Resident #93 which included a regular diet, mechanical soft texture. On 9/21/22 at 1:13 p.m., The DON reviewed Resident #93 meal ticket and confirmed he should have received a full meal not just peas and mushrooms. The DON also said the Certified Nursing Assistants (CNAs) should be checking the meal itself against the meal ticket to ensure it is correct. interviewed DON about process for following diets. The DON said if the speech therapist is making a dietary change, they complete the communication form and send to the kitchen. If it is nursing, then they complete the order and bring to the kitchen. 3. On 9/19/22 at 12:45 p.m., observed Resident #158 with lunch tray in front of her which consisted of a full slice of turkey and gravy, mashed potatoes and a yogurt. Resident #158's spouse said, I wish they would only give her soft stuff to eat. She is still having issues with swallowing and does fine with soft stuff. Review of Resident #158's clinical record revealed an order summary report with dietary orders dated 9/17/22 for a regular diet, pureed texture. Resident #158's care plan documented a pureed diet for swallowing concerns. On 9/21/22 at 12:05 p.m., the CDM said Resident #158 has had her diet changed a lot since she has been here. Upon reviewing the physician's orders, the CDM said as of 9/17/22, She was ordered for a regular diet pureed texture. The CDM said he did not know why the resident received a full slice of turkey with the lunch meal of Monday 9/19/22. He said, I guess the order hadn't been changed in the dietary system yet. I entered it after lunch on Monday to be pureed. The CDM added, I am not sure what happened. Maybe someone didn't send the communication paper to the kitchen. I know I entered it once I had the paper. That's no excuse she should not have gotten full turkey slice she should have gotten the pureed turkey. It was our error. On 9/21/22 at 1245 p.m., the Registered Dietitian with CDM present said it was not appropriate for a resident on a pureed diet to receive a full slice of turkey. On 9/21/22 at 1:13 p.m., the DON said if speech is making a dietary change, they complete the communication form and send it to the kitchen. If it is nursing, then they complete the order and bring to the kitchen. The DON reviewed Resident # 158 dietary orders and confirmed the resident was ordered a pureed regular diet on 9/17/22 and should not have received a full slice of turkey.

Based on record review, review of facility policy, resident and staff interview, the facility failed to provide timely assistance in a manner to promote dignity for 3 (#492, #10, and #77) of 3 residents reviewed who are dependent on staff for activities of daily living. The findings included: Review of the facility's admission packet (undated) revealed a Florida Patient /Resident Rights and Responsibilities which read residents . have the right to be treated with courtesy, respect and full recognition of your dignity and individuality by all employees.with whom you come in contact . Each patient has the right to. Privacy in treatment and in caring for personal needs; to close room doors and to have facility personnel knock before entering the room . Be treated courteously, fairly, and with the fullest measure of dignity. 1. Review of the clinical record revealed Resident #492 had an admission date of 3/29/21. The care plan noted the resident had alteration in neurological status and required cueing and reorientation as needed. Resident #492 also had self-care deficit related to a recent stroke with a goal to improve activities of daily living self-performance. On 4/11/21 at 9:25 a.m., observed Resident #492, on his bed wearing only an incontinence brief. The resident was not covered, the bedroom door was open and the resident was clearly visible from the hallway. Several staff members observed walking past the room in the hallway and did not intervene. On 4/11/21 at 10:33 a.m., Resident #492 was observed in bed with his incontinent brief partially open, exposing his penis. The bedroom door was open and the resident was clearly visible from the hallway. On 4/13/21 at 11:29 a.m., observed resident #492 in a wheelchair in his room facing the doorway. Resident #492 pants were lowered around his ankles exposing the incontinence brief. On 4/13/21 at 12:50 p.m., observed resident #492 sitting in a chair in his room facing the window. The resident's pants remained lowered around his ankles exposing his incontinent brief. The bedroom door to the hall was open, the window curtain was open, and the Resident was clearly visible from hallway. On 4/13/21 at 12:52 p.m., in an interview Registered Nurse (RN) Staff E said Resident #492 did not have behaviors and was a very sweet man. Certified Nursing Assistant (CNA) Staff A was present during the interview and said I check on him a lot. RN Staff E and CNA Staff A said they were not aware the resident's brief was exposed and the door open. They both went in the room to assist Resident #492. On 4/14/21 at 10:19 a.m., the observations on 4/11/21 and 4/13/21 were shared with the Director of Nursing (DON). The DON said, that is a dignity problem and not acceptable, I will follow-up with the team. 2. On 4/11/21 at 9:51 a.m., in an interview Resident #10 said, There is not enough staff or CNAs. The longest I have had to sit in a wet brief is three hours. On 4/12/21 at 1015 a.m., while conducting a second interview, observed CNA Staff A entering Resident #10's room without knocking. Resident #10 said, They come in without knocking all of the time. On 4/12/21 at 4:20 p.m., observed resident #10 telling RN Staff E he needed to be changed. During the observation, CNA Staff L walked in room without knocking and was informed of resident's need. On 4/12/21 at 4:53 p.m., observed CNA Staff L entering room to assist Resident #10, 33 minutes after Resident #10 asked for assistance. On 4/13/2021 review of the care plan for resident #10 revealed the resident has incontinence interventions and required total assist with toileting and incontinence care. On 4/14/21 at 9:45 a.m., in an interview Resident #10 resident said, I'm aggravated. The resident said he had an incontinent episode of bowel and had been sitting in his feces for 45 minutes. He said he asked RN Staff E to be changed 45 minutes ago. CNA Staff H said she would change him but that was a long time ago. On 4/14/21 at 10:03 a.m., The Assistant Director of Nursing (ADON) was observed leaving the resident's room. In an interview the Assistant Director of Nursing (ADON) said residents should not wait more than 20 minutes for an incontinence brief change. On 4/14/21 at 10:19 a.m., Resident #10's concerns were reviewed with the DON. The DON said, at most a resident should only wait 15 minutes for a brief change . Informed of observation on 4/12/21 when resident #10 waited 33 minutes for a brief change. The DON said, that's unacceptable. 3. In an interview on 4/12/21 at 9:50 a.m., Resident #77 said staff did not respond to his call bell in a timely manner and was a weak spot for the facility, especially on the weekends. The resident said on Saturday, he rang his bell and had to wait 45 minutes to receive care after an incontinent episode with both bowel and bladder. He said the nurse came in and confirmed his call light was functioning and said she would send someone in. He said the incident made him feel worthless as he is dependent on staff for care. Resident #77 said this was not the first time and had happened before. He said staff use the excuse as they were busy. He said this is a regular occurrence on the weekends and he usually has to wait an average of 30 minutes for assistance from staff. On 4/14/21 at 10:20 a.m., reviewed with the Director of Nursing (DON) the concern of Resident #77 not being treated in a dignified manner by waiting 45 minutes to receive incontinent care. The DON acknowledged that waiting for 30 to 45 minutes for the call bell to be answered was not acceptable and would address this with staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a safe, sanitary, comfortable and home like environment for residents. Not maintaining a sanitary environment has the potential to spread disease causing organisms. The findings included: On 4/11/21 at 11:00 a.m., during a tour of the facility, the following observations were made: room [ROOM NUMBER] was observed with peeling wall with brown substance on the wall behind the resident's bed. The toilet was rusted and constantly flushing. The raised toilet seat was broken. **Photographic Evidence Obtained** room [ROOM NUMBER] was observed to have peeling baseboards. A large crack observed in the wall, and a hole in the wall behind the door. **Photographic Evidence Obtained** room [ROOM NUMBER] had a heavily soiled floor with grime and debris around the base of the toilet in the bathroom. **Photographic Evidence Obtained** room [ROOM NUMBER] had peeling baseboard walls behind the bed. **Photographic Evidence Obtained** room [ROOM NUMBER] observed with peeling baseboards. **Photographic Evidence Obtained** room [ROOM NUMBER] had a hole in the wall behind the baseboard, a large gouge and crack in the wall under the window. The residents personal care items (deodorant, toothpaste, and comb) were stored uncovered on the toilet tank, which could become cross contaminated. **Photographic Evidence Obtained** room [ROOM NUMBER] observed with rusted and broken toilet seat riser. **Photographic Evidence Obtained** room [ROOM NUMBER] with gouged walls behind the dressers and beds. room [ROOM NUMBER] heavily stained toilet, broken and hanging electrical outlet plates, toilet constantly flushing. **Photographic Evidence Obtained** 300 hall day room observed with large hole in the wall. **Photographic Evidence Obtained** room [ROOM NUMBER] observed with peeling baseboards. **Photographic Evidence Obtained** room [ROOM NUMBER], bed pan in handrail in the bathroom and an uncovered hairbrush stored on the sink not which could become cross contaminated. **Photographic Evidence Obtained** room [ROOM NUMBER], residents personal care items (toothbrush and toothpaste) stored uncovered on the sink in the bathroom, which could become cross contaminated. On 4/14/21 at 10:44 a.m., the same observations were made during a facility tour conducted with the Maintenance Director. He verified and acknowledged the findings. On 4/14/21 at 11:00 a.m., the Administrator was informed of the findings. He said he would get with the Maintenance Director and fix the issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to ensure the MDS (Minimum data set) assessment accurately reflected the resident's urinary status for 1 (Resident #6) of 1 resident with an indwelling urinary catheter. Inaccurate MDS assessments can result in a resident not receiving appropriate health care. The findings included: On 4/11/21 at 10:30 a.m., and 4/12/21 at 11:07 a.m., Resident #6 was observed with an indwelling urinary catheter (Catheter placed in the bladder to drain urine). The catheter was in a privacy bag attached to the side of the bed. Record review on 4/12/21 at 3:30 p.m., showed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. The assessment noted Resident #6 was always incontinent of urine but did not note the use of an indwelling urinary catheter. The clinical record did not include a care plan for the indwelling urinary catheter. On 04/13/21 at 9:17 a.m., in an interview Registered Nurse (RN) staff F said Resident #6 had a chronic catheter that is usually changed on the day shift. On 04/13/21 at 9:30 a.m., RN Staff M said he did not see any physician's orders for the Foley (indwelling urinary) in the resident's clinical record. On 04/13/21 at 9:32 a.m., in an interview MDS RN Staff N and MDS RN Staff O said they gather their information to code the MDS from all sources, they interview the residents, family members, staff, review progress notes and therapy notes. On 04/13/21 at 10:15 a.m., MDS RN Staff O said there was an order dated 8/17/20 to discontinue the catheter, but no other orders. She said, We did not know she had one. Review of the progress notes showed the catheter was changed on 11/23/20. On 04/13/21 at 10:45 a.m., in an interview the Director of Nursing (DON) said he did not know what happened. He said Resident #6 had gone out to the hospital and came back with the Foley catheter. The orders never got picked up. He said the last progress note was dated 11/23/20 for a Foley catheter change.

Based on observation, review of facility policy and procedure and staff interviews, the facility failed to appropriately store and protect residents' medications in a manner to prevent loss and reduced efficacy for 1 of 3 medication carts and 1 of 2 medication rooms. The findings included: The facility policy 5.3 (October 2016) Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles specified . Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 4/13/21 at 9:20 a.m., reviewed medication cart for 500 hall with LPN Staff K. Observed four loose pills and two loose predated menthol medication patches in the cart. LPN Staff K, confirmed she could not identify the loose pills and which residents the loose medications belonged to. Observed a bag of intravenous micafungin (medication to treat fungal infection) 100 milligrams belonging to Resident #542 stored on the shelf, out of brown plastic bag and in direct light. The medication label from pharmacy specified to protect from light. RN Staff G confirmed the medication was not protected from light as specified on the pharmacy label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview the facility failed to provide reasonable accommodation to promote residents rights to receive visitors. The findings included: The resident rights and responsibilities included in the admission packet specified, Each patient has the right to . visiting with any person of your choice during visiting hours . Center visiting hours shall be flexible, taking into consideration special circumstances such as, but not limited to, out-of-town visitors and working relatives or friends . The Center for Medicare and Medicaid Services (CMS) memo QSO-20-39 (Revised Nursing Home Visitation) revised 3/10/21 read Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status) except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission . These scenarios include limiting indoor visitation for: Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is > [greater than] 10% and < [less than] 70% of residents in the facility are fully vaccinated; Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. 1. On 4/12/21 at 2:31 p.m., in a confidential group interview, all members of the Resident Council present for the meeting said nobody can come inside the facility to visit. Residents relayed this included immediate family members who will visit them through the window if they are able. Another resident said his wife wanted to come inside to visit and had not been allowed to do this for over a year. A council member relayed there was no inside visitation but the facility had started allowing outside visits with a 6 foot table between them which can be arranged with the Activity Director. 2. On 4/13/21 at 11:05 a.m., in an interview resident #38 said, Nothing to do at this place, I get an hour a day of therapy and 23 hours to lay in this bed. They have not offered me anything to read or do. I am trapped in this room like a prison. Resident #38 said, it is depressing, being sick since January and having nothing to do. I have not been offered anything, not even a newspaper . When asked about visitation he said when I was in the other room my wife could come to the driveway and we could wave at each other and talk on the phone, now in this room no luck, she isn't going to climb over bushes. It's like a punishment or bullying. 3. In an interview on 4/13/21 at 9:00 a.m., the Activity Director (AD) said all visitation was conducted outside and at this time no inside visitation is allowed per facility policy regardless of vaccination status. The outside visits are supervised by herself or her assistant to ensure the visitor and resident do not touch each other and remain 6 feet apart. The AD said she would intervene and redirect them if that happened. They allow one visitation to take place at a time and are usually for 30 minutes. The visitor screening log from September 2020 to April 2021 was reviewed. Inside visits were noted to have been conducted on 4 occasions, 11/14/20, 11/23/20, 3/1/21 and 3/2/21. The AD said these 4 visits were for compassionate care. 4. On 4/11/21 at 2:30 p.m., in interview with Director of Nursing (DON) he said the facility has not been allowing any visitor inside the facility at this time. He said they have allowed compassionate care visits to Hospice resident who were actively dying but this has only happened a few times since the start of the pandemic. The DON said the [NAME] County COVID positivity rate is 7.9%, 58 plus residents (Census of 95) and 78 staff have been fully vaccinated with the COVID-19 vaccine. 5. On 4/12/21 at 8:44 a.m. in interview with administrator He said the facility has allowed outdoor visitation but has not allowed indoor visitation yet. The Administrator said he was aware of the most recent memorandum from CMS and the Center of Disease Control (CDC) Regarding the updated Nursing Home Visitation - COVID-19 guidelines. 6. On 4/12/21 at 11:34 a.m. in interview with Regional Corporate Nurse for the company she stated that the facilities Administrator and Senior management all discussed the new update from CMS and CDC on a virtual meeting on 3/12/21. It was discussed in depth the need to open up visitation as indicated in the memo. She said that she knows the company has detailed plans and she does not know why this facility has not started yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. On 4/11/21 at 12:35 p.m., in an interview Resident #38 said, There is no activities at this place. I'm only allowed to be in my room. On 4/13/21 at 11:05 a.m., in an interview resident #38 said, Nothing to do at this place, I get an hour a day of therapy and 23 hours to lay in this bed. They have not offered me anything to read or do. I am trapped in this room like a prison. The Resident said he has not been offered anything to keep him occupied the entire time he has been here. Resident #38 said, it is depressing, being sick since January and having nothing to do. I have not been offered anything, not even a newspaper . When asked about visitation he said when I was in the other room my wife could come to the driveway and we could wave at each other and talk on the phone, now in this room no luck, she isn't going to climb over bushes. It's like a punishment or bullying. On 4/13/21 at 12:56 p.m., review of Resident #38's clinical record revealed an activity care plan which included interventions to familiarize with center environment and activity programs on regular basis, provide supplies/materials for leisure activities as needed or requested. The clinical record lacked documented recreation or activity notes for Resident # 38. On 4/14/21 at 11:00 a.m., reviewed with Resident #38 an activity packet received from activities director as sample of what was distributed to residents daily. Resident #38 said, Are you showing me what I am supposed to be receiving? I have never seen that before, it's like being in jail here. 10. On 4/12/21 at 1045 a.m., in an interview resident #10 was asked if the facility had activities he'd like to participate in. Resident #10 said, No they have no activities here and I have not been offered any activities. I just watch TV or sleep. On 4/13/21 at 3:00 p.m., record review showed a care plan dated 1/11/21 for Resident #10. The care plan did not document activities or recreational interests. The Recreational / Activity assessment dated [DATE] had no documentation. The clinical record showed no documented notes for recreational services for Resident #10. 11. On 4/11/21 at 10:35 a.m., in an interview Resident #27 said, There are no activities at this facility. They offer nothing to do. On 4/12/21 at 10:09 a.m., in an interview Resident #27 said, we stay in this room and do nothing. Resident # 27 said she was lucky she and her roommate liked each other since, we never get to leave the room. On 4/13/21 at 3:02 p.m., review of the recreation/activities progress note dated 1/26/21 revealed when resident #27 requested to go outside staff offered to take her out in 45 minutes but documented resident was too tired at that time. Staff documented they would follow up the next day. The clinical record lacked documentation of a follow-up the next day. The Resident's comprehensive care plan did not address activities. 12. On 4/14/21 at 09:45 a.m., in an interview the activity packet received from the Activity Director as a sample of what was distributed to residents daily was reviewed with Resident #492. Resident #492 said, I don't think I have received those I don't see any in my room. On 4/14/21 at 10:09 a.m., review of the clinical record for resident #492 revealed a care plan which did not address any recreation or activities or choices. The clinical record had no documented recreation or activity notes. On 4/13/21 at 3:37 p.m., interviewed activities director who said, All residents should have an initial, quarterly and annual note for recreation and activities. She confirmed the facility was not permitting visitors inside, and said she provides a paper activity packet for residents. 5. On 4/11/21 at 11:00 a.m., observed resident #80 sitting in a wheelchair in her room dressed and groomed, looking out the window. The television was not on and the resident was not participating in any activity. Resident # 80 stated she has not had any activity, and no one has given her an activity calendar or talked to her about activities. On 4/12/21 at 10:00 a.m., observation of resident #80 in room sitting in a wheelchair, reading church paper, the television was not on and no activity observed. On 4/13/21 at 9:45 a.m., observation of resident #80 sitting in a wheelchair in her room. Resident # 80 stated she was just sitting and waiting for lunch, as there was nothing more to do, she stated she would do more if there were more activities to do. Resident # 80 said she never received any packets about activities, so she watched television sometimes, but she could only do that for so long. On 4/14/21 at 10:00 a.m., in an interview the Activity Director confirmed resident # 80 did not have an activity care plan. She said she had no explanation as to why it was not completed. 6. On 4/11/21 at 11:18 a.m., observation of resident # 83 lying in bed in a hospital gown with the television on. She stated there were no activities at the facility, she has not been given an activity calendar and no one has spoken to her about activities. Resident #83 stated she would participate in activities if she knew what activities were offered but she just watched television for the most part, and when she is up and dressed, she just sits in her chair unless doing therapy. On 4/12/21 at 11:30 a.m., observation of resident #83 sitting in her wheelchair, looking out the window. She stated she was waiting for lunch, and just looking outside since there was nothing else to do. Resident # 83 stated she was never given any packet for activities or any books for reading, she had her friend bring a book for her to read, as it gets boring at times, and she would love to go outside for some fresh air sometimes. On 4/13/21 at 11:32 a.m., observation of resident #83 in room sitting in a wheel chair looking out the window, no activity, no television on, Resident # 83 stated she was just sitting, there was nothing to do, until therapy came back again. She said she wished there was more to do but there was not, there was no activities, and she was tired of reading her book, so she was just looking out the window. 7. On 4/12/21 at 9:09 a.m., observation of resident # 88 lying in bed in a hospital gown, no activity, television not on. Resident #88 stated no one came to get her for activities, and no one has informed her of any activities. On 4/13/21 at 10:30 a.m., observation of resident #88 lying in bed, dressed in a hospital gown, no activity, television not on. Resident #88 stated she would love to participate in card games if the facility was having them, but nothing has been offered, no one has come to offer any activity and she has not received any activity information, and no one has even offered individual activity to her. On 4/13/21 at 4:06 p.m., review of Resident # 88's recreation/activity assessment revealed documentation Resident #88 liked to keep busy and expressed interest in group activities and enjoyed participating in outdoor leisure activities. On 4/13/21 at 10:06 a.m., in an interview the Activity Director said the facility was not having any group activities or outdoor activities, only independent activities for the residents. She said group activities were canceled when the pandemic started and had not restarted. She stated the residents were currently having independent activities by themselves, and residents were given activities packets. The Activity Director provided the survey team with an activity packet and said she had no documentation indicating when the residents received the activities packet. On 4/14/21 at 9:17 a.m., observation of Resident #88 in room, lying in bed in hospital gown, no television. The surveyor reviewed with resident #88 the activity packet the Activity Director provided the survey team. Resident # 88 said she had never seen the packet; she no one gave including the Activity Director gave her such packet. On 4/14/21 at 10:00 a.m., in an interview the Activity Director said she was responsible for performing the recreation/activity assessment and activity care plan for the residents. The Activity Director confirmed resident #88's recreation/activity assessment indicated she expressed interest in group activities and playing cards. The Activity director stated she had not done any in room activity or played cards with resident #88, and there were no group activities for the resident to participate in as indicated in her assessment. On 4/14/21 at 9:42 a.m., in an interview Certified Nursing Assistant (CAN) Staff H said she could not help with activities as she was busy providing care services to her residents. CAN Staff H stated there was no group activities at the facility, and she has not seen anyone from the activities department conducting one on one activities with the residents. 8. On 4/11/21 at 10:10 a.m., observed Resident #9 laying in his bed. Resident #9 said he would participate in activities if the facility offered them but there was no activities program at this time. On 4/12/21 at 9:47 a.m., observed Resident #9 laying in bed. He said there really was no activities to get involved in. He said once in a while they would bring him outside but otherwise, we just stay in our rooms and mostly in bed all day. Review of the Minimum Data Set (MDS) assessment dated [DATE] showed Resident #9 was alert and oriented, liked music, pets and keeping up with the news. It was very important to him to do his favorite activities, and very important to be able to go out and get fresh air. Review of Resident #9's Recreation/Activity Evaluation dated 1/19/21 showed the resident was interested in group leisure activities, as well as outdoor leisure activities. It was also noted the resident liked to stay busy. Resident #9's activity care plan goal stated the resident Prefers to pursue independent activities. The Goals included the resident would participate in independent leisure activities of choice daily. Interventions included to take resident outside as needed and on request, familiarize him with activity programs on a regular basis and provide supplies and materials for leisure activities as needed. 13. On 04/12/21 at 1:28 p.m., in an interview Resident #6 said there had been no activities at the facility since COVID started. When asked what she does, she stated she watched television, there was nothing else to do. She stated they were unable to leave their rooms. On 4/14/21 at 9:00 a.m. Resident #6 said she had not received an activities packet and did not know what it was. 15. On 4/12/21 at 1:28 p.m., in an interview Resident #15 said there had been no activities in the facility since COVID started. When asked what she does, she stated she just stayed in her room, there was nothing else to do. She stated they were unable to leave their rooms. On 4/14/21 at 9:00 a.m., in an interview Resident #15 said she had not received an activities packet. She did not know what it was. On 04/13/21 at 3:32 p. m., the Activity Director said morning devotions was a devotional segment she printed off the internet for the residents to read. She said We can't have groups as our policy states. We do our devotions that way. The devotions are included in the packet. Plant appreciation stuff was printed out and put in the packet. Trivia sheets are printed out and put in the packet. Bingo independent, word search puzzle. Jeopardy is basically jeopardy questions with answers. Dolphin day, information about dolphins. Coloring sheets with dolphins and the residents get colored pencils. Afternoon art is an adult coloring sheet. Cranium sheets is like a picture puzzle. If they have a vision impairment, I would sit with the resident I would give the resident the title of the puzzle and ask the resident what some items of the title would be and cross them off. So, all activities are coming to the resident in paper form. There is a different packet every day. On 4/11/21 at 2:30 p.m., in an interview the Director of Nursing (DON) said the facility has not been allowing any visitor inside the facility at this time. He said they have allowed compassionate care visits to Hospice resident who were actively dying but this has only happened a few times since the start of the pandemic. The DON said the facility has not been having communal dining or group activities even with social distancing and wearing of mask. The DON said the [NAME] County COVID positivity rate was 7.9%, 58 plus residents and 78 staff have been fully vaccinated with the COVID-19 vaccine. On 4/12/21 at 8:44 a.m., in an interview the Administrator said the facility has not started communal dining or group activities since the start of the COVID pandemic. He said the facility has allowed outdoor visitation but has not allowed indoor visitation yet. The Administrator said he was aware of the most recent memorandum from CMS and the Center of Disease Control (CDC) Regarding the updated Nursing Home Visitation - COVID-19 guidelines. On 4/12/21 at 11:34 a.m., in an interview the Regional Corporate Nurse said Facilities Administrators and Senior management all discussed the new update from CMS and CDC on a virtual meeting on 3/12/21. It was discussed in depth the need to open up visitation as indicated in the memo. She said she knew the company had detailed plans and she did not know why this facility had not started yet. Based on observation, record review, resident and staff interview, the facility failed to implement meaningful resident centered activities to meet the interest and well-being of 13 (Resident #45, #56, #57, #15, #6, #88, #80, #83, #27, #10, #38, #9, and #492) of 13 residents reviewed for activities. The lack of an individualized activity program had the potential to cause social isolation, apathy, and boredom. The facility also failed to promote communal activities and dining while adhering to core principles of COVID-19 infection prevention. The findings included: Review of the facility policy Activity and Recreation Service (dated July 2019) documented the activity programs are provided to enable patients to achieve the highest level of physical, mental, psychosocial, and spiritual well-being. The program of activities is designed to recognize and accommodate patient limitations while maximizing strengths, interests, and abilities. The Center for Medicare and Medicaid Services memorandum (QSO-20-39-NH) revised on 3/10/2021 read, While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering (except while eating). Facilities may be able to offer a variety of activities while also taking necessary precautions. For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. 1. On 4/11/21 at 11:30 a.m., Resident #45 was observed lying in bed wearing a hospital gown. The resident said he had been here for 2 months and staff are not allowing him out his room. Resident #45 said he used to live at an assisted living facility and participated in the entertainment they offered. He said there was no activity here and TV is the activity. Review of the clinical record for Resident #45 revealed an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE]. Section F 0500 interview for Activity Preferences indicated the resident liked to be around animals, keep up with the news, do things with groups of people, go outside, and participate in religious services. On 4/12/21 at 9:48 a.m., in an interview Registered Nurse (RN) Staff J said the residents do not leave the unit unless going to rehab with therapy staff. She said they used to have activities in the day room but not since the onset of COVID-19. 2. On 4/11/21 at 1:45 p.m., Resident #56 was observed lying in bed wearing a hospital gown. The resident shared a room with his wife, Resident #57. The resident said no one had asked if he wanted to attend any activities. He did not know if there was anything to do, no one has told us. We sit in the chair all day and nobody takes us out of the room except for therapy. The resident said he would like to do something but nobody tells us. On 4/13/21 at 1:20 p.m., in an interview the Activity Director said she has not done any group activities for about a year due to COVID-19 but does give out packets for the activity listed on the activity calendar. The packet includes the Daily Chronicles, independent bingo games, word search puzzles, Trivia, and other items as per the calendar. A list of the residents who receive this daily activity packet was reviewed. Resident #56 was identified as getting the Daily Chronicles and entire activity packet daily. The resident was also to read it to his wife. On 4/14/21 at 10:06 a.m., Resident #56 said he had never seen the activity packet, just the Daily Chronicle. Review of the clinical record for Resident #56 revealed an admission MDS 3.0 assessment dated [DATE]. Section F 0500 interview for Activity Preferences indicated the resident liked music, to be around animals, keep up with the news, do things with groups of people, go outside, and participate in religious services. 3. Review of the clinical record for Resident #57 revealed an admission MDS 3.0 assessment dated [DATE]. Section F 0500 interview for Activity Preferences indicated the resident liked to keep up with the news, do her favorite activities, and go outside. On 4/13/21 at 1:05 p.m., Resident #56 was observed in his room sitting in the wheelchair. The facility's Daily Chronicle newsletter dated 4/12/21 was on the bed. The resident said he did get the facility's Chronicle about once a week but would like to play bingo or any activity. Resident #57 was observed sitting in the wheelchair next to Resident #56. She said in regards to activities, she likes to do anything. 4. On 4/12/21 at 2:31 p.m., in a confidential group interview, members of the Resident Council said they used to play bingo but not any longer. They can color and the Daily Newsletter comes around but no activities like they used to enjoy.